Criticism and comments on “Emergency preparedness for those who care for infants in developed country contexts”

To: Whom it May Concern

Re: Criticism and comments on Karleen D. Gribble and Berry, Nina J.; “Emergency preparedness for those who care for infants in developed country contexts”. International Breastfeeding Journal 2011, 6:16.

From: The collective voices of FearlessFormulaFeeder.com

We the undersigned are gravely concerned with the assumptions, myths, and potentially harmful information presented in the paper, “”Emergency preparedness for those who care for infants in developed country contexts”, appearing in the International Breastfeeding Journal on November 7, 2011 (henceforth referred to as “the paper”).

In the course of the past week, we have been engaged in an online discussion with the lead author of this review, Karleen Gribble. While her intentions are clearly admirable, and her willingness to debate is appreciated, we feel strongly that her paper has the potential to do far more harm than good.

Who we are

This commentary was compiled through the feedback received on a post at FearlessFormulaFeeder.com, a website dedicated to supporting women who have either struggled to breastfeed or have made a well-informed choice to formula feed for a variety of personal reasons. The international readership of this site encompasses a wide range of feeding experiences (many of the readers are/were exclusively breastfeeding mothers or are “combo feeders” who supplement with formula, but primarily breastfeed) as well as ethnic and socioeconomic backgrounds. The author and members of this site are steadfastly in favor of protecting and supporting breastfeeding; however, we are also concerned with the impact the “breast is always best” mentality has had on Western society in terms of both the emotional and physical health of mothers, fathers, and babies; and on public discourse and policy surrounding feeding choices.

The paper

This review paper, according to Gribble, is written to give emergency management authorities information to “provide those who care for infants with accurate and detailed information on the supplies necessary to care for them in an emergency, distinguishing between the needs of breastfed infants and the needs of formula fed infants. Those who care for formula fed infants should be provided with detailed information on the supplies necessary for an emergency preparedness kit and with information on how to prepare formula feeds in an emergency.”

We don’t doubt that, provided a mother is physically and emotionally able to breastfeed her infant in the wake of a disaster, breastfeeding is a safer and more economical way to ensure that the nutritional needs of an infant are met. However, rather than simply illustrating this point and providing logistics for those who cannot exercise this option, the authors have offered a biased, embarrassingly inaccurate portrait of what formula feeds should entail in times of disaster. We feel that this paper not only adds to a growing body of breastfeeding literature that relies on a limiting, unrealistic, one-size-fits-all view of infant feeding, but could also 1) lead parents to spend needless money on emergency supplies 2) contribute to the already despicable lack of knowledge surrounding formula feeding and 3) mislead breastfeeding mothers into being ill-prepared for disaster situations.

Lack of impartiality

The paper begins with the WHO recommendations for infant feeding. This frames the remaining information as a diatribe on the dangers and inconvenience of formula, rather than what the paper claims to be (a manual of sorts, providing real, useful, and necessary information for all parents). Instead of explaining the reasoning behind the authors’ recommendations vis-à-vis actual disaster data – possible time frame of being left without aid, clean water, shelter, etc – the message we are left with is “breast is best”, not only in terms of disaster preparation, but “in general”. This seems punitive; while many women in our society do combo-feed (both formula and breastfeeding) and may be able to choose one over the other, women will either be breastfeeding or formula feeding at the time a disaster strikes, many others will have no choice but to continue their previously initiated method of feeding. Relactation is indeed possible (1), and was in fact recommended by UNICEF as a strategy superior to formula donation and distribution during the 2010 disaster in Haiti (2). However, there is no available data on mass, post-disaster relactation that provided evidence for the efficacy of this recommendation, and the experience of the women who frequent this website suggests that relactation is difficult in the best, most privileged of circumstances. Even the WHO document cited above (2) states, “(l)ittle research has been conducted specifically into the physiology of relactation in humans” and later advocates ensuring that a relactating woman should have “enough rest and relief from other jobs while she re-establishes a breastmilk supply.” It seems logical that the reality of a disaster situation might make an already arduous process more difficult, and possibly unrealistic, at least in the short term.

