No-BS breastfeeding resources (an ongoing project)

Suppose you're a normal mother-to-be who is planning to breastfeed... or, maybe thinking about it but not committed either way. You're looking forward to doing the sort of things the ordinary, everyday mothers around you do--you're planning a hospital birth with lots of nice drugs, you want to get your baby onto some vague sort of routine so you can plan the day, you'd certainly like baby to start "sleeping through" sooner rather than later, and you'll want to be able to leave your baby with your husband/mother-in-law/babysitter regularly so you can go out. You might go back to work while your child is still young.

Or maybe you're a second-time mother. You tried to breastfeed the first time round--oh, so very, very hard. And it didn't work out. Trouble is, by then you'd already spent months reading all the books and blogs--the ones that told you in no uncertain terms that your formula-fed child was going to be stupid, asthmatic and fat, that you wouldn't "bond" properly, and that anyway this was all your fault because you didn't have an all-natural birth bouncing up and down on a yoga ball, and because you caved and let the nurses take baby to the nursery for a couple of hours because you were too exhausted to see straight. A spiral into gloom, anxiety and hystronic post-partum depression was more or less guaranteed. Now you're girding your loins to try breastfeeding again. But the thought of reading those books again... the ones that were whispering in your ears at 3AM every morning while the tears rolled down your face...

I think you can see why most breastfeeding resources--the books, the blogs, the forums--are problematic for either one of these women. Such resources are heavily oriented towards natural birth, "natural" parenting, and natural just-about-everything-else, and waste no time in telling you about the horrors that await you and your child should you weaken and allow even a single bottle of that ghastly white stuff. And they are full of sloppy science, urban legends and pet theories.

Other books (usually not "breastfeeding books" but rather general how-to-look-after-your baby books) talk about routines and sleeping-through-the-night (almost fanatically, sometimes) yet fail to get the basics right regarding breastfeeding. For example, Gina Ford tells exhausted new mothers to start pumping pretty much from Day 1 in order to stretch out the gaps between feeds. Claire Byam-Cook and Tracy Hogg (the Baby Whisperer) tell women to measure how much milk they are producing by doing a "yield," i.e., pumping and measuring their output, apparently unaware that there are many women--including Yours Truly--who have a good supply but are mediocre at pumping. If I had followed these writers' advice, I would have been convinced that I was starving Little Seal with every feed.

For these reasons, I've decided to start compiling a comprehensive list of breastfeeding resources which I reckon are credible, science-based and reasonably representative of how most of us actually mother. I'll keep updating this as I come across more sources, but this is a start. There's some practical stuff here; there are also discussions of breastfeeding research and politics to muse on, or to wheel in as counter-evidence when someone online is talking bollocks.


Books

Actual breastfeeding books

As I moaned here, it is very hard to find breastfeeding books that don't seem to be written by someone with the shining light of the fanatic in her eyes. Marianne Neifert (in Dr. Mom's Guide to Breastfeeding and Great Expectations: Essential Guide to Breastfeeding advocates for breastfeeding but manages to do so without the harshly judgmental tone of other lactivists. She is almost alone in the breastfeeding book annals in her outspokenness about the difficulties and barriers many breastfeeders experience, and in stating frankly that low supply really exists and is not a myth. Most importantly, her books get all the nuts and bolts right; they are full of great, practical information about how the breasts work, the mechanics of breastfeeding, latching, troubleshooting, pumping and much, much more--everything you'll get in the Womanly Art of Breastfeeding, in short, but without the scaremongering and condescension. By the way, it was Estherar at Mainstream Parenting who first put me onto this book.; check out her review here. 

Solids ("weaning")

Weaning Made Easy is a fun yet evidence-based approach to weaning (=solids introduction, not breastfeeding cessation) which avoids the tedium of the gourmet-icecube tray approach (making overelaborate purees and then spending mealtimes trying to get it all inside the baby) and the pitfalls of the Gill Rapley baby-led weaning method (potential iron/zinc shortages, babies going for months on end without eating anything, neverending mess). It encourages parents to offer different foods in a variety of ways, including soft finger foods and purees of nutritious-yet-hard-to-eat things, based on sound nutritional principles--always with a stress on the individuality of each child and the need for you to feel comfortable with what you are doing. Which, I suspect, is how most people would wean anyway if we didn't have babycare writers telling us how to do it...

