Bedsharing and breastfeeding in the media - an analysis

This morning on Facebook the first thing I read was on one of the breastfeeding support pages I contribute to, from a mum who'd heard reports of the latest bedsharing research, published in the BMJ Open online, on the radio, worried about what she'd heard. I read the paper itself and the various articles about it, as well as a host of responses to it. A thread about the research on Mumsnet had over 300 posts last time I looked, and many of the articles have attracted numerous comments.

There's no question that reports of research in the mainstream media can have a massive impact on audiences. How could they not, with headlines and subheads like these: 'Bed-sharing newborns five times more likely to die suddenly than those who sleep in a cot, study shows' (Guardian), "Sudden infant death risk 'is five times higher if the baby sleeps in its parents' bed'" (Daily Mail), 'Parents should never allow babies to sleep in bed alongside them due to the risk of cot death, according to research which has prompted the Government to order an “urgent” review into official guidance.' (Telegraph), 'Bed-sharing "raises cot death risk fivefold" (BBC). The Mumsnet thread is full of people questioning their own behaviour in the light of the new research. The Facebook mum is not alone; all over the web there have been concerned parents, who've heard snippets on the radio or seen TV news items, wondering whether this new research can be believed.

There's a marked tendency in us to feel as though any 'new' report somehow trumps any previous research and this is certainly apparent in many of the comments on media reports - people believe that scientific research is a progression, and that each new finding is more reliable than the last, because it must build on what has gone before. That couldn't be further from the truth. The reality of scientific research is that it is much more complex a web than we might think. The research that is done depends on the interests of researchers, the availability of research funding grants, the whims of senior academics with preferred pet topics, the commercial aspirations of companies with cash, the declared aims of charitable organisations and many more variables. There are endless dead-ends, blind alleys and studies that contradict one another. And once the research is done there's the issue of making something of it, getting it noticed. Academic careers, the standing of institutions and future funding applications depend upon research reputations. Even when, as in this case, there is no suggestion of a conflict of interest among the authors, or of the funding for the study having come from a commercial interested party, there is still a need to publicise research, which is why editors and interested parties got a press release about this paper, which highlighted the most striking aspects of the research (as identified by the authors, or the press office?).

Another important point to make is that whatever the scientific ins and outs of the data presented in the paper, of which more below, researchers and academics are nonetheless able to draw their own subjective conclusions and have their own opinions about their research, based on their own experiences, culture and background, and this comes across strongly in the discussion/conclusions in the full paper. My feeling is that the paper's authors, while they may not have set out to provoke a media storm, nonetheless wanted to make a 'statement', and a recommendation that we reconsider the current UK guidelines is certainly that. (Several people I've talked to or seen comments from have thought, based on the reporting, that the guidelines are being or have already been changed to reflect this research - this is not true, although the BBC reports that the government have asked NICE to review their guidance in light of the findings.) I don't think the paper's authors have considered how their findings will be viewed by parents, or that they have much understanding or experience of our culture of parenting and infant feeding in the UK, although they do make some efforts to link their research to the UNICEF report on the cost savings associated with breastfeeding that I blogged about here.

Matters don't improve when the research is published. In the translation from the press release to finished articles, TV snippets, reports and local radio phone-ins much that is important is lost, and the discussions become less about what the research really shows, and more about the broad brushstrokes of an uninformed debate (much like the breastfeeding/bottle-feeding articles I regularly comment on).

Making sense of the crowded landscape of information requires time, an in-depth understanding of the subject in question and critical thinking, and the reality is that many of us rely on others to do this for us. (I am a non-fiction editor well used to reading and sifting large amounts of information, with a specialist interest in parenting and breastfeeding, and I still struggle at times to get to the heart of the matter.) Which is why I was delighted, having read the paper and some of the articles in the press, to find that UNICEF, Professor Helen Ball of ISIS online, and The Praeclarus Press, among others, had issued detailed statements that dig deeper into the research and expose some of its limitations. Professor Helen Ball also contributed to Radio 4s PM programme, where she discussed the findings with one of the paper's authors, Professor Bob Carpenter.