In our online discussion (3) on FearlessFormulaFeeder.com, Gribble infers that the heavy-handed focus on the superiority of breastfeeding was in part a logistical tactic to discourage unnecessary use of formula – a practice which can, in theory, sabotage breastfeeding. Again, we do not argue that breastfeeding should be encouraged and protected during disasters; however, we are concerned that the overwhelming bias of UNICEF and like-minded aid organizations is coloring the determination of what is “unnecessary” or inappropriate. We cannot blur the lines between breastfeeding promotion and post-disaster survival.

Gribble admits that UNICEF will not “touch” donations (even of ready-to-feed, single-serve formula containers which would negate the need for washing and sterilizing during the formula prep process – more on this later) from formula companies. “UNICEF’s sponsorship policy places companies that breach the International Code of Marketing of Breastmilk Substitutes as more untouchable than tobacco companies because of the impact of their unethical marketing practices on the wellbeing of children. They purchase what they need at market prices,” she states (3). In our opinion, this speaks to an obvious bias: if the aid organizations in question would refuse help due to moral convictions, what does that say about their worldview? If formula is an instrument of the proverbial devil, then anything formula-related is going to be looked as an avoid-at-all-costs evil. UNICEF does have a large body of research and documentation regarding the unethical promotion of formula in third world countries (4); this is not an argument about their reasoning, but rather the bias inherent in the way they approach infant feeding in every situation, including disasters. We feel that especially in the developed world, where “unethical marketing” of formula is a matter of debate (5) depending on where you stand on the issue of infant feeding choice, it is irresponsible for aid organizations to deny contributions which would help infants and mothers, instead opting to spend precious dollars on buying formula at market price.

Lack of due diligence

The authors spend a good portion of the paper detailing what a formula feeding parent needs for their emergency preparedness kit: A breastfeeding mother needs only “100 nappies and wipes”; in contrast, the formula feeding parent needs “56 serves of ready-to-use liquid infant formula, 84L water, storage container, metal knife, small bowl, 56 feeding bottles and teats/cups, 56 ziplock plastic bags, 220 paper towels, detergent, 120 antiseptic wipes, 100 nappies and 200 nappy wipes. If powdered infant formula is used, an emergency preparedness kit should include: two 900g tins powdered infant formula, 170L drinking water, storage container, large cooking pot with lid, kettle, gas stove, box of matches/ lighter, 14kg liquid petroleum gas, measuring container, metal knife, metal tongs, feeding cup, 300 large sheets paper towel, detergent, 100 nappies and 200 nappy wipes”, which will cost $250 (Australian dollars) for the powdered version, and $550 for the ready-to-use liquid.
We do not disagree that a laboratory-perfect, sterile preparation of formula would be ideal in a situation where sewage is present and resources for hand-washing are scarce; however, we believe that this list of supplies (and the corresponding instructions on how to prepare feeds) is misguided at best; deliberately misleading at worst. Firstly, many of the “dangers” of formula feeding in both disaster situations and resource-poor areas are due to contaminated water sources; using ready-to-feed formula would minimize most of these risks. Gribble also argues that water is needed for cleaning hands (something breastfeeding mothers need not do, apparently, even if they are breaking a latch with a finger; we also question whether a breast could not be similarly germ-ridden as a hand, considering both are covered by the same epidermal layer). Depending on the disaster in question,couldn’t antibacterial wipes (6) be sufficient for cleaning hands prior to preparation of ready-to-feed formula in disposable bottles? Considering many of us were given ready-to-feed nursers in maternity wards with pre-sterilized nipples, and given no instructions except to attach the nipple to the bottle, it seems odd that this would be good enough for an hours-old baby and yet deadly (in a statistically significant regard) for a 5-month-old trapped in his home after an earthquake.