Sleep

I have half a dozen infant sleep books on my shelf (ordered by my husband in a fit of Amazon-inspired shopping mania). There they sit, their spines almost uncracked. When it comes to sleep there's only one book I use--Good Night, Sleep Tight by Kim West--and it's never failed me yet. This book (by a sleep specialist who's helped countless families) is moderate, eminently sensible, and flexible enough to work with a whole range of parenting "styles"--while she emphasizes sensible routines and self-soothing, she is also extremely sensitive to the needs and feelings of babies and young kids... and she has a gentler alternative to cry-it-out for those who can't quite face Ferberizing. She also breastfed both her daughters, and that's important because breastfeeding and formula feeding have subtly different dynamics that affect sleeping patterns. A lot of "sleep books".... well, they may give lip service to "bottles/breastfeeds" in their routines, but you can tell it's really formula feeders they have in mind. When a sleep book is written from the point of view of a breastfeeder, it makes the breastfeeding mother feel "This is advice that's realistic for my baby. I feel we have a chance of succeeding with this." With sleep advice it's vital to feel confident that it's achievable and practical for your situation, or you'll never be able to put it into practice. West is not super "into" bedsharing, but discusses it in a sensitive and nuanced manner--the various reasons people bedshare, how to do it safely, how to combine it with learning good sleep habits, and how to transition away from it when the time comes--unlike some other writers who just scold and shame parents who take their babies into bed with them. She is even not-rude about mothers who nurse longer than 12 months (not common in parenting books).

Colic/fussiness
The Happiest Baby on the Block is a mildly attachment parent-y book with some good and practical advice for getting through the colicky weeks months. Generally I'm all for keeping babies on a loose routine, but when colic is wreaking its merry hell, sometimes you just have to grit your teeth and do what's necessary to get through the day. I recommend going straight to the second half of the book and ignoring the first section, which goes on a bit too much about how primitive tribespeople's babies don't have colic because they are carried round all day long (or something).

Other possibilities (recommended by others--I haven't read them)
Milk Memos (nursing and working) sounds like a good and non-judgey read, looking at the Amazon reviews. Child of Mine: Feeding with Love and Good Sense (feeding in general) was recommended by a blog reader. Baby Love (baby's first year) by Robin Barker got a good write-up from several people: "No nonsense; and she calls a poo a poo."


Blogs and websites

Kellymom
Ah yes, Kellymom. I've moaned about Kellymom a few times on this blog (and will be writing a longer post on them in the future). And yet I've sent struggling new mothers off to Kellymom for information several times, and there is presumably a reason for that. Kellymom can be really useful as long as you confine yourself to the “How many wet/dirty diapers should my newborn be producing?” kind of stuff, and bear in mind that this is an attachment parenting promotion site more than anything else. I've compiled a list of pages that I think give decent advice, but with everything that comes from Kellymom keep your skepticism close at hand. If it smells like bullshit, it may well be.  Confirm with other sources if you are not sure!

Low supply
Milk supply worries
Breastfeeding and medications
Weight gain (but see the FFF also here and here for your pinch of skepticism)
Pumping  
Milk supply and the older baby
Newborn basics
 
Much of the other stuff on the site is dodgy, especially the stuff on weaning age, solids/iron and the exaggerated benefits claimed for nursing, especially extended nursing. The forums have some pretty crazy ladies.
PS: Stay away from the sleep advice on that site if you value your sanity.

Science of Mom

A blogger I have a girl-crush on. The post on why breastmilk is so low in iron shreds some myths and misunderstandings about iron and breastmilk. It's refreshing to see a mother who can describe the joys of nursing past a year while questioning some of the dodgy data being used to push this choice onto all mothers. Meanwhile, can breastmilk clear up an eye infection? Possibly yes (admittedly, most of the breastfeeding sites have similar information, but it's nice to see Science of Mom actually confirming this with some data). Other posts cover breastmilk and prematurity, maternal diet and colic, improving milk production in the NICU and more.

Seattle Mama Doc combines evidence-based advice (sleep, breastfeeding, nutrition and more) with a kind and non-judgmental tone that makes for reassuring reading. She's worth a read!

Good Enough Mum

A terrific set of posts from a terrific blogger. She writes about nightweaning for a breastfeeding mother, and breastfeeding the second time around, gives her view on the "Watch your language" thing, and on why brutally unpleasant lactivism is everyone's business, while giving her vision for what positive breastfeeding promotion could look like. She also shreds some of bad science surrounding extended nursing--it's not as beneficial as you think (which doesn't mean you shouldn't do it if you want to)--and takes issue with the idea that a single bottle of formula will ruin your child's "gut" forever.

