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To: ADC Fetal and Neonatal Edition Letters and ADC Education and Practice Letters

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Original articles: C A Walshaw, J M Owens, A J Scally, and M J Walshaw Does breastfeeding method influence infant weight gain? Arch Dis Child 2008; 93: 292-296 [Abstract] [Full text] [PDF]

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method of breast feeding

dr sudarshan kumari   (23 February 2007)

'Rigid' vs 'baby-led' - no contest

Michael W Woolridge, Jenny Ingram (University of Bristol)   (21 March 2007)

Breastfeeding method and infant weight gain: look at the evidence.

Carol A Walshaw, Jenny Owens and Martin Walshaw   (19 April 2007)

method of breast feeding 23 February 2007
dr sudarshan kumari, neonatologist sunderlal jain hospital, ashok vihar ,delhi ,India Send letter to journal: Re: method of breast feeding sudrshan{at}hotmail.com dr sudarshan kumari	Dear Editor, The authors of the article did not find any differnce in weight gain of infants according to type of breast feeding advice. How ever, i feel rather than the method used to breast feed , it is important to see the attachment to breast is adequate for breast feeding to succeed. Having worked with neonates for more than 30 years, i am confident that if a health professional at first contact with mom-baby dyad spends 5 minutes with mother about how to offer breast , boost her confidence about ability to breast feed , discourage early supplementary feeds, success at exclusive breast feeding is enhanced.If a baby sucks at breast longer, many a times it is a pleasure trip and bonding. It is a pain to find a young mother who decides for a place for delivery, the obstetrician and at time the time too, but is ignorant about what and how she will feed the child, unaware if the nipple is ok to feed , the urban educated ignorant mom. I have noted this for even doctors and nurses.Advise about breast feeding at birth saves a lifetime misery for baby and parents,position of mother and child during feeding is irrelevant. I would like to cite an example , learnt during my residency.There were two consultants, one male (Late Dr PN Taneja ) who beleived tha babies should be fed ,mom sitting in bed, book picture of ideal feeding.The other consultant was a female,Dr SHANTI GHOSH ,who beleived let mother feed the baby ,the way she prefers, lying down or sitting. As a resident whom to follow?. I followed a middle path. the day male ocnsultant was on rounds all the poastnatal ward mothers were made to sit up in bed and feed the child, after professors round they were free to feed in position they felt at ease. The next day on Dr ghosh,s round mothers were advised to breast feed whichever way was convenient to them, the patients were the same for both consultant's round. Beleive it most mothers were discharged on exclusive breast feeding. Also weight gain on exclusive breast feeding includes mothers confidence, her diet,and willing ness to breast feed, and family support, which are difficult to control
'Rigid' vs 'baby-led' - no contest 21 March 2007
Michael W Woolridge, senior lecturer University of Leeds, Jenny Ingram (University of Bristol) Send letter to journal: Re: 'Rigid' vs 'baby-led' - no contest m.w.woolridge{at}leeds.ac.uk Michael W Woolridge, et al.	Dear Editor, When an entrenched piece of evidence-based practice is challenged there is a responsibility to mount a serious research protocol to scrutinise accepted practice. This study is weaker than that on which the previous evidence was based, and is very weak by most methodological standards. The study design is inadequate to provide an effective evaluation of the experimental hypothesis, which causes us ethical concerns. The study comprised a ‘before-after’ study design, conducted over four and a quarter years. During the before period, lasting just over two years, women were encouraged to practice ‘baby-led’ feeding and records of 32 ‘exclusively breastfeeding’ women were analysed retrospectively. In the subsequent two-year period, 31 women studied prospectively were instructed to offer both breasts for 10 minutes at 3-hourly intervals during the daytime. Data on infant weights were extracted from records. Feeding patterns for both groups were collected by retrospective questionnaires; these were sent out between 4 months to 2.5 years after birth, with data collection being some 14 weeks later on average for the no intervention group. Mothers were asked to recall information on 11 distinct aspects of feeding, and to discriminate this information between the first and second breast, if & when offered; the authors produced mean values for feed length using this remembered information. This design is methodologically weak for evaluating a change in practice. The switch from retrospective to prospective data collection, concurrent with the change in practice, weakens this further. The small study size (63 women), and the long period of time over which ‘recruitment’ took place, maximises the probability that secular changes will have occurred alongside the study intervention. The intervention was delivered by one health visitor, with the support of a GP; community midwives were not involved. During the course of the study there were national changes in practice/policy (UNICEF-UK Baby Friendly Hospital Initiative) and the advice given in this study will have been contrary to the local hospital and community-based policy (Airedale Infant Feeding Policy implemented 1998). Hospital and community midwives will therefore have been assisting women to implement ‘baby-led’ feeding as a component of ‘Baby-Friendly’ care which will have been discordant with the study advice on scheduled feeding, so undermining the message given to women. Blinding of the researcher was not possible, creating the potential for bias both in implementing the intervention and with collection and interpretation of the data. No information is reported on any feeding- related problems: whether mothers experienced sore nipples, engorgement or mastitis; whether the babies were unsettled, cried more than expected; suffered from ‘colic’ or disturbed bowel movements (central to the clinical hypothesis challenged by these authors – Woolridge & Fisher, 1988). These are relevant and were recorded in the two