I've been interested in the whole media maelstrom from a breastfeeding perspective, because in peer support I'm often asked about sleep in the context of breastfeeding. Since studies suggest that co-sleeping and breastfeeding have an interdependent relationship, and we know that night feeds are important for maintaining mums' supply and on Radio 4 Professor Ball cited her own research that showed breastfeeding rates were twice as high among mothers who bedshared with their infants younger than three months, coupled with the fact that not breastfeeding increases the risk of SIDS, I've always believed, along with many others who work to support families, that black and white advice about bedsharing, as advocated by the authors of the paper, is inappropriate for breastfeeding mothers. I direct parents to UNICEFs leaflet Caring for Your Baby at Night and to Isis online for more information to help them make informed decisions. The NCT's page about bedsharing (cited by the authors of the BMJ study as evidence of 'a pro-bedsharing lobby', which I thought might be a clue as to their personal hang-ups on the subject) says that up to 50 per cent of parents admit to bedsharing on occasion. On the Mumsnet thread I mentioned above there were many contributions from mothers of infants who resorted to bedsharing as a practical solution to meet the needs of the whole family, and as the mother of three babies who breastfed frequently at night for many months I have been there myself.

So what of the relative risks for breastfeeding mothers who choose to co-sleep? Some interesting numbers can be extracted from the full paper. In the study, of 1,444 babies who died, 540 were breastfed (any breastfeeding - in this study even babies fed artificial milk at night in an attempt to get them to sleep longer would be in this group) and 940 were bottlefed. Of 1,405 babies who died (the exact numbers change slightly because of missing data), 1,091 had one or two parents that smoked. Of 1,422 babies who died, 607 had been put to sleep on their front (another criticism of the study is that it uses old data, including many babies who slept on their front). Overall, the rate of SIDS in the UK is approximately 3 in 10,000. Among breastfed babies, of parents who don't smoke and whose mothers have not had alcohol or illegal drugs, that is reduced to 1 in 10,000 for crib sleepers in parents' room and is 2 in 10,000 for co-sleepers. Breastfed babies thus have a lower than average risk of SIDS. In 2010 there were 254 unexplained deaths in England and Wales and 723,165 live births. (ONS). Given the above, it is easy to see why Professor Ball commented: '...both sleep locations for breastfed infants of non-smoking parents in the absence of alcohol experience very few SIDS deaths. It is curious, therefore, that the authors issued a press release to call attention only to this small difference in predicted SIDS rates for breastfed babies of non-smoking parents who bed-share compared to room-sharing – while ignoring the hugely inflated risks associated with hazardous bed-sharing environments. It appears as though the authors choose to target breastfeeding mothers in this way as they are a sub-group with strong opinions about the benefits of bed-sharing, even though the infants of these mothers contribute negligibly to UK SIDS rates.' Without wanting to overstate the case it seems that even in the conclusions of research papers there is an undercurrent that undermines breastfeeding and parenting behaviour that promotes it. Fascinatingly this chimes with something else I read today, the Alpha Parent's look at how societies can be 'gendered' - some of our problems with this research and the reporting of it may be able to be explained by 'masculine' traits in our culture.

Of milk and memories: how my breastfeeding story ends

I knew this time would come eventually. I can't remember when I last fed my baby. It might have been on Friday morning, or last Tuesday. It would have been first thing in the morning, and I would have gone into her room, having heard her calling brightly 'Mummy-Daddy! Mummy-Daddy!' from her cot. I would have gathered her up, warm and sleepy in her pyjamas, still clutching her comfort blanket, and carried her through to my bedroom. She might have said, 'My want my milks', and I would have propped up my pillow, and sat back in bed, and she would have dropped her blanket and draped herself across my lap. She might have said 'That one first, Mummy, then that one [pointing].' She might have paused mid-feed to look up at me and say 'Yummy, yummy, in my tummy rummy!' with a wide grin. Then she might have said, 'All done now, mummy. Can my have some weetabix?' And wriggled down from the bed, and run to the door, turning back to say, impatiently, 'Come ON, mummy!'

My daughter Ada, my third and very likely last baby, is thirty months old and just about weaned (I think). The morning feeds have been becoming less frequent as the months pass, and they've been short (though very sweet). And this week it feels as though the end is nigh; this morning she said 'Milks?' when I got her up and I said 'Ok', but she shook her head, and squirmed to get down, and spotted her brother through the banisters, and went off to play instead.