Fearless Formula Feeder
The majority of breastfeeders will use formula at some point, yet most breastfeeding resources say little about formula other than "Don't" followed by a list of terrifying reasons why--or descriptions of "correct formula preparation" which one suspects have been presented with the deliberate intention of making formula use look as intimidating as possible. That's why the Fearless Formula Feeder site (and upcoming book) can be the breastfeeding mother's friend. Learn the real deal about combo feeding and supplementing, jaundice, the mechanics of formula feeding, spotting formula allergy/intolerance, why you can't use goat's/cow's milk as a formula replacement, growth charts for formula-fed and breastfed babies and much, much more. Suzanne's site is extremely respectful of all safe feeding choices for babies... and what's more, it manages to be scientifically rigorous, well-written and nice--three things that are very hard to combine in online writing.    

Mainstream Parenting, while now defunct, is still a great source of skeptical commentary and mythbusting, some of which covers breastfeeding.


Miscellaneous

Skeptically Speaking's 15-minute podcast on breastfeeding is well worth a listen for an interesting scientific slant on lactation.

Trolls With Wooden Spoons

Trolls (you have to join; oh, and despite the name, the group has nothing to do with the internet phenomenon of "trolling") was created by a bunch of Mothering.com escapees who had become disillusioned with the craziness and horrible moderation on that site. So it's crunchier than I am, yet is also one of the few places where you will seldom get extremist natural-parenting stuff pushed at you; people started this site to get away from all that. And it's full of experienced breastfeeding mothers. There is a refreshing absence of pretension and bullshit on the site. The Woo-Busters page is a good place to get a second opinion on anything which sounds like woo but you are not quite sure!

NB: Avoid Trolls threads on carseat safety or Thanksgiving.

Mammals Suck... Milk! looks at the science of lactation across the animal kingdom, including human beings. Not a "how to breastfeed" blog, certainly, but fascination stuff and great background information.

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 Months: For 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.

Bullshitometer: Baby led weaning/Gill Rapley

Baby led weaning, a term invented by British health visitor Gill Rapley, may not be "breastfeeding" as such, but it's so popular on breastfeeding-centered boards and blogs that it's worth a little scrutiny. Confusingly for North Americans, BLW is not about weaning from the breast; rather, it refers to a method of solid food introduction which consists (roughly) of forgoing the traditional spoonfeeding of purees, and instead giving the baby large-ish pieces of table food to self-feed... or chuck on the floor if they are so disposed, the idea being that this is about "following the baby's lead" in terms of what and how much solid food they eat. BLWers usually wait at least six months--sometimes later--before starting solids, and BLW is typically characterized by a much slower shift towards solids than the spoonfeeding approach, with babies not infrequently getting little in the way of solids until they approach a year old.


Definitions
Because BLW has become quite fashionable, everyone seems to have started using the term and you will often hear people using it to describe what is more traditionally called "finger foods" ("We're doing some purees with a spoon, and also some BLW"). However, people who take BLW Very Very Seriously--I'm going to refer to them as the BLW purists--scoff at such approaches, saying that you can't do BLW by halves. The whole philosophy of bona fide BLW, you see, is based on the idea that babies should be entirely in charge of the feeding process; once you start doing any spoonfeeding, the whole weaning process becomes... like... not BLW. In this respect, the purists actually go even further than Rapley herself, who admits that a bit of spoonfeeding may be okay if you really have to. Gill Rapley's philosophy of BLW is set out in her book;  however, aficionados tend to say that this weaning method is as old as time itself ("What do you think people did before blenders?") and that by contrast, puree-based spoonfeeding is a new invention, necessitated by the invention of infant formula and pushed on parents by the babyfood industry, which has a vested interest in getting parents to give solids more and earlier than is natural for babies.

Finger foods are not the subject of this Bulshitometer post--everyone does finger foods and all pediatricians recommend them, including my parents' 1970-something Dr Spock book if I remember rightly. What I am scrutinizing is BLW as per the second definition, and the claims that have been made for it by Gill Rapley and her fans--namely, that there is a particular virtue in avoiding pureed/mashed foods and spoonfeeding, and that forgoing these things will lead to children with better eating habits, that parent-led feeding will make children more prone to obesity or pickiness, that children allowed to self-feed everything will gain better motor skills and instinctively avoid things they are allergic to, that pureed foods cause constipation, and that BLW is the "natural" way and represents the biological and historical norm for human babies.


