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.

Cow's milk and the Law of the Lowest Common Denominator

Happy first birthday Baby Seal! First birthday, first ever chocolate cake (with homemade ganache). I appreciated your cake-eating enthusiasm.

As we all know, birthdays are magic and the first birthday is the most magic of all, because at the moment the clock strikes midnight on the day baby turns 12 calendar months old, something strange happens. In the upside-down carnival of the first birthday, all sorts of things which were previously "bad" become "good" and vice versa. Things that were fine to do before suddenly become A Problem. And everything baby does must be interpreted in a different light. Twelve months is officially the age at which solid food stops being "for fun," and becomes an essential nutrition source. Up until that fated birthday, baby's needs were the same as baby's wants; now baby has lost her innocence and becomes capable of manipulation. Pacifiers, which were fine yesterday, are now a Bad Thing. Bottles too (time to drink from a cup). If you are like a lot of westerners, one year old is the age at which breastmilk suddenly loses all nutritional benefit (exactly how is never explained) and the act of breastfeeding becomes something unseemly and not far from Child As Sex Toy. If you are a certain type of lactivist, 12 months is the point at which you will grudgingly tolerate another woman weaning without actually making snarky remarks (possibly).

And then there's cow's milk. There is a lot of confusion on parenting boards about cow's milk, formula and breastmilk...the when and the how and the why (and that's even before you bring in bottles vs. cups and other factors). The American Association of Pediatrics states that "Whole cow's milk is considered an inappropriate option for infants, which FDA defines as babies not more than 12 months old. According to the AAP, cow's milk contains very little iron and the small amount present is poorly absorbed into the body. Starting an infant on cow's milk too early can result in iron-deficiency anemia, particularly if the baby is not given an iron supplement or foods with iron." Formula or breastmilk should be the only milk given to the baby. Meanwhile, this National Health Service (NHS) resource advises us that "Babies shouldn’t drink cow’s milk before 12 months," but adds that "you can add cow’s milk to food before 12 months" and also recommends "full fat, low sugar dairy products like cheese, yoghurt, fromage frais, or custard."

Given this, us ordinary mothers on the discussion boards could be forgiven for being a bit confused. "My health visitor said it was fine to give DS cottage cheese or yogurt. I'm confused; they say no cow's milk before 12 months... why are yogurt and cheese so different?" Someone else will then chime in to speculate that it might be because yogurt and cheese are "cultured" foods which alters the proteins and sugars contained therein. To which someone else will point out that they have been mixing small amounts of cow's milk with their baby's cereal for the last month--with the health visitor's blessing. Surely if cow's milk has these evil iron-destroying powers, they are not going to magically disappear just because you've added a bit of Ready Brek, no?

I think the key to resolving this is to understand that this is an example of a common phenomenon in the world of official childrearing advice: The Law of the Lowest Common Denominator. Basically, what are the AAP and NHS worried about? Well, not about the perfectly healthy children of mothers who are conscientious enough to be on a childrearing-related discussion board in the first place. They worry about the children of parents who are young, poor and a bit clueless. Who might be tempted one day, when looking into the refrigerator, to think "Hey, we've got milk here. In a carton, all ready to drink. I know, why don't we just fill Suzy's bottles up with this stuff instead of fiddling about with that expensive formula bollocks?" Bad idea. Cow's milk and goat's milk, unlike formula/breastmilk, are not a complete diet, and babies fed in this way are at real risk of dehydration, kidney damage and anemia. Even older babies risk iron deficiency if cow's milk starts making up a substantial proportion of their diet. On the other hand.... a bit of cow's milk, for an older baby? No problem. It's essentially no different to any other complementary food. Can you give an older baby apple as a complementary food? Sure. Should you start giving them cupfuls of pureed apple all day long instead of formula/breastmilk? Of course not.