When we presented Gribble with the suggestion of ready-to-feed single-serve nursers (available from all three major formula companies in the United States) and disposable, pre-sterilized nipples, she claimed that these were not available in Australia or Japan, and were in fact illegal to purchase in Australia. A reader of the FFF blog did a few hours of research on this matter, and discovered that in Australia:

“…You can purchase Ready to feed formula in disposable bottles from here: http://www.fishpond.com.au/Lif…. I rang Australian Quarantine and Inspection Services and Steve on the floor in Brisbane said that milk imports from USA are fine at the moment unless the value is over $1000 in which case it maybe looked into but probably passed as long as there is a legit reason for that quantity.” (3)

This is a far cry from “unavailable” or “illegal”; a parent provided with the right resources could easily obtain this much safer and more economical option. Within the United States – one of the countries that this protocol is presumably directed towards – these products are readily available. A baby under 4 months could likely survive on 20 oz/day. To do this with Similac 2-oz nursettes, this would come out to be about $250; with Good Start, which makes 6-oz nursers, it would be under $200. Another option is a pack of 48, 2-oz nursers which come with a ready to use nipple and ring – Similac offers a pack of 48 for $41.94 on Amazon.com (7).

Even if a mother is relegated to using ready-to-feed formula which does not come in serving-size nursers, the same Australian mother did a breakdown of costs for this method and found the following:

A five month old will need approximately 42 250ml RTF cartons. The standard way to calculate how much formula a baby needs is 150mls – 200mls of formula x body weight of baby. According to my Queensland government personal health record chart by the National Center of health Statistics a 5 month old averages about 7kgs. 7kgs x 200mls (to be on the safe side) equals 1400 mls per 24 hours or 6 250ml cartons/day (again to be on the safe side) x 7 days equals – 42 cartons.

COST: $41.75 from Chemist warehouse. (this cost is based on buying them in lots of 6 – I am sure you maybe able to find them cheaper in bulk.)

WATER

To wash hands: I DID THIS and I used approximately 100ml to thoroughly clean my hands. (Give it a go – see how much you need)

To clean preparation surface: again DID THIS and used another 100 mls.

Approximately 200mls of water per feed for cleaning – 1.2L a day or 8.4L a week

COST: 10L (with a little extra just in case) – $6.09 (Coles)

BOTTLES

You can buy disposable sterile bottles (50 for about $50) or my local Crazy Clarks (a discount chain) sells 6 250ml standard plastic bottles for $6.95

COST: $48.65 for 42 bottles

A storage container $11.00 (crazy clarks)

50 Large Zip lock bags – $5 (Coles)

Paper towels – 400 $4.70 (Coles)

Detergent – 1L $1.06 (Coles)

Antiseptic Wipes – 80 pack – $10.68 (Coles)

Packet of strong sharp disposable knives – 50 pack – $3.20

TOTAL COST: $132.13

This is based on one mother’s research, and we are concerned that if her cost assessment was significantly different than Gribble’s (both women are from the same country), something is amiss. Perhaps a little non-biased, real-world perspective might go a long way in honing these recommendations. We wonder if formula feeding recommendation written by admitted breastfeeding activists is really the way to go?

Lack of adequate information

As many of us are, or have been breastfeeding mothers, we are also concerned with what we feel is a lack of information (and a lack of realism) about breastfeeding in the developed world. Many women have a steep learning curve with breastfeeding; it is often a learned skill (8). Some of us have struggled with insufficient supply in the best of situations; we wonder how a brand new mother, possibly dealing with the death of loved ones, a loss of a home, etc, would be able to handle successful breastfeeding in the worst of situations? Furthermore, what would happen if an exclusively breastfeeding mother were at work or out at the time the disaster hits? Or if the mother is severely injured or killed? If a baby is separated from its mother, an alternative food supply will be needed; it seems that it would be far safer to suggest that even breastfeeding families have a supply of formula on hand.