Better eaters
Less obesity! Better eating habits! Children who eat vegetables without complaining! Rapley could hardly have come up with a more appealing laundry list of points with which to entice 21st century parents engaged in that very modern pursuit of worrying about food. Based on her 20-odd years as a health visitor, "Rapley believes that babies allowed to feed themselves tend to become less picky, develop better hand control more quickly and to avoid foods to which they are later found to be intolerant."

I'm sure she does believe all this. Similarly, people in the 17th century apparently believed that bloodletting cured all manner of ills and that fever could be cured by taking live pigeons to bed with you. All together now: "The plural of anecdote is not evidence."

Considering the fervor that BLW inspires in some of its devotees, it's striking how little evidence there is to support its claims--"little" as in basically "none." Rapley's book's claim that BLW will result in less picky eaters rests upon a single experiment conducted before WWII--a trial for which almost no data was ever presented and which can never be replicated for ethical reasons. Rapley also includes a study she conducted among a small group of babies which proved, not very excitingly, that if you present babies with a variety of table foods, by nine months they will be... eating a variety of table foods. So yes, if you want to skip the purees and go slower on solids, it's probably fine. But none of this provides any evidence for Rapley's other claims of less picky eaters or magic allergy avoidance.

The other "evidence" provided by the book consists largely of proud parents saying things like "I'm doing BLW with my nine-month-old and she's eating broccoli! See? BLW totes works!" No. Your child is eating green veggies with gusto because she is a baby. Come back when she's two and we'll talk. Two is generally when the food fussies kick in, probably for evolutionary reasons related to the fact that toddlers in neolithic societies were at real risk of being poisoned by unknown plants found in their environment. The BLW site's toddler forum is full of parents moaning that their two- and three-year-olds have suddenly started rejecting foods they used to eat with relish.

Other parents compare the fact that their BLW-ed younger child is a better eater than their traditionally weaned older child--a comparison which, on the individual level, tells us precisely nothing, given that in any pair of siblings, even those weaned in exactly the same way, one will typically be a better eater than the other simply because genes play a powerful role in our eating preferences.This is Bad Science 101--seriously, I could use exactly the same approach to "prove" the efficacy of homeopathy (or the live pigeon treatment, for that matter).

I mean, I do get that obesity and the dreaded "kiddie food" culture of bland junk foods are worries for parents; but these are problems that have become acute only in the last half-century, so it seems a bit odd to blame them on parent-led feeding of mashed foods, which has gone on for millennia (see below). Cross-culturally too, it's hard to see any patterns; as one poster notes here (with thinly disguised annoyance), French babies get bland mush on a spoon and cereal in their formula bottles, and still seem to end up better eaters than British and American children. So do Japanese kids, for that manner, in spite of their parents Doin It Rong in terms of first foods (spoon-fed gluey rice porridge, since you asked).


Better motor skills
Manipulating finger foods doubtless is indeed a way for babies to practice their fine motor skills, but in Rapley's claims that BLW results in better motor skills, I detect the whiff of a burning straw man; I don't think many people actually do wean babies on nothing but spoonfed mushes. Most parents have always given finger foods in addition to spoonfeeding, and it's hard to see how the benefits of finger food practice get magically erased as soon as you give the kid a bit of mashed potato on a spoon. As for the vague parental claims that their BLWed babies have better motor skills, see above comments about anecdotes vs evidence.


Purees cause constipation
There is no reason why pureed foods should cause constipation any more than non-pureed foods. A quick visit to Ask the Dietitian confirms that pureeing or even blenderizing foods leaves their fiber intact--although anyone who regularly consumes fruit smoothies can testify to their, ahem, bowel loosening effect without the need to go online. Perhaps Rapley is confusing pureeing with juicing, a very different process? Constipation is a common temporary effect of solids-introduction as the baby's gut tries to get used to new foods; if it is less noticeable with BLW, a simpler explanation is that if you are hardcore about the baby only eating what he/she can self-feed, it will probably take a while before they actually eat enough to have any effect on the digestive tract.


