Does a baby’s first food really matter? Human milk has an inescapable connection to human evolution – filled with genetic components, bioactive factors, stem cells, and bacteria to populate the human microbiome. Discover how unique this amazing fluid is and why human milk is designed specifically for humans.
Laurel Wilson, IBCLC, RLC, BSc, CLE, CCCE, CLD is an international speaker, pregnancy and breastfeeding specialist, consultant, educator, and author. Laurel is the co-author of two books, The Attachment Pregnancy and The Greatest Pregnancy Ever; original editor of The CAPPA Lactation Educator Manual; as well as a contributing author to Round the Circle: Doulas Talk About Themselves.
Her passion is blending today’s recent scientific findings with the mind/body/spirit wisdom to help professionals and families realize the magnitude and importance of the perinatal period. Her 17 years as Executive Director for Lactation Programs with the Childbirth and Postpartum Professionals Association formed the foundation of her inquiry into the science of human milk. She acted as a board director for the United States Breastfeeding Committee from 2016-2019 and currently serves as an advisor for InJoy Health. Laurel is a member of Kindred’s International Editorial Advisory Board.
Laurel has been joyfully married to her husband for nearly three decades and has two wonderful grown sons, whose difficult births led her on a path towards helping emerging families create positive experiences. She believes that the journey into parenthood is a life-changing rite of passage that should be deeply honored and celebrated. www.motherjourney.com This talk was given at a TEDx event using the TED conference format but independently organized by a local community.
TRANSCRIPT and REFERENCES
Courtesy of Laurel Wilson
Cockroaches, flamingos, emperor penguins, cows, and humans, we all make milk like fluids for our babies. Milk is the magic of mothering. Birds make something called crop milk in the back of their throats for their newborns. And Pacific beetle cockroaches and toxeus magnus spiders make fluids for their new little hatchlings. So, making milk is not unique to mammals, but delivering it through the mammary gland is. Mammalian milk has evolved 310 million years to nourish and protect baby mammals. The human body has adapted over time to make milk that helps humans flourish. Breastmilk is an evolutionary food. It has helped humans succeed in inhospitable places, during traumatic times, and in habitats that would not otherwise have been possible. None of us would be here if it weren’t for breastmilk.
I have more certifications around breastfeeding and childbirth than most people know exist. I am a board-certified lactation consultant, a certified lactation educator, a registered lactation consultant, and even have my degree in lactation consulting, yes it is a thing! And yet, it’s actually a wonder that I stand before you today, to talk about breastfeeding. As a little girl I can’t say I was fascinated by babies and mothering like most of my friends. I did not willingly babysit as a child, didn’t find little ones adorable like all of my girlfriends. And while I had babydolls, I was more fascinated by the ones that could talk and eat and poop and how that worked, less so about taking care of them. I never thought about growing up and mothering, breastfeeding. My main plan, after being a princess, I mean let’s be honest, was that I was going to be the next Diane Fossey and work with gorillas in the jungle when I grew up. That was clear to me. I wanted to follow in my father’s footsteps who worked with chimpanzees when I was little. But I fell in love, young. I got married, young. He was in the Air Force and we were stationed at a military base in Guam. In spite of my best efforts I got pregnant, very young. Not only was I surprised by a pregnancy, I had a particularly difficult delivery. I was scheduled for a C-section because my baby was breech. The night before, he turned around and was head down, ready for a vaginal delivery. I didn’t want to have a C-section, but the military doctor had already be woken up, so we were doing it his way. Early motherhood was extremely difficult, and much of that difficulty for me was breastfeeding. But there was something in me that made me do it anyway. The delivery of my second baby was just as traumatic and I suffered massive postpartum depression and difficulty breastfeeding a second time around. I loved both of my boys, deeply with an almost ache, and I loved the closeness I felt with my boys when I fed them. But I can’t say I loved breastfeeding. It wasn’t until several years later when working as a childbirth advocate that I discovered how truly instrumental breastmilk is that I fell in love with breastmilk. It was when I discovered milk’s ancient origins and role in human health that became all goolgy eyed about milk.