Ada's first feed, November 2010

I find myself with mixed emotions: pride when I see how my daughter is growing up and becoming her own person, more separate from me; wistfulness when I recall her babyhood and realise how quickly it has passed; and a gentle sadness that my own experience of breastfeeding, which has brought me so much, in all aspects of my life, is coming to an end. When I wrote up my breastfeeding experiences for my collection of positive breastfeeding stories, Breastfeeding: stories to inspire and inform (published when Ada was eighteen months old), I concluded: 'It seems strange to think that I might be approaching the end of breastfeeding when it has been so central to our family life over the last few years. There's no doubt I will look back on it as one of my most precious experiences of motherhood.' I feel very lucky to have had almost another year of breastfeeding since I wrote those words, and that Ada has had such a gradual, gentle weaning. It will be fascinating to see whether, as she gets older, she will remember breastfeeding. A few weeks ago, my older daughter, aged six, came into the bedroom in the early morning while I was feeding Ada. 'Mummy!' she exclaimed in shock as she looked at us, 'I'd completely forgotten that you breastfeed Ada! How could I have forgotten that?' We all laughed, but I was struck by how, when we don't have constant reminders, even things that were once a completely integral part of the family 'furniture' can slip into memory.

Ada's favourite book at the moment is The Paper Dolls by Julia Donaldson, illustrated by Rebecca Cobb. We currently read it every single night. It's a beautiful book and the part that brings a lump to my throat, even on the umpteenth reading, is the part where, after the paper dolls have been snipped into pieces by a little boy with scissors, they continue to sing their song:..

'And the pieces all joined together,
and the paper dolls flew... 
...into the little girl's memory
where they found white mice and fireworks,
and a starfish soap,
and a kind granny,
and the butterfly hairslide,
and more and more lovely things
each year.'

I'm hoping that buried in the corners of my children's minds, along with all the other lovely things, there are some memories of breastfeeding that will be there all their lives. As for me, it's not so much a corner of my mind as an overflowing treasure chest.

And in some ways it's definitely not the end of the story: with publishing, writing, peer supporting and campaigning, I think I'll be busy with breastfeeding for a long while yet.

Baby milk shortages - formula manufacturers, the politics of infant feeding, breastfeeding

The news that Danone, which makes Aptamil and Cow & Gate formula milks, has imposed sales restrictions on parents in the UK has been all over the media this week. Shoppers are now limited to purchasing two packs of powdered infant formula per day. Supposedly this is to prevent bulk buying and informal export of formula to China - at least, that is the explanation that Danone have given on the brands' respective websites, in a letter from managing director John Sykes.

However, there can be no denying that the story has generated massive publicity for the brands involved. For example, in this segment on the BBC website the mother is filmed using Aptamil formula, and this article from the Daily Mail carries a prominent shot of both Danone brands on supermarket shelves, complete with shelf-edge explanation of the buying restrictions.

What better way to add cachet to the Danone brand than to let its UK market know how highly prized its products are in China? The fact that millions of Chinese consumers (in a country beset by formula milk scandals, where formula advertising is aggressive and unregulated, and breastfeeding rates are on the way down) trust the brand and will pay inflated sums for it is surely something worth (from Danone's perspective) instilling in the minds of UK consumers. In addition, products in short supply have 'rarity value' - it's like must-have toys at Christmas, or petrol, or limited-edition designer handbags - that 'value', in the minds of consumers, is great news for retailers and manufacturers. Crucially, 'news' stories are not seen as 'advertising', although in practice, as anyone involved in the media knows, they fulfil the same function - there is truth in the old maxim 'all publicity is good publicity'.

The knock-on effects of all this on our culture of infant feeding on the UK are more subtle. A slew of articles about formula feeding normalises it further - a shortage that affects millions of parents across the UK gives the message that 'everyone' is using formula as opposed to breastfeeding. Images of specific brands accompanying the articles make it more likely that parents, faced with a shelf full of products and with little access to accurate, unbiased information about infant formula, will reach for the product they recognise. As shown by the Daily Mail article mentioned above, a focus in the media on formula feeding can bring with it a wave of anti-breastfeeding feeling. The author of the article claims that "the breastapo are out in force, berating the formula feeding pariahs who feed our babies this manufactured 'poison'." I don't believe this or see any evidence of it; all this article shows is that, given a convenient peg to hang it on (news of a formula shortage), the same tired elements of a FF v BF argument that helps no one and only serves to divide women and line the pockets of the formula manufacturers, can be trotted out yet again.