Tradition/"naturalness"
BLW is popularly considered to be more "natural" than feeding purees or mashes. Now..... trying to define what is "natural" for human beings is always a bit of a philosophical headache. However, it's not clear on what grounds BLW qualifies.

The whole "What Would Cavemama Do" approach to childrearing gets a bit daft, but for the sake of arguing.... Rapley's book states that prior to the 20th century, most babies didn't start solids till they were "eight or nine months old" (she gives no source for this alleged fact). It's surprisingly hard to find proper sources on solids introduction in pre-industrialized societies; from those which can be found, what kind of picture emerges? Well.... surprisingly, lots of mush, lots of parent-led feeding, and lots of starch, to be honest (see here, here, here and here, for example... if you don't want to wade through the last one, there is a summary here). Feeding babies foods that have been mashed in some way--between two rocks, your fingers or even your own jaws--has a long history, and no, you don't need a spoon or a blender (slummy mummies like me could have told you that already, though).

Do babies in "traditional" societies also self-feed? Probably: the casual nature of such culinary encounters is such that they probably aren't going to make it into an anthropologist's report, but given how grabby older babies are it would be surprising if this didn't happen. In other words, throughout human history, most babies most likely have received a mixture of parent-fed mushy things and larger pieces for self-feeding.... which, funnily enough, is pretty much what most parents in industrialized societies also end up doing.

What I can say is that I could not, in all my researches, come across any "traditional" societies that do solids-introduction the way Gill Rapley sets out (no parent-led feeding, baby only eats what baby self-feeds, blah blah). Not one. To be honest, I'm not even sure how Rapley-esque weaning would really work in a traditional society. For a start, I can't see women in a food-poor environment being cool with a baby throwing good food all over the floor in the name of play and exploration. They don't really do the whole "child-centered" thing in traditional societies.

Curiously, Rapley also mentions pre-chewing in her book, and says that she thinks it is fine; she does not, however, clarify how this differs from spoon-feeding (on which she blames for everything from gagging to pickiness to overeating).


Convenience
Rapley's devotees insist that BLW is the most convenient way of giving solids. I am not sure I agree. I think the most convenient way, for most people, is to do some finger foods and some parent-led feeding, depending on the food, the situation and what seems to suit you and your child best (unless you end up with one of those kids who simply refuses to be spoonfed at all). After all, traditional weaning has always included finger foods; Rapley's innovation is largely to say that pureeing and spoonfeeding should be ruled out. Ruling stuff out rarely makes the whole childrearing thing easier.

For example, giving baby an apple chunk/loaded spoon to nibble at (so you can eat your dinner) is one of the first things you learn in Mum School... it makes sense, especially, in the evening, since both baby and clothes will soon be going in the wash anyway. But when you are in a restaurant, it may not be very convenient (or polite) to basically allow your child to throw food everywhere--make no mistake, self-feeding is messy, and while you don't have to spend time mashing or feeding, you will probably spend about as much time cleaning up, changing clothes and getting food out of the kid's hair. One hears of hardcore BLWers carting splash mats and portable highchairs around with them, leaving honking tips for waiters to make up for the blizzard of mess, or sticking to "child-friendly" restaurants, rather than subject young Sparkleigh to the dreaded sp00nfeeding of d00m. One has to ask, would it not be easier to just sit Junior on your lap and offer them something mushed up on a spoon or finger?

Similarly, if you have to get to the doctor's at 2pm, it makes more sense to quickly and neatly spoon kiddo a bit of food, and then DONE. Rather than hang around waiting while the child thoughtfully pushes avocado chunks around on a food tray, then change clothes and wipe down the floor/bumbo/baby, and then have to stop on the way to nurse again, because the kid didn't actually get more a mouthful of food inside them.

Because that is the other thing about true, purist BLW; if your baby really does only eat what he or she is able to self-feed, most likely he or she will take to solids as a pretty slow pace--in some cases very slow (on crunchy forums one is constantly reading about children who are 12, 15, 18 months old and still almost completely breastfed). This may or may not suit your agenda. I can see it being convenient, maybe, for a SAHM who loves breastfeeding. But if you are working, you will have to pump (and sterilize and set up pumps, and store and defrost) more milk... unless you are happy to give formula as well. And I strongly suspect that nightweaning, and moving away from nursing to sleep and constant comfort feeding are psychologically easier to see through if you are seeing your baby put away a certain consistent amount of solids every day, so that you are not constantly fighting the voice in the back of your head that says "But what if she's still HUNGRY??"