Dehydration and stress can also have a deleterious effect on breastfeeding. While stress has not been shown to impede milk production, as Gribble points out in our discussion, it has been shown to cease lactation in a few documented cases (9) and has been proven to inhibit letdown response (10); by Gribble’s own account, handling this problem requires support from those knowledgeable in lactation. Regardless of the mechanics involved, if the milk is not flowing, a baby is not getting fed. Considering the amount of psychological and physical stress in times of disaster (11)(12), we wonder: how many lactation professionals will need to be deployed to meet the needs of every struggling lactating mother? It may be true that for a mother who has already established breastfeeding, even times of extreme stress and lack of food and water will not affect the nursing dyad; we are concerned with the new mothers who suddenly find themselves trapped in their homes, and who are struggling to breastfeed in the way we all have (13) in much more comfortable situations (and our experiences run the gamut). If these mothers have been told not to have an emergency stash of formula in case of disaster, what will happen? It is a well-known argument that having formula in the home can discourage breastfeeding (14), but we feel that a paper focusing on disaster prep, not breastfeeding promotion, should look beyond a few self-reported studies and concentrate on the worst-case scenarios.

Ultimately, while no one here is arguing the fundamental point of this paper – that breastfeeding is a better disaster preparedness strategy – we feel it is obscenely dismissive of the lived realities of most women in “developed” nations. To suggest that a woman delays weaning in case of emergency is inane. To ignore the possibility that a breastfeeding mother may not be able to breastfeed her baby, either due to injury, emotional state or separation/death, is unrealistic. To ignore the options available to formula feeding parents, and to the aid organizations themselves, out of a disgust for formula companies or formula feeding as a practice, is irresponsible.

We ask that this paper be amended to include better, less biased information that is truly concerned with helping all babies rather than presenting yet another reason why breastfeeding is best. If nothing else, we hope that government agencies dealing with disaster preparedness will think seriously about the points we have illustrated, and refrain from using this biased, poorly-researched paper as a reference for recommendations.

Sincerely,

The Readers and Author of FearlessFormulaFeeder.com

Sources

1) http://www.ennonline.net/pool/files/ife/who-chs-cah-98-14-relactation-document.pdf

2) http://www.ennonline.net/pool/files/ife/joint-statement-iycf-haiti.pdf

3) http://www.fearlessformulafeeder.com/2011/11/formula-feeding-in-disaster-situations.html

4) http://www.unicef.org/nutrition/index_24824.html

5) http://www.fearlessformulafeeder.com/search/label/WHO%20Code

6) http://www.homefrontemergency.com/sadexanwi.html

7) http://www.amazon.com/Similac-Advance-Newborn-2-Fluid-Packaging/dp/B000N351WQ

8) http://www.bestforbabes.org/prepare-the-learning-curve-of-breastfeeding

9) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1307254/pdf/westjmed00150-0094.pdf

10)http://www.sciencedirect.com/science/article/pii/S0031395505702960

11) http://psycnet.apa.org/journals/amp/39/3/252/

12) http://www.ptsd.va.gov/professional/pages/phases-trauma-reactions.asp

13) http://www.fearlessformulafeeder.com/search/label/FFF%20Friday

14) http://health.usnews.com/health-news/managing-your-healthcare/healthcare/articles/011/09/26/breast-feeding-boost-fewer-hospitals-handing-out-free-formula

About the Author:

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.


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43 thoughts on “Criticism and comments on “Emergency preparedness for those who care for infants in developed country contexts”

  1. Dayam…this is awesome. I can't think of anything else. If this paper is not retracted…well, it says a lot more about the poor standards of breastfeeding research out there than perhaps the authors would like to admit.

  2. (I would possibly make a bigger thing about the Mother being ill or injured, just because I think that's a major oversight…..I still think the letter is absolutely outstanding though!!!!) THANK YOU!