Trouble is, official organizations know perfectly well that if they start wheezing out long-winded explanations about core foods versus complementary foods and iron and how it's okay to give this much milk but not more than this... unless you are giving other dairy products as well, in which case you should probably give less milk... and it depends on how quickly they take to solids, and.... well, people's eyes are going to start glazing over (especially the kind of parents who are most likely to ignore sensible pediatric advice in the first place). On the other hand, if you make a crude blanket rule of "No cow's milk as a drink before 12 months. A bit with cereal is fine, and a bit of yogurt and cheese is fine," then people are more likely to remember the advice and adhere to it.

The same rule governs a lot of other childrearing advice. I remember (pre-baby) pursing my lips disapprovingly when I heard my sister had acquired a baby walker--didn't she know all the official guidelines said they were Bad For Babies? But (as my father pointed out to me) the reason baby walkers have a bad press is because some idiots leave babies in them for hours or use them as a excuse for not supervising, resulting in serious accidents. Used for short periods under supervision like other toys, there is nothing terrible about them. I think a lot of arguing on message boards and within mothers' groups could probably be avoided if the Law of the Lowest Common Denominator was more widely understood.

Anyway, I have been breaking the official recommendations by leaving Baby Seal with a cup of cow's milk plus water and solids whenever I go out in the evening (about once a week) since the age of 10 months. I hate pumping and have the smallest freezer known to man; while I have nothing against formula, there was a recall on Japanese formula at the end of last year due to the radiation scare, and frankly it's put me off a bit. With her only eight weeks to go until her first birthday, it hardly seemed worth dragging British formula all the way home on the plane. Also, I have heard too many stories of babies who were kept away from cow's milk completely during the first year, and then refused it vehemently when their parents tried to introduce it later on. So cow's milk it is. Now all I need to do is to get her drinking it from an open cup without throwing it everywhere. We can but hope.

Going with the flow...

It's now March, and this month Baby Seal will turn one.

Before Baby Seal was born, I said to anyone who asked that I would "give breastfeeding a try, but if it didn't work out, I would feed formula with pride and joy." After she was born, and I astonished myself with being about to actually, like, produce milk from my own body with next to no problems, I decided to breastfeed for "at least six months... maybe nine." Nine months came and went, and I realized with a jolt that I only had three months or so left. Then I realized with another jolt that I didn't actually "have" to wean her at 12 months. I could keep right on going, just as long as I wanted to.

It was a strange moment. It wasn't that I had ever thought of nursing past 12 months as being improper or icky (I've been in too many parts of the world where women will flip an entire tit out to feed a toddler to be under such delusions). It's just that I never, ever thought of "extended nursing" (even now, it seems so odd to see those words applied to myself!) as something that people like me did. Extended nursing was for mothers who gave birth in paddling pools and kept their babies in slings on a permanent basis (except, of course, when in the Family Bed). Or for women in poor countries who had to nurse for years on end. Not for normal developed-world mothers like me, who do paid employment for The Man and who told their obstetricians that during labor they wanted to be as high as a ****ing kite throughout.

For this change in attitude, I have my beloved knitting website, Ravelry (aka "Facebook for knitters") to thank in part. It's crunchy-ish, but not insanely crunchy, and above all does seem to have a lot of "mothers who think"(well, we are knitters/crocheters, after all). And there are lots of women who nurse past 12 months over there. Call it "peer orientation" or whatever you will, but just being around mothers who nurse for longer really does make it seem less of a freakish thing to do.

The flip side of websites and forums that supported extended nursing is that in general, they can't limit themselves to supporting extended nursing; rather, they tend to foster an atmosphere that pushes it on every woman. Ravelry, thank God, is largely free from overt pressure in this respect... unlike, say, Kellymom or Mothering, where a mother asking for tips on how to get her 12-month-old to accept cow's milk so that she can wean her will get responses ranging from outright criticism to "Could you explain why you are weaning her right now?" In that polite tone of voice that tells you so much more than the words themselves.

There was recently a post on one of the Ravelry groups where the posters were discussing the scientific case for nursing past 12 months. All the usual sources were cited in favor--Kellymom, the World Health Organization, that bloody Gulick study. I kept quiet, as I suspected that my own opinion might not be too popular--my opinion being that in developed countries, the benefits of extended nursing are likely to be extremely small for the child (ironically, there is probably better scientific evidence for extended breastfeeding's benefits for the mother, in the form of a slightly lowered risk of certain cancers).

