I wrote:
>  The question being asked was whether early limited supplementation, 
>in this group of mothers who had been identified as at increased 
>risk of running into breastfeeding problems


Heather replied
<The mothers were ID'd as at increased risk of their babies losing 10 
per cent or more weight, were they not? I am not splitting hairs - it 
is  not the same as 'at increased risk of running into breastfeeding 
problems'. To ID a group of babies who lost > 5 per cent weight at 36 
hours as 'at risk' and then treating them possibly unnecessarily with 
anything other than breastfeeding support raises ethical questions. 
Babies who have lost > 5 per cent at 36 hours do show up as being 
more likely to continue to lose, but this does not mean they are at 
risk of 'running into breastfeeding problems' *per se*., still less 
the 'serious problems' you mentioned in a previous post.>

I haven't at any point claimed that these babies were at risk of *serious* problems. With regard to being at risk of problems, the issue the researchers had identified in their unit was that mothers whose babies were losing a lot of weight were more likely to become disillusioned with breastfeeding and turn to supplementation or give up altogether, despite health staff's best efforts to persuade them otherwise. That clearly is a problem. If I'm understanding you correctly, you feel it's a problem that can be avoided with sufficient breastfeeding support and encouragement. That's certainly something worth looking at. However, I do feel dubious about the idea that breastfeeding support, no matter how good, is going to persuade every woman to keep on steering clear of any supplementation even in the face of difficulties. Whatever we say, whatever we provide, aren't there still going to be some women who feel happier with adding in some supplementation? That being the case, isn't it at least worth looking at whether a subgroup can be identified here who are better off knowing how to supplement in such a way that it has minimum likelihood of disrupting the breastfeeding relationship?

At the risk of sending this off in a completely different highly controversial direction... isn't it similar to the issues that come up with regard to bedsharing? We do, sadly, have an increasing amount of evidence that bedsharing carries at least some risk in the early months. Yet at the same time we recognise that some mothers are going to do it whatever we say and that a flat-out 'just say no' stance on bedsharing only increases the risk that those mothers will do so in particularly unsafe ways due to not having been given information on minimising the risk. Surely we've got an analogous situation here? Yes, we certainly do need to look at every way possible of maximising breastfeeding support and information to women to minimise the chance that they'll turn to supplementation - but can we really assume that it's simply a matter of doing these things well enough and that this will convince every woman to follow our advice? Or should we be looking at whether there's also a role for sympathetic, appropriate advice on risk minimisation for women who do turn to supplementation?


Best wishes,

Dr Sarah Vaughan
MBChB MRCGP

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