  3. You are an excellent writer. I appreciate that you took the time to write this out in a format that condenses all the things discussed in the thread into a coherent argument in favor of amending or retracting the paper as it is currently written.

  4. Good stuff. I would emphasize a few things differently however. One, don't knock “just one mother's research” vs peer review. the fact that someone went out to stores and priced things over the counter and came up with a very different price estimate in the same country suggests a serious lack of due diligence on the part of the researcher (the peer review process cannot price things so it doesn't matter there). Two, I would suggest that instead of asking for the paper to be retracted, it should seriously consider revisions to reflect facts that are presented here. Three, and most important, I would STRONGLY emphasize that many of the studies cited in this paper to argue that formula donations do more harm than good in terms of health outcomes for babies rely on the assumption that there is no safe water available to mix formula, and so much of this is negated by using RTF that the recommendations of the paper should make a case for relief agencies distributing RTF rather than simply rejecting formula distribution altogether. I think it's good to be constructive about specifics in the paper and show where anti-formula bias prevents agencies from doing their job in serving disaster victims rather than emphasizing this is part of a wider breast v bottle debate (I am thinking particularly of the latter section on the challenges of BFing – best to just emphasize that in a disaster women can be separated from their children, BFing rates may or may not have been high – hey and shouldn't relief agencies have a sense of rates in areas they are serving? – and it is good to have contingency formula supplies available for those who need them along with good distribution and educational support).

  5. Oh, and you have the author as “Kathleen” rather than “Karleen” in the second mention, which you might want to correct.

  6. Quick grammar edit: 3rd paragraph-
    “This review paper, according to Gribble, is written

    FOR TO [probably just "to"]

    give emergency management authorities information to “provide those who care for infants with accurate and detailed information on the supplies necessary to care for them in an emergency, distinguishing between the needs of breastfed infants and the needs of formula fed infants. Those who care for formula fed infants should be provided with detailed information on the supplies necessary for an emergency preparedness kit and with information on how to prepare formula feeds in an emergency.”"

    I think this sounds great. I agree with Perfesser about how to emphasize the reasons behind RTF and making it about less than cost and more as a public health thing.

  7. I still say that in a disaster scenario, having a feeding method that is solely reliant on mother being available (not injured, separated from the family due to something impeding her, or her not becoming a zombie for instance) is a secondary disaster waiting to happen. What happens when mom can't get to the baby for 14 hours, and dad/grandma/grandpa/etc don't know when she's going to get there if she will get there? Basically if mom isn't there, baby goes without. It's not a good disaster plan when you can just knock out one block and the whole thing topples. Having formula as a back up 'just in case' simply makes sense.

  8. I mentioned a couple points in the other thread that I'm not sure if they would be good to work in or not.

    Someone else pointed out that breastfeeding doesn't solve the problem of older children caught in a disaster; if emergency preparedness were the major motivation then we would in theory be expected to breastfeed children well past the toddler stage (and what age is the cut-off? 5? 6? 10?) This paper turns the decision to wean into one in which recently weaning moms could be labeled selfish if their children die in the disaster, a double-victimization.

    The second point is that if long-term unsanitary water is such a problem, what happens when a woman drinks it–what does that do to her supply? We talked about what stress does to supply, but what about if a woman has such diarrhea that she is dehydrated? Perhaps the better focus would be on how to get clean water supplies to disaster zones (and developing countries) quickly. Lack of clean water is indiscriminate; yes, babies are more vulnerable but they are by no means the only ones who could die of dehydration or water-borne disease. And that leads us back to the question of what do you do for a baby when the mother is not around?