(A separate, but I suspect related, article in the Mirror about vitamin D deficiency mentioned Cow & Gate Growing Up Milk by name, causing me to wonder whether the article had been 'inspired' by a Danone press release... the formula companies are very keen for parents to know that children consuming more than 450ml of first stage or follow-on formula per day do not need vitamin D supplements.)

Consider the context of all this. We already know from the Infant Feeding Survey 2010 that in the UK many parents are unaware of the differences between infant (first stage) formula and follow-on formula (suitable from six months) - the latter being an unnecessary product specifically designed to circumvent the restrictions on marketing infant formula imposed by the WHO code on the marketing of breastmilk substitutes, which is not even fully implemented in the UK. We also know that the formula companies will battle incessantly for market share with a huge array of marketing tactics (carelines, baby clubs, marketing to health professionals, roadshows... the list goes on). All this is funded by marketing budgets, paid for by formula consumers. Increased market share means increased profits. In this sort of climate a shortage of product makes perfect sense as an aggressive marketing ploy.

In case you think I'm overstating the case here, I'd like to highlight the work of Baby Milk Action, which has recently published a new report Look What They're Doing in the UK!. In the press release that accompanies the report Mike Brady, Campaigns and Networking Coordinator, says:

"Given the massive production capacity that Danone has in nearby Ireland there is something about this story that does not ring true: it is surely more likely Danone that is prioritising other markets than people exporting supermarket stocks. Danone is locked in fierce competition with Nestlé, particularly in Asia. Danone is gaining massive publicity for its products on the back of this shortage scare, but parents who use formula can heed Department of Health advice and switch to other brands. Claims made that one particular brand is better than another do not stand up to scrutiny. As our Look What They're Doing in the UK report demonstrates, companies are endlessly imaginative in how they push their products."

In the BBC report on the issue, Nestle, the second largest formula manufacturer in the UK market, said that it had not seen an increase in demand due to unofficial exports, and that there was no shortage of its products. (Nevertheless, some supermarkets are limiting sales of Nestle brands too.)

It seems to me that what's needed, as usual in reference to infant feeding, is wider access to clear, unbiased information that doesn't come from the formula manufacturers themselves, and this article in the Telegraph made the same point. UNICEFs Babyfriendly initiative publishes A guide to infant formula for parents who are bottle-feeding, which is a great place to start. Another good source (aimed at health professionals, but anyone can download the report) is Infant Milks in the UK.

It's also not unreasonable, as part of the ongoing discussion, to talk about breastfeeding. It's not shaming of those who use formula to point out that, on a population level, increased breastfeeding would mean both improved public health and less reliance on commercially-driven formula milk manufacturers. The 'shortage' story could be seen as demonstrating perfectly some of the most amazing qualities of breastfeeding: most mothers can produce hundreds of litres of breastmilk (incomparable to formula) for a zero carbon footprint - no food miles, no energy costs of manufacture or reconstitution, no supply-chain issues. 

I've been considering the implications of all this for breastfeeding support. I had a conversation with a formula-feeding mother while I was planning this article: she asked me what, as a breastfeeding peer supporter, I would do if someone asked me about formula feeding. I thought hard about what I could do in this situation, aside from talking to the mother about her reasons for switching to see if there was anything I could help her with before she stopped breastfeeding, and discussing the option of mixed feeding (on the grounds that any breastfeeding is better than none). I realised there's a lot of information I can give, although I would be upfront about my lack of personal experience of bottle or formula feeding. I do, however, know about the most recent guidelines for making up bottles and the reasons for them, and am happy to talk to mothers about them. I have also read the guides above and feel that I could tell a mother that since the composition of formula in the UK is regulated, and claims about differences between brands don't hold water, her decision can be based on price and what her child seems to prefer, and she needn't be restricted to one brand. I'd hope, in doing this, to leave the mother feeling better-informed about her options, and not let-down by a sudden lack of support when her circumstances change. I'd love to hear what other breastfeeding supporters think about this.