So, let’s go back in time, when humans were first evolving. Breastmilk both nourished the baby and kept the mother and baby together for longer periods of time to ensure continued protection and increase survival rates. But not only did the mother’s presence increase the baby’s odds, it was the fact the fact that her milk was customized to meet the specific needs of her baby. Human milk is customized. Human milk changes based on the foods she is eating, the bacteria she and her baby are exposed to, the viruses she comes in contact with, and even where she lives. Mother’s provide a custom brew, like a milky microbrew, produced just for her specific baby. Milk goes through its own evolution every day to optimize the baby’s growth and development. Through this primary food, humans have had the capacity to progress and change -TO EVOLVE.
As mammals evolved, their milk delivery systems transformed. Not all mammals developed breasts. For example, some mammals give birth to eggs which hatch, like the platypus.
The milk of the platypus leaks out of their glands onto their fur and the babies lick the fur! I remember feeling touched out when I was breastfeeding I can’t imagine feeling licked out. Humans, however, developed the magnificent mammary gland. We have remarkable evolutionary breasts. It is partly through this evolution of the mammary gland and the evolution of milk that has allowed humans to prosper on most continents.
When early humans crossed the Bering Straight, researchers theorize that their breasts adapted to this low sun light environment by allowing the mammary gland to deliver higher amounts of vitamin D to babies. Human milk normally has very little vitamin D because we make it through sun exposure, not from our food. This genetic adaptation protected the vulnerable babies until they could grow teeth and eat seal meat and fish rich in fatty acids. This evolutionary change can still be found in the descendants of those that made this ancient journey.
There are so many extraordinary things we are learning about human milk. Many parents think they know a lot about human milk. That it’s perfect nutrition, reduces cancer risk for parent and child, improves immune function for the baby, reduces the risk of countless diseases. However, there is a story that is not being told. Most babies will wind up drinking the milk from another animal by the time they are six months old, ¾ of them according to the CDC. Pharmaceutical companies make formula out of cow milk and plant milk instead of human milk. Because of this, we may now be outsourcing one of our most critical resources during this important period. Babies need milk during the critical 1000 days, between conception and age 2. It is at this time when all of the body’s system develop and our genes are the most vulnerable to our environment. Researchers are now coming to terms with the fact that our first food helps to determine the trajectory of our health. Our early foods communicate instructions either for health or lack thereof.
When a baby receives food that is not from their own species, it’s body has instructions for a different development. Human milk contains genetic information, for humam, microRNAs and MRNAs that tell genes to turn on and off; stem cells that embed themselves in a baby’s organs for future needs. Human milk also populates the baby’s microbiome, which is made up of all of the bacteria, fungi, and protozoa than live on and within us and keep our body functioning. Breastmilk contains nutrition for the baby but it also contains food just to feed the bacteria in a baby’s gut. Human milk is even made up of hundreds of sugars whose sole purpose is to feed the bacteria in the baby’s gut. These sugars, called HMOS, are found in abundance in human milk, but they are particularly absent in cow’s milk. With human milk, babies are colonized with pathogenic bacteria in their guts instead of healthy bacteria. Current research now suggest that the human microbiome helps dictate our mood, releases hormones, communicates with our brain, affect cardiac and other organ system health, and it is suspected that it influences pheromones. This means milk may help influence who we fall in love and mate with. So parents if you have ever wanted to influence who your kids marry, breastfeed them!
Milk is powerful. It helps to determine who we are, potentially for many generations out.
In adopting another animal or plant’s milk, we are, in essence, outsourcing the baby’s food. I worry that most people have no idea what this really means. As a culture, we have become complacent about outsourcing this evolutionary resource. We have gotten used to outsourcing our lives. We no longer need a memory, we have google. We don’t need to read a map, we have Waze. We don’t even need to have sex with a person, there is internet porn. We don’t need to walk anywhere, we have Uber, Lyft, electric scooters. We don’t need to breastfeed, we have formula. Right? Our outsourcing has put our evolution in the hands of big pharma instead of our own very capable hands.