  9. Hi everyone, I'm back now and was pleased to see that my encouragement to write a comment was taken seriously. Just a heads up. In commenting on a paper for a professional journal the editor will want you just to respond to the paper only. Much of what is written in this letter is responding to comments made by me on this blog and that makes it very unlikely that an editor would publish it. Furthermore, a journal will not publish an anonymous comment, you will need to add your names and emails to the letter. I shall get to looking at the posts in the other thread over the next few days.

  10. ^ Perhaps this is part of the problem of the professional journals, that people with the right credentials can say whatever the hell they want outside the journal and the regular people who have to bear the fallout are left powerless. I'd love to know how this somehow empowers women.

  11. The conversation here has allowed anyone to respond in the way that they wish to my comments within the parameters of how the blog works. Different forums have different conventions and I was just letting you know how professional journals work so that you could comment on the paper. It has nothing to do with credentials but with understanding how a system works. That can make it difficult for those who don' t know the “rules of the game” and that is why I gave the heads up so you would not be disadvantaged.

  12. What about you – do you take these critiques seriously as a person and a scholar? I'm an academic and I know about journal conventions but I also know about being called on basic facts by those outside academia who may be familiar with my field. At the end of the day if you are serving women and children's health then women and children are your constituency too.

  13. I think that you can tell that I take the comments seriously by how I have responded to the questions and comments. Yes, I take them seriously, I might not agree with them but I respect the opinions of those who have engaged in the conversation here.

  14. Hi, I'd just like to point out that this letter is intended for a wider audience then just the journal in which it was pulished. An edited form can be sent to them and ways of adding signatures and email addresses are currently being considered.

  15. FFF, a great piece! I've read both with a great degree of interest, being a FFF from birth for both my kids in Japan, where breastfeeding rates are quite high.

    The triple disaster this past March (earthquake/tsunami/nuclear reactor) was an eyeopener for many people with regard to both breastfeeding and formula feeding mothers. Many of the domestic aid agencies (mostly grassroots-led) requested formula, bottles, nipples, etc. to be sent to the affected areas, which was a wonderful thing to see, as they were thinking about both formula-fed and breast-fed babies.

    FWIW, I also have not seen pre-sterilized(?) nipples or ready-made formula on the shelves in Japan, although maybe it can be ordered from one of the 3 major domestic formula companies.

  16. Facts are not to be “agreed” with or shrugged aside as the “opinions” of those who don't share your worldview – they are facts. We can disagree on what policies we should follow based on what we believe is the best use of these facts but there is no denying them. What about the fact that your basic costing was revealed to be incredibly exaggerated and much of your argument weakened by a glaring lack of due diligence? The researcher friend I showed your argument too pointed me to a WHO document that actually runs completely counter to what you have suggested is the state of the research on HIV transmission and breast vs formula feeding (I posted it here too). I am not sure if it's your vague writing style or a desire to dodge inconvenient facts that makes it difficult to communicate but you seem to be unwilling to reassess your proposals based on facts like the availability of RTF. Honestly I don't think your work is going to be influential, flawed as it is by basic inaccuracies, so I will stop here.

  17. I have not yet addressed the posting by your friend. I shall, as well as the costings, probably tomorrow. It has been a little difficult at times to respond to people's responses to my posts when what I have said has been misinterpreted to a great degree. It's been interesting though. I have wondered why this is the case?

  18. FFF, I think this is a terrific article, but an article is what it is. If you want to post it as a comment, you should probably be summarising it down a lot, because I don't think a journal's going to be keen on publishing something this long. You could always post a summary to the comments and either link back here or send a longer letter to the journal.

  19. I also think it's worth gauging what your audience is actually going to accept/listen to/take in. I mean, if we start a letter to the International Breastfeeding Journal by complaining that the paper's message is 'Breast is best… in general', then their response is going to be to say “Well, yes, and they're right. So?” and we won't have got anywhere. I'd recommend making it much more focused on possible drawbacks of the paper/Gribble's approach, and more bullet-pointed. If I have time this evening (not hugely likely, unfortunately), I'll try and make some notes.