Then there is the conundrum of what to do with foods that beg to be spoonfed (preloading spoons for the baby to self-feed with doesn't always work). As one poster here put it, "If we're eating pasta or noodles or a roast dinner DD eats with her hands. If it's soup or yoghurt or mash I use a spoon. Common sense. A friend went to such great lengths to avoid a spoon it was comedy. Chunks of pear dipped in yoghurt (which got chucked on the floor), toast dipped in porridge, yum! It's just a spoon FFS!" Some BLW purists apparently try to facilitate self-feeding by circumcising bananas with scissors (Freud'd have a field day with that one), lovingly rolling slippery foods in crushed cheerios, or snipping them up with crinkle cutters.  All good fun, no doubt, but it's unclear how any of this is actually less work than just offering said food on a spoon. Anyway, I'm pretty sure cavemama didn't have crinkle-cutters.

Finally, I LOLed at Rapley's suggestion that parents should get round the whole salt issue by simply not using any salt in their own cooking. Are there parents who actually do this... for everything they cook? Remind me never to eat at their houses. A stir-fry, a curry, a pasta sauce simply will not taste as tasty without a certain minimal amount of salt. I like eating tasty food. Sorry.

The nutrition thing
Many babies take to self-feeding early and easily--indeed, these babies often reject spoon-feeding altogether and clearly it makes sense to just let them get on with it. But other babies, particularly those whose motor skills are slower to develop, will not be able to self-feed useful amounts of food until they are much older than six months; if you really do have this strict rule about Baby Must Only Eat What Baby Puts In Own Mouth, it could be a really long time before they are able to actually eat more than minuscule amounts of food (as evidenced by all those non-eating older babies and toddlers on BLW forums). However, as I discuss here, once babies get much past six months they do start to need more nutrients than they can realistically need from breastmilk. The "food before one is just for fun" thing is one aspect of BLW that I just can't agree with. The Maternal and Child Nutrition Journal has expressed similar views, by the way--suggesting that while many babies will do OK with self-feeding alone, some could be put at risk of micronutrient deficiency if their parents are hardcore about not doing any spoon-feeding. I personally feel that offering foods in different ways and being flexible is probably the best approach.


Bullshitometer verdict
I have a confession: I actually really, really like most of the ideas found in BLW. I like the idea of giving children table foods where possible, including spicy and unusual things; I agree that babies can generally start finger foods as early as six months; I particularly like the idea of using BLW as a motivation for improving the food that the family eats as a whole. I just think it's a shame that Rapley had to spoil some sensible ideas with silly claims about purees being constipating and parent-led weaning causing bad eating habits, none of which is backed up by any data.

I think BLW was in some ways a necessary corrective to bossy Gina Ford types lecturing people about introducing the "right" foods in the "right order" and the "right amounts," and baby food manufacturers going on about "stages," causing parents whose babies didn't respond well to this to feel a lot of stress. But it's not much of an improvement if we just exchange that for all the self-conscious agonizing seen among many posters on BLW boards (debating about whether using a mesh feeder is "real" BLW weaning, whether we are "allowed" to hold food up to their mouths or is that helping them too much, blah blah), with parents fretting that if they break any of the "rules" their children will end up obese, terrible eaters or what have you.

I hereby propose the Breastfeeding Without Bullshit Patented Bone Idle Can't Be Bothered Weaning Method, which consists of trying out lots of things (finger foods, cereal, puree, finger feeding, mesh feeder, feeding them with a spoon, handing them loaded spoons, giving them pieces to self-feed, holding up bits for them to take a bit out, whatever) and doing what you and your child enjoy most and find the least hassle. Because at the end of the day it isn't going to make any long-term difference anyway.

Finally: if any mother, online or in real life, spends her time banging on to other mothers about how her proposed weaning "system" (BLW, gourmet-meals-in-an-icecube-tray or whatever) is inherently superior and guaranteed to produce a marvelous eater, the laws of karma dictate that her baby will grow into one of those toddlers who refuses to eat anything except luminous orange macaroni cheese. You Have Been Warned.

Further reading
Weaning Made Easy by Rana Conway. I discovered this book after writing this post; Conway discusses some of the ideas talked about here, with a good run-down of some of the advantages and potential issues with puree-only or "pure" baby led weaning approach, and recommends a mixed and flexible approach to feeding as being the best suited to the majority of parents and babies.