We ARE getting better at breastfeeding in the US. But the pressure is real for most families. Many US families return to work by two weeks after delivery, and many new parents work in jobs where breastfeeding and pumping is treated as a burden by their employers. Formula companies have power, they have money, and they profit off of the need to outsource feeding our children. In spite of international recommendations and research, billions of dollars are spent every year to make it easier to formula feed than to find better ways to support families to breastfeed. Just as we evolve biologically, we evolve culturally. Today, providing babies breastmilk is not as easy as it should be. We need a cultural evolution offers a better model and a better solutions for making human milk available for all families. We need things like real access for every lactating parent to breastfeed at work. We need to listen and respond to family needs, particularly in our under-resourced communities and within our communities of color. We need to increase access to help to new parents. More donor milk, and less shame around cooperative, peer to peer, milk sharing. The human mammary gland is powerful. I ask you to think twice before you outsource that power, the potential power of our evolution, to someone else. And now that you know, if you are ever in trouble, if you ever have a problem, just squirt a little bit of breastmilk on it. I am Laurel Wilson, thank you.
Chen, Z., Corlett, R. T., Jiao, X., Liu, S. J., Charles-Dominique, T., Zhang, S., … & Quan, R. C. (2018). Prolonged milk provisioning in a jumping spider. Science, 362(6418), 1052-1055.
Dong, B., Quan, R. C., & Chen, Z. Q. (2019). Prolonged milk provisioning and extended maternal care in the milking spider Toxeus magnus: biological implications and questions unresolved. 动物学研究, 9.
Dumont, J. N. (1965). Prolactin-induced cytologic changes in the mucosa of the pigeon crop during crop-“milk” formation. Zeitschrift für Zellforschung und Mikroskopische Anatomie, 68(6), 755-782.
Hu, X. C., Gao, C. Q., Wang, X. H., Yan, H. C., Chen, Z. S., & Wang, X. Q. (2016). Crop milk protein is synthesised following activation of the IRS1/Akt/TOR signalling pathway in the domestic pigeon (Columba livia). British poultry science, 57(6), 855-862.
Schiemer, C., Halloran, A., Jespersen, K., & Kaukua, P. (2018). Marketing Insects: Superfood or Solution-Food?. In Edible Insects in Sustainable Food Systems (pp. 213-236). Springer, Cham.
Vandeputte-Poma, J. (1980). Feeding, growth and metabolism of the pigeon, Columba livia domestica: duration and role of crop milk feeding. Journal of Comparative Physiology B: Biochemical, Systemic, and Environmental Physiology, 135(2), 97-99.
Warren, W. C., Hillier, L. W., Graves, J. A. M., Birney, E., Ponting, C. P., Grützner, F., … & Yang, S. P. (2008). Genome analysis of the platypus reveals unique signatures of evolution. Nature, 453(7192), 175.
Wheeler, D. E. (2009). Eggs. In Encyclopedia of Insects (pp. 311-312). Academic Press.
Williford, A., Stay, B., & Bhattacharya, D. (2004). Evolution of a novel function: nutritive milk in the viviparous cockroach, Diploptera punctata. Evolution & development, 6(2), 67-77.
Evolution of Mammalian Milk
BLACKBURN, D. G., HAYSSEN, V., & Murphy, C. J. (1989). The origins of lactation and the evolution of milk: a review with new hypotheses. Mammal Review, 19(1), 1-26.
Capuco, A. V., & Akers, R. M. (2009). The origin and evolution of lactation. Journal of biology, 8(4), 37.
Goldman, A. S. (2002). Evolution of the mammary gland defense system and the ontogeny of the immune system. Journal of mammary gland biology and neoplasia, 7(3), 277-289.
Hinde, K., & German, J. B. (2012). Food in an evolutionary context: insights from mother’s milk. Journal of the Science of Food and Agriculture, 92(11), 2219-2223.
Lemay, D. G., Lynn, D. J., Martin, W. F., Neville, M. C., Casey, T. M., Rincon, G., … & Pollard, K. S. (2009). The bovine lactation genome: insights into the evolution of mammalian milk. Genome biology, 10(4), R43.
McClellan, H. L., Miller, S. J., & Hartmann, P. E. (2008). Evolution of lactation: nutrition v. protection with special reference to five mammalian species. Nutrition research reviews, 21(2), 97-116.
Oftedal, O. T. (2012). The evolution of milk secretion and its ancient origins. Animal, 6(3), 355-368.
Power, M. L., & Schulkin, J. (2016). Milk: the biology of lactation. JHU Press.
Skibiel, A. L., Downing, L. M., Orr, T. J., & Hood, W. R. (2013). The evolution of the nutrient composition of mammalian milks. Journal of Animal Ecology, 1254-1264.