  20. Perhaps we ought to focus on Gribble's apparently intentional shoddy research meant to make a formula disaster kit out to be prohibitively expensive, and how that was disproven by another mom in her area with a few hours of research.

    It is unethical that research this poor be published where others will believe it and use it to form disaster preparedness plans. This is no less unethical than some of the tactics of Nestle that lactivists rail against. Are people going to call for Nestle-like international boycotts of researchers like Gribble if babies die during a disaster because people heeded her bogus research and didn't hear about the research Lisa did to counter it? Perhaps they should.

    Gribble's colleagues ought to be ashamed of themselves that they find this level of poor research to be acceptable. The world of lactation experts seems to be suffering a serious case of groupthink. Unfortunately real people will suffer and possibly die because of their blindness to their unethical approach.

  21. Considering how little work you appear to have put into verifying your numbers, I'm not sure if I feel better or worse that it seems to be taking you a while to address that. Doing due diligence in the first place would be more efficient, even if it yields unpopular results. The fact that one of us could call you on your numbers with a few hours of research makes your whole article look like a hit piece on formula in disguise. There's nothing misunderstood, there, on our part.

    The reason this is such a heated subject is that the bulk of FFF's readers have, at least at one point or another, had some study shoved in her face by snotty lactivists intent on proving themselves right rather than actually helping women and children. Typically, that study is deeply flawed, yet it seems like no one in the lactivist community is calling for honest research. Your numbers would have stood if we hadn't called you on them. Can you see why that makes all of us here shudder? Those numbers would have been thrown in our faces–perhaps already have been–as yet another attack on our dedication to our children, our intelligence, and our sanity.

    Can you perhaps understand how aggravating it is for us to be kicked out of playgroups and doctors' offices, made to feel like pariahs in hospitals, and are told via public service announcements that we're child abusers for merely doing what is best for our families? Much of the discrimination we face traces its genesis to the flawed, biased, and outright dishonest “research” that's quoted as gospel. But debunking the “breast is best” mantra, revealing the groupthink endemic to a lot of the researchers out there and insisting on truth in research isn't sexy, so instead, formula feeding parents are left to explain yet AGAIN things like correlation vs. causation, how studies like yours feature numbers that are flat wrong, and explain the culture of bias against formula as a viable alternative that exists in academia and public policy.

    It's an uphill battle because researchers who have the power to change worlds with their research don't seem to want a little thing like ethics get in the way of ideals. You have said you're learning more about us than perhaps we realize, well, I know where you're discussing what you supposedly are learning, and I can say that I too am learning more than you realize. It shocks and saddens me that people who have legitimate concerns about the validity of breastfeeding research and whether that research will lead to more harm than good are dismissed as bitter and angry. Downplaying the FACTS–not just opinions–of others the way you have does nothing to further respect for women in a professional environment, nor does it help improve the state of breastfeeding research. I knew that things were bad in academia, but the response of your colleagues shows me just how much groupthink has permeated the culture–to the detriment of all women.

  22. We put a lot of work into our numbers and they are still OK.

    I do understand where the anger comes from and that is why I have not responded in kind. I don't think that it is OK for judgements to be made about people based on how they feed their baby in ANY way. I also know that the things that you describe are also applied to mothers who are breastfeeding (less so with the research issue but certainly with the other things). It seems that mothering is a highly regulated activity in which any deviation from what is considered “good mothering” is censured- no one wins and very harmful to all mothers.
    I haven't dismissed any of you because you are angry. I have listened to you and as I mentioned, I will be using some of what I have learned here in amending the information we provide on infant feeding in emergencies.