randomised studies of alternative feeding patterns (Righard et al, 1993; Evans et al, 1995). The evidence needed to overturn current evidence-based practice has not been provided by this study. Such evidence should only come from large -scale, well-planned and conducted research employing an adequately sized sample of women. The essential comparison in this study is between a supervised group, followed prospectively, and an unsupervised group, studied retrospectively. The reported differences may equally well be attributable to enhanced attention from the researcher/health visitor, and not necessarily to the ‘intervention’ she was delivering. All health professionals should continue to encourage flexible feeding patterns that best suit each mother to her individual baby’s personal needs. We urge healthcare workers to enable women to be confident in implementing flexible feeding patterns with their baby, because, by this means, they will retain the necessary flexibility to adapt their milk output to their baby’s growing/changing needs. References: 1) Evans K, Evans R, & Simmer K. Effect of the method of feeding on breast engorgement, mastitis and infantile colic. Acta Paediatrica, 1995; 84: 849-52. 2) Righard L, Flodmark C-E, Lothe L, & Jakobsson I. Breastfeeding patterns: comparing the effects of infant behaviour and maternal satisfaction of using one or two breasts. Birth, 1993; 20: 182-5. 3) Woolridge MW & Fisher C. Colic, “overfeeding”, and symptoms of lactose malabsorption in the breast-fed baby: a possible artifact of feed management. The Lancet, 1988; ii:382-384.
Breastfeeding method and infant weight gain: look at the evidence. 19 April 2007
Carol A Walshaw, GP Bradford and Airedale Teaching Primary Care Trust, Jenny Owens and Martin Walshaw Send letter to journal: Re: Breastfeeding method and infant weight gain: look at the evidence. anne.walshaw{at}bradford.nhs.uk Carol A Walshaw, et al.	Dear Editor, We are delighted that our paper “Does breastfeeding method influence infant weight gain” has stimulated Woolridge and Ingram to look again at current breastfeeding practice,1 and now take the opportunity to reply to their letter.2 They describe the “baby-led” breastfeeding method as “entrenched evidence-based practice”: “entrenched” it may be, but we find the use of the term “evidence-based” surprising since this was not the conclusion reached in “Enabling Women to Breastfeed” co-authored by Woolridge himself.3 This was a structured literature review commissioned by the Department of Health to identify research studies assessing interventions which enabled or interfered with the continuation of breastfeeding. It concluded that there wasn’t sufficient evidence on which to base breastfeeding advice. Indeed, we quote “the most striking finding is the paucity of good, well-designed research to inform an area of health care which has profound short and long term effects on such large numbers of people.”3 Based on this, Woolridge and Ingram’s criticism that “[our] study is weaker than that on which the previous evidence was based” is clearly incorrect. Despite this, in 1988 breastfeeding advice was changed to the new untried and untested “baby-led” advice, based on a single case report of infant colic, and an associated hypothesis.4 Like Woolridge and Ingram, we too have ethical concerns when practice is changed without a firm evidence base. Despite these ethical issues, the RCM’s book “Successful Breastfeeding” containing the new “baby-led” advice was sent free of charge to all midwives and this policy is now, as Woolridge states, “entrenched”. We believe the time to revisit it is long overdue. As regards other criticisms of our study, we encourage Woolridge and Ingram to read our manuscript more carefully. Both groups of mothers were supervised to the same extent, all as part of normal working practice. Hospital and community midwives played no part in the supervision of these mothers and babies beyond the first few days, in either group. Secular changes could not be responsible for any of the changes we noted: contemporaneous National Infant Feeding Surveys5 showed a diminution in breastfeeding rates, contrary to our data. A study involving 63 exclusively breastfeeding mothers cannot be described as “small”: indeed, this is one of the largest in the literature looking at infant weight gain and different breastfeeding methods. Our questionnaire data were backed up by contemporaneous information from clinical records; in any event, recall over time for breastfeeding events is generally considered to be good, and such data over far longer periods than employed in our study have recently been used.6 The criticism that we did not comment on feeding-related symptoms is irrelevant since these were not the focus of our study: it is of note that whilst the papers Woolridge and Ingram cite in support of baby-led breastfeeding not only had poor compliance and were contradictory, they ultimately supported the two-breast model of infant feeding. We concur with Woolridge and Ingram that it is time to review the advice given to nursing mothers to ensure that breastfeeding practice is targeted towards achieving the best outcome for the baby. In our view, traditional advice based on established evidence-based lactation physiology is likely to be of most benefit. Baby-led versus traditional breastfeeding advice - we submit that, based on the evidence, there really is no contest. References: 1) Walshaw CA, Owens JM, Scally AJ, Walshaw MJ. Does breastfeeding method influence infant weight gain? Arch. Dis. Child. Published Online First: 14 February 2007;doi:10.1136/adc.2006.107102. 2) Woolridge MW, Ingram J, “Rigid” vs “baby-led” – no contest. Arch. Dis Child. E-letter 21 March 2007. 3) Renfrew MJ, Woolridge MW, Ross McGill H. Enabling women to breastfeed. London.The Stationery Office. ISBN 0 11 321873 7. quote from Pxi, repeated on P88. 4) Woolridge MW, Fisher C. Colic, “Overfeeding”, and symptoms of lactose malabsorption in the breast-fed baby: a possible artifact of feed management?Lancet 1988ii:382-384. 5) Hamlyn B, Brooker S, Oleinikova K, Woods S. Infant Feeding 2000. London. The Stationery Office. ISBN 0113225709. 6) Leeson CPM, Katterhorn M, Deanfield JE, Lucas A. Duration of breast feeding and arterial distensibility in early adult life: population based study. BMJ 2001;322:643- 647