Tao, N., Wu, S., Kim, J., An, H. J., Hinde, K., Power, M. L., … & Lebrilla, C. B. (2011). Evolutionary glycomics: characterization of milk oligosaccharides in primates. Journal of proteome research, 10(4), 1548-1557.
Walzem, R. L., Dillard, C. J., & German, J. B. (2002). Whey components: millennia of evolution create functionalities for mammalian nutrition: what we know and what we may be overlooking. Critical reviews in food science and nutrition, 42(4), 353-375.
Wiley, A. S. (2015). Re-imagining milk: cultural and biological perspectives. Routledge.
Human Milk Changes According to Infant Need
Skibiel, A. L., & Hood, W. R. (2015). Milk matters: offspring survival in Columbian ground squirrels is affected by nutrient composition of mother’s milk. Frontiers in Ecology and Evolution, 3, 111.
Unique Components in Human Milk (mRNAs, oligosaccharides, stem cells) and Response to Environment
Oliveira, D. L., Wilbey, R. A., Grandison, A. S., & Roseiro, L. B. (2015). Milk oligosaccharides: A review. International journal of dairy technology, 68(3), 305-321.
Golan‐Gerstl, R., Elbaum Shiff, Y., Moshayoff, V., Schecter, D., Leshkowitz, D., & Reif, S. (2017). Characterization and biological function of milk‐derived miRNAs. Molecular nutrition & food research, 61(10), 1700009.
Hoashi, M., Meche, L., Mahal, L. K., Bakacs, E., Nardella, D., Naftolin, F., … & Dominguez-Bello, M. G. (2016). Human milk bacterial and glycosylation patterns differ by delivery mode. Reproductive sciences, 23(7), 902-907.
Katayama, T. (2016). Host-derived glycans serve as selected nutrients for the gut microbe: human milk oligosaccharides and bifidobacteria. Bioscience, biotechnology, and biochemistry, 80(4), 621-632.
Vitamin and Bering Straight Research
Hlusko, L. J., Carlson, J. P., Chaplin, G., Elias, S. A., Hoffecker, J. F., Huffman, M., … & Scott, G. R. (2018). Environmental selection during the last ice age on the mother-to-infant transmission of vitamin D and fatty acids through breast milk. Proceedings of the National Academy of Sciences, 115(19), E4426-E4432.
The Critical 1000
Binns, C., Lee, M., & Low, W. Y. (2016). The long-term public health benefits of breastfeeding. Asia Pacific Journal of Public Health, 28(1), 7-14.
Cusick, S. E., & Georgieff, M. K. (2016). The role of nutrition in brain development: the golden opportunity of the “first 1000 days”. The Journal of pediatrics, 175, 16-21.
Mameli, C., Mazzantini, S., & Zuccotti, G. (2016). Nutrition in the first 1000 days: the origin of childhood obesity. International journal of environmental research and public health, 13(9), 838.
Pietrobelli, A., & Agosti, M. (2017). Nutrition in the first 1000 days: Ten practices to minimize obesity emerging from published science. International journal of environmental research and public health, 14(12), 1491.
Epigenetics and Milk
Alsaweed, M., Lai, C. T., Hartmann, P. E., Geddes, D. T., & Kakulas, F. (2016). Human milk miRNAs primarily originate from the mammary gland resulting in unique miRNA profiles of fractionated milk. Scientific reports, 6, 20680.
Eidelman, A. I. (2019). Epigenetic Basis for the Beneficial Effect of Breastfeeding.
Hartwig, F. P., de Mola, C. L., Davies, N. M., Victora, C. G., & Relton, C. L. (2017). Breastfeeding effects on DNA methylation in the offspring: A systematic literature review. PloS one, 12(3), e0173070
Hock, A., Miyake, H., Li, B., Lee, C., Ermini, L., Koike, Y., … & Pierro, A. (2017). Breast milk-derived exosomes promote intestinal epithelial cell growth. Journal of pediatric surgery, 52(5), 755-759.
Indrio, F., Martini, S., Francavilla, R., Corvaglia, L., Cristofori, F., Mastrolia, S. A., … & Loverro, G. (2017). Epigenetic matters: the link between early nutrition, microbiome, and long-term health development. Frontiers in Pediatrics, 5, 178.
(Below also info on evolution of human milk)
Ivell, R., & Anand-Ivell, R. (2017). Neohormones in milk. Best Practice & Research Clinical Endocrinology & Metabolism, 31(4), 419-425.