As for the fact that the WHO recommends breastfeeding to two years or more, I am afraid I really could not care less. The WHO is the World Health Organization, and as such it (reasonably enough) tailors its advice primarily to those most in need of it: poor parts of the world with high infant and child mortality rates. If you are living in a community with no clean water, no pasteurized animal milks, not a lot of nutritious food for toddlers and no birth control for mum, then breastfeeding for years genuinely does raise children's survival rates. If you are living in the developed world, breastfeeding for years is more on the level of taking your child to Mommy and Me classes; it's harmless and a pleasant thing to do if that's your thing. It's not remotely necessary for producing a surviving, thriving child.

However, I am going to shut up now, since Good Enough Mum has discussed all this far more eloquently than I could ever do.

While I'm glad whenever I see the You Must Wean At 12 Months, Because Nursing After Then Suddenly Becomes Icky attitude being questioned, I'm not sure how much of an improvement it is if this just gets replaced with You Must Breastfeed Until Two Otherwise Your Child Is Being Deprived (especially when the claims as to why are so scientifically dodgy). Just a modest proposal, but how about a different idea; the idea of just stopping when you damn well want to... for whatever reason? No plans, no dates or deadlines (in either direction), no pressure. Just you and your child and whatever feels "right" for both of you. The more I think about this idea, the more I like it. Just stepping into the water and letting the current take you, and seeing where you end up. Going with the flow.

So why am I going to keep going for a while? Well, mostly because we both enjoy it and I see no reason to stop. Plus--can I be honest?--it's a convenient lifestyle tool for me, because nursing time is increasingly my internet time! The to-wean-or-not-to-wean question has come up recently in my due date club, and all I can say is that there seems to be a very strong correlation between babies' distractability and mothers' weaning intentions: those of us who were planning to keep going were all saying things like "It's our relaxation time, he blisses out at the breast while I catch up on Facebook," while those who were stopping or planning to stop shared stories about how their babies were so distractible that nursing has become a fight and a bore, and they were taking this is a signal that He's Just Not That Into You any more. An example of "seeing where the current takes you," and a very good one.

By the way, this is another reason why I'm so wary of the increasing pressure found in some quarters to breastfeed until two as a maternal duty. Extended nursers may enthuse loudly about how nursing an older baby or toddler makes parenting a toddler more convenient, but it would be truer perhaps to say "No, nursing your particular child makes life more convenient for you." Increasing pressure on all mothers to breastfeed for two years no matter what will inevitably mean that many women will feel obliged to keep struggling away with nursing even when their particular circumstances or child means that this is not convenient or a tool that makes parenting easier; for example, even if their child is so distractible that the only way to nurse is to shut yourself and baby away in a darkened room, or even if they get pregnant again and are in pain and resenting their child. As if that's not bad enough, there seems to be more and more cases of advice along the lines of "If you [give bottles regularly/spoonfeed solids/nightwean/don't allow access to the breast at all times] your baby is likely to self-wean early" (which then means you are breaking those all-important finger-wagging WHO guidelines). "Nurse to two years no matter what" thus easily becomes a tool for frightening or guilting mothers into practicing certain mothering styles which they may or may not be comfortable with. Not good.

That said, since I am fortunate enough to have a baby who is prepared to ignore my flickering PC screen during milky time, and since we both still enjoy the closeness of nursing, I am going to "go with the flow" and take full advantage of this, and nurse until I feel like stopping.

I even had nursing to thank for getting me through a hellish day last week when my childcare provider cancelled on me on a day when I had several deadlines to meet--somehow the day's work got done, though a mixture of making the most of naptimes and letting Baby Seal hang out at the milk bar as much as possible while I typed with one hand. Oh, and Peppa Pig on DVD, if I'm honest. And letting her pull things out of cupboards and strew them all over the room and destroy the baby gate, as demonstrated above. Such is the life of a freelance worker with a small child. Bring on Year 12-24 Months--I'm ready!