  23. Sorry to keep harping on this, I have one suggestion for elaborating on what you FFF write in para 4 above, re: how to provide aid to BF vs FF mothers in emergencies. There is one part of the original paper that bothered me in this regard and I have tried to put my finger on why (“Wherever possible, women who are mixed breastfeeding/formula feeding should be encouraged to avoid using infant formula – and assisted to provide for all of their babies’ nutritional needs by breastfeeding them very frequently (as often as hourly should be expected). Enormous care should be taken to ensure that infant formula is not distributed to breastfeeding mothers; previous experience has shown that where infant formula is given to breastfeeding mothers it is frequently used and results in increased rates of diarrhoeal illness in infants [24]. It should also be considered that mothers of young, fully formula fed infants may still be lactating and be able to reinitiate breastfeeding fairly easily. In the stressful circumstances of an emergency, it cannot be assumed that mothers will think of reinitiating breastfeeding”)

    The assumption here is that just having formula on hand in an emergency may be a bad thing for babies and mothers, again based mainly on the assumption of bad water leading to diarrhea (negated by availability of RTF), and so the option of offering formula should be restricted. This bothers me because it doesn't consider what mothers and families may WANT in a disaster or what THEY may think they can or cannot do re: lactation. It's paternalistic, on par with initiatives to ban formula from maternity wards. It suggests that in a time of stress emergency care workers should prioritize not just encouraging those who can and want to continue BF to do so, but actively pushing those who may have weaned (even partially) to relactate or focus on getting their supply back up, because it makes aid workers' job easier. this is the part of the paper where it seems like the authors' bias may encourage putting parents under extreme pressure at an already stressful time to do something that may not even be possible. I don't think a disaster zone is the time to worry about booby traps or sneer at women for not trying hard enough to nurse. Yes, formula is harder to provide hygienically in emergencies, and certainly relief workers should explain the options and costs/benefits of either feeding option to parents. But the tone of the paper gets ideological here (even passive aggressive, assuming that the “big bad formula culture” is going to capitalize on disaster to force poor little BFing mothers to wean) and makes it harder to see the facts presented in the rest of the paper as truly focused on disaster relief vs. lactivism.

  24. I whole heartedly agree with this, it's what I mean in one of my first comments on that whole thread although I wasn't nearly as eloquent. Karleen has written another article with the words 'protecting women's reproductive rights' in it, she only talks about breastfeeding in this paper, which seems OK because the paper is specifically related to breastfeeding. I think the problem arises when you hold that paper up against comments such as the above and see that the belief is that it is only breastfeeding women who are considered to have reproductive rights. Women who have chosen to formula feed have their reproductive rights completely eroded in an emergency situation and are expected to just re-lactate regardless of their wishes.

    Sorry for always jumping on the end of your posts just to agree with you Perfesser, I think you're a very clever lady! :)

  25. “It seems that mothering is a highly regulated activity in which any deviation from what is considered “good mothering” is censured- no one wins and very harmful to all mothers.” I agree. So why not accept that formula is safe, useful for many people, and that BFing should not be considered to be the gold standard of “good mothering”? Your article paints FFers as all kinds of irresponsible, from requiring more resources in an emergency to giving their babies diarrhea, to the extent that you would rather push women to relactate than use it. Few of us here are worried about deviating from Good Mothering standards, I think we're all pretty confident that our choices have stood our children in good stead. Have you considered whether you might be contributing to the problem?

  26. She has not. We're in True-Believer-ville, indicated by the dodging and weaving of answering direct questions and attributing disagreement to ignorance. I'm impressed by the fancy footwork, but not so much by the integrity of the researcher.

  27. Just a comment about the amount of water needed to clean your hands in an emergency situation. I helped clean up after last years Brisbane floods. The mud was indescribable. It probably took 500 mls rather than 100 mls to clean my hands properly, even with gloves on. Lots of heavy duty rubber gloves need to be added to any emergency kit.

  28. Whether a mother chooses to breast feed or bottle feed, clean water is a must in any type of emergency. I recommend a water purifier of some kind. When I was having my family I always made sure I had a few months supply of formula for my baby. The last thing anyone needs in emergency situations is a crying baby.

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