Karlsson, O., Rodosthenous, R. S., Jara, C., Brennan, K. J., Wright, R. O., Baccarelli, A. A., & Wright, R. J. (2016). Detection of long non-coding RNAs in human breastmilk extracellular vesicles: Implications for early child development. Epigenetics, 11(10), 721-729.
Langley-Evans, SC. Nutrition in early life and the programming of adult disease: a review. J Hum Nutr Diet. 2014 Jan 31. doi: 10.1111/jhn.12212.
Lemas, D. J., Young, B. E., Baker, P. R., Tomczik, A. C., Soderborg, T. K., Hernandez, T. L., … & Patinkin, Z. W. (2016). Alterations in human milk leptin and insulin are associated with early changes in the infant intestinal microbiome. The American journal of clinical nutrition, 103(5), 1291-1300.
Lester, B. M., Conradt, E., LaGasse, L. L., Tronick, E. Z., Padbury, J. F., & Marsit, C. J. (2018). Epigenetic programming by maternal behavior in the human infant. Pediatrics, 142(4), e20171890.
Melnik, B. C. (2015). Milk: an epigenetic amplifier of FTO-mediated transcription? Implications for Western diseases. Journal of translational medicine, 13(1), 385.
Melnik, B., & Schmitz, G. (2017). Milk’s role as an epigenetic regulator in health and disease. Diseases, 5(1), 12.
Melnik, B. C., & Schmitz, G. (2017). MicroRNAs: Milk’s epigenetic regulators. Best Practice & Research Clinical Endocrinology & Metabolism, 31(4), 427-442.
Verduci, E.; Banderali, G.; Barberi, S.; Radaelli, G.; Lops, A.; Betti, F.; Riva, E.; Giovannini, M. Epigenetic Effects of Human Breast Milk. Nutrients 2014, 6, 1711-1724.
Victora, C. G., Bahl, R., Barros, A. J., França, G. V., Horton, S., Krasevec, J., … & Group, T. L. B. S. (2016). Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017), 475-490.
Wagner, C. L., & Eidelman, A. I. (2018). The Impact of Vitamin D on the Maternal and Infant Epigenome: The Role of Pregnancy and Breastfeeding.
Stem Cells in Breastmilk
Aydin MS, Yiğit EN, Vatandaşlar E, Erdoğan E, Öztürk G (2018). Transfer and integration of breast milk stem cells to the brain of suckling pups. Scientific Reports 8:14289.
Cregan MD, Fan Y, Appelbee A, Brown ML, Klopcic B, Koppen J, Mitoulas LR, Piper KM, Choolani MA, Chong YS, Hartmann PE (2007). Identification of nestin-positive putative mammary stem cells in human breastmilk. Cell and Tissue Research 329:129-136.
Hassiotou, F., Beltran, A., Chetwynd, E., Stuebe, A. M., Twigger, A. J., Metzger, P., … & Hartmann, P. E. (2012). Breastmilk is a novel source of stem cells with multilineage differentiation potential. Stem cells, 30(10), 2164-2174.
Hassiotou, F., & Hartmann, P. E. (2014). At the dawn of a new discovery: the potential of breast milk stem cells. Advances in Nutrition, 5(6), 770-778.
Hassiotou, F., Heath, B., Ocal, O., Filgueira, L., Geddes, D., Hartmann, P., & Wilkie, T. (2014). Breastmilk stem cell transfer from mother to neonatal organs (216.4). The FASEB Journal, 28(1_supplement), 216-4.
Hassiotou F, Mobley A, Geddes DT, Hartmann PE, Wilkie T (2015). Breastmilk imparts the mother’s stem cells to the infant. FASEB Journal 29:876.
Kakulas F (2015). Breast milk: a source of stem cells and protective cells for the infant. Infant 11(6):187-191.
Matsushita T, Kibayashi T, Katayama T, Yamashita Y, Suzuki S, Kawamata J, Honmou O, Minami M, Shimohama S (2011). Mesenchymal stem cells transmigrate across brain microvascular endothelial cell monolayers through transiently formed inter-endothelial gaps. Neuroscience Letters 502:41-45.
Molès, J. P., Tuaillon, E., Kankasa, C., Bedin, A. S., Nagot, N., Marchant, A., … & Van de Perre, P. (2017). Breastfeeding-related maternal microchimerism. Nature Reviews Immunology, 17(11), 729.
