Over 400 doctors, most specialising in child health, have signed an open letter to the coroner expressing concerns about a judgement which blamed alcohol in breast milk for the death of an infant.

Update 13/08: The open letter to the coroner has now been submitted with a total of 727 doctors’ signatures.

Sapphire Rose and her twin sister Honey were born on November 4, 2016 at 33 weeks gestation. Honey and Sapphire should be two and a half now. But only one little girl is still alive. Sapphire died on 2 January, 2017.

Contributing factors cited included a dangerous sleeping environment, prematurity, possible septicaemia, suffocation – and acute alcohol intoxication. Sapphire’s mum mostly formula-fed her but said she sometimes breastfed too. And the day before Sapphire died her mum said she consumed a large amount of alcohol.

There are other factors, too. Sapphire had six siblings. And she, along with her mum and dad, were homeless. They were waiting on a Housing New Zealand home.

Subsequent reporting has focused on Coroner Debra Bell’s comments regarding Sapphire’s blood alcohol content and the direct line she draws to her mother’s breast milk. “[Sapphire’s mother] accepts the alcohol in Sapphire’s blood must have come from her consumption of alcohol. Sapphire’s mother’s actions highlight what has been well documented; alcohol can pass to a child via breast milk,” she said.

“Therefore, I stress the importance of breastfeeding mothers not to consume alcohol at any stage,” she is reported to have written.

Yet pathologist Dr Simon Stables and Coroner Debra Bell could not ascertain Sapphire’s direct cause of death. Somehow, as we have seen before with coroners, this has been translated into a blanket message for mothers. This time it’s not to have alcohol if you’re breastfeeding. This is an easy comment to make – as popular as “don’t let your child walk to school” or “don’t ever co-sleep”.

This time, however, a groundswell of medical professionals have hit back. More than 400 doctors have so far signed an open letter to the coroner expressing their concerns at the judgement and questioning whether the amount of alcohol in Sapphire’s system could have been ingested through breastmilk alone. The letter, which The Spinoff has seen, was written by Dr Heather Johnston in collaboration with other doctors around the country. Dr Johnston said she was astonished by the Coroner’s judgements.

“General consensus is that a breastfeeding mother consuming alcohol in moderation is unlikely to put her baby at risk. A mother who has a drink or two, and would still be under the New Zealand blood alcohol limit to drive (50mg alcohol/ 100ml) would have a breastmilk alcohol level of 50mg/ 100mL (or 0.05% alcohol by volume) – which is the same as a glass of orange or apple juice, a ripe banana, and less than a glass of kombucha or some types of bread rolls,” she told The Spinoff in an email.

“There is no evidence that a baby being fed breastmilk with this kind of alcohol concentration is at risk of harm. If a woman is safe to drive, she is safe to feed her baby breastmilk.”

She said that a recent cohort study from Australia confirmed that mothers who are breastfeeding will usually consume alcohol at a low level if they are going to consume any, or that they will employ strategies to minimise the alcohol passing to their baby. “The study also confirms that there are no known adverse health effects in babies under 12 months, who are exposed to low levels of alcohol via breastmilk.”

The research into the effects of alcohol through breastmilk is cited heavily in the letter to the coroner.

“Despite the old wives’ tales, alcohol does not increase breastmilk production, or relax babies,” Dr Johnston said. “Alcohol inhibits the milk letdown reflex when at high levels in the mother’s blood, after around five standard drinks, reducing the amount of breastmilk that the baby receives. It’s like a built-in protective mechanism. It has been postulated that an even higher amount of alcohol, 12 standard drinks or above, could completely inhibit the suckling-induced oxytocin surge, meaning no milk letdown at all.”

That’s not at all to say that drinking is a good idea when you’re looking after a small baby, but where the coroner is looking is confusing at best, according to Dr Johnston.

“The main dangers from drinking and breastfeeding are not the ingestion of alcohol by the baby, but rather the intoxication or limitations of the mother.

“Dangers of making poor decisions, dropping the baby, or falling asleep in bed with the baby while under the influence of alcohol and unsafely bedsharing, are much more dangerous than the baby consuming a small amount of alcohol via the breastmilk,” Dr Johnston said.

Sapphire’s siblings slept five to a bed because there was nowhere else to sleep. Because they were homeless, her mother did not have access to her medication. Her mother consumed a lot of alcohol the day before she died.

The amount of alcohol in Sapphire’s blood was 308mg per 100mL of blood. Yet no alcohol was found in her stomach. Forensic pathologist Dr Simon Stables was at a loss to explain the high reading. Health professionals have publicly and privately said they’re baffled by the result. Auckland paediatrician Dr Alison Leversha told the New Zealand Herald that the case was “very unusual”.

“I haven’t, in my professional experience, ever seen a case of alcohol poisoning through breast milk,” she said.

Dr Johnston agrees. “My letter has gathered over 400 signatures from doctors in less than 24 hours, and I expect that this will only continue to gain traction as everyone finishes work for the day. Many of the concerned doctors are obstetricians, paediatricians and general practitioners, and several have a joint qualification as lactation consultants.”

“When the information publicly available is used, and combined with some reasonable assumptions, the science of alcohol ingestion and metabolism, as well as infant feeding knowledge – it can be calculated that the maximum blood alcohol concentration that baby Sapphire could have reached by ingesting her mother’s breastmilk is around a tenth of what has been reported,” Dr Johnston said.

She, along with other health professionals have run the numbers. “To reach a blood alcohol level of over 300mg/ 100mL from drinking breastmilk, her mother’s blood and breast alcohol level would likely have needed to be four times higher than the highest levels ever recorded,” Dr Johnston said.

“Breastmilk alcohol is not the same percentage alcohol as a beverage that has just been consumed, it is a tiny fraction of that. Just like if you drink a glass of 12% wine, your blood alcohol is nowhere near 12% – in fact it would usually be less than 0.05% and you would be safe to drive. If we take this case at face value, Sapphire would be the first baby ever reported to have died from acute alcohol intoxication from breastmilk.”

Years ago I wrote about how the coroner’s guidelines on co-sleeping. It’s my view that the guidelines actually put children at risk. By placing a blanket ban on co-sleeping instead of explaining how to do it safely, they have mothers up all night, falling asleep on couches and rocking chairs with their babies in a desperate attempt not to fall asleep in bed because they’ve been told that’s dangerous. And then the worst happens – and the coroner says: “See? No co-sleeping”.

Again, in the current case, the target for judgement and popular condemnation is mothers. The evidence, however, offers no discernible basis for a blanket ban on having a drink while breastfeeding.

“By recommending that all mothers who breastfeed entirely abstain from alcohol, the potential to make really meaningful recommendations was lost,” says Dr Johnston. “Instead of placing the blame and responsibility at an individual level, change could have been made on a population level. What could have been learnt from this case, is what moderation looks like for a breastfeeding mother, or what steps a mother could take to help increase safety.”

The national conversation has instead turned into another chance to vilify mothers.

“It is not fair to scaremonger and recommend all mothers to remain alcohol-free for the duration of her time trying to conceive, her pregnancy, and then two years or longer of breastfeeding. Breastfeeding mothers already get an incredibly hard time in our culture. They’re told they’re breastfeeding too long or stopping too early, they’re told off when they do it publicly, when they eat certain foods or take certain medications.

“There’s so much judgement,” Dr Johnston said. “A breastfeeding mother’s body is subject to a lot of arbitrary rules and perspectives by the public. To have a non-evidence based recommendation of total sobriety serves only to isolate mothers further.”

A spokesperson for the Ministry of Justice said it is Coronial Services policy not to comment on individual coroner’s findings.