Molès JP, Tuaillon E, Kankasa C, Bedin AS, Nagot N, Marchant A, McDermid JM, Van de Perre P (2018). Breastmilk cell trafficking induces microchimerism-mediated immune system maturation in the infant. Pediatric Allergy and Immunology 29:133-143.
Patki, S., Kadam, S., Chandra, V., & Bhonde, R. (2010). Human breast milk is a rich source of multipotent mesenchymal stem cells. Human cell, 23(2), 35-40.
Pichiri, G., Lanzano, D., Piras, M., Dessì, A., Reali, A., Puddu, M., … & Coni, P. (2016). Human breast milk stem cells: a new challenge for perinatologists. Journal of Pediatric and Neonatal Individualized Medicine (JPNIM), 5(1), e050120.
Weiler IJ, Hickler W, Sprenger R (1983). Demonstration that milk cells invade the suckling neonatal mouse. American Journal of Reproductive Immunology 4:95-98.
Witkowska-Zimny, M., & Kaminska-El-Hassan, E. (2017). Cells of human breast milk. Cellular & molecular biology letters, 22(1), 11.
Zhou L, Yoshimura Y, Huang Y, Suzuki R, Yokoyama M, Okabe M, Shimamura M (2000). Two independent pathways of maternal cell transmission to offspring: through placenta during pregnancy and by breastfeeding after birth. Immunology 101:570-580.
Microbiome and Human Milk
Azad, M. B., Konya, T., Persaud, R. R., Guttman, D. S., Chari, R. S., Field, C. J., … & Becker, A. B. (2016). Impact of maternal intrapartum antibiotics, method of birth and breastfeeding on gut microbiota during the first year of life: a prospective cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 123(6), 983-993.
Dallas, D. C., & German, J. B. (2017). Enzymes in human milk. In Intestinal microbiome: functional aspects in health and disease (Vol. 88, pp. 129-136). Karger Publishers.
Rosenberg, E., & Zilber-Rosenberg, I. (2018). The hologenome concept of evolution after 10 years. Microbiome, 6(1), 78.
Lackey, K. A., Williams, J. E., Meehan, C. L., Zachek, J. A., Benda, E. D., Price, W. J., … & Mbugua, S. (2019). What’s Normal? Microbiomes In Human Milk And Infant Feces Are Related To Each Other But Vary Geographically: The INSPIRE Study. Frontiers in Nutrition, 6, 45. https://doi.org/10.3389/fnut.2019.00045
Lynch, S. V., & Pedersen, O. (2016). The human intestinal microbiome in health and disease. New England Journal of Medicine, 375(24), 2369-2379.
Martin, C. R., Osadchiy, V., Kalani, A., & Mayer, E. A. (2018). The brain-gut-microbiome axis. Cellular and molecular gastroenterology and hepatology, 6(2), 133-148.
Neuman, H., Debelius, J. W., Knight, R., & Koren, O. (2015). Microbial endocrinology: the interplay between the microbiota and the endocrine system. FEMS microbiology reviews, 39(4), 509-521.
Turroni, F., Milani, C., Duranti, S., Ferrario, C., Lugli, G. A., Mancabelli, L., … & Ventura, M. (2018). Bifidobacteria and the infant gut: an example of co-evolution and natural selection. Cellular and molecular life sciences, 75(1), 103-118.
Yamada, C., Gotoh, A., Sakanaka, M., Hattie, M., Stubbs, K. A., Katayama-Ikegami, A., … & Okuda, S. (2017). Molecular insight into evolution of symbiosis between breast-fed infants and a member of the human gut microbiome Bifidobacterium longum. Cell chemical biology, 24(4), 515-524.
Pietrobelli, A., & Agosti, M. (2017). Nutrition in the first 1000 days: Ten practices to minimize obesity emerging from published science. International journal of environmental research and public health, 14(12), 1491.
Cost of Marketing of FormulaSave the Children. Don’t Push It: Why the formula milk industry must clean up its act . 2018 https://www.savethechildren.org.uk/content/dam/gb/reports/health/dont-push-it.pdf?Source%20Code=&cid=esm–bms_001-5R44428VW&utm_campaign=bms_001&utm_medium=earnedsocial&utm_source