Formula feeding in disaster situations: Is there a dose of reality in your emegency kit?

I hope there is a correlation between formula feeding and developing a good bullshit meter, because guys – you all need one to survive what’s going on in the world of infant feeding.

Someone emailed me today about emergency preparedness. She was in the process of weaning, after an extremely difficult struggle with breastfeeding and an emotionally draining decision to stop the madness. There were storms where she lived, and she got to thinking that in the case of emergency, she’d need formula. So she did what any educated, concerned, modern mother would do: she googled. And instead of finding practical information on what should be in a formula feeding parent’s emergency preparedness kit, she found endless supplies of breast-is-best admonishments.

Her email could not have come at a more opportune time, because later in the day, I came across a series of Tweets about a “new study” outlining the specifics of emergency preparedness for both breastfeeding and formula feeding moms. The tweets linked to articles alluding to this paper from the International Breastfeeding Journal (surprising, isn’t it?), which the media presented as a “study” about how dangerous it is to be a formula fed baby in a disaster, even in a developed country.

Erm, no.

The “study” is actually a paper talking about the stuff mothers should have in stock in case of emergency. Now, it’s perfectly understandable that breastfeeding is far more ideal than formula feeding in emergency situations. Formula feeding in times of disaster, especially when water and supplies are scarce, is terribly difficult. But the way that this paper presents these facts is highly offensive, as it reads like a bad joke: What do formula feeding moms need in disasters? $500 worth of gasoline, formula, bottled water, cleaning supplies, a tool kit, knife, and Davy Crockett. What do breastfeeding moms need? Diapers and wipes.

There’s truth to this, of course. The abstract states that “Emergency management authorities should 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.” Fair enough… I agree that it is vitally important that parents and emergency workers know how to prepare and provide safe formula to babies.

Going back to that bullshit meter, though, mine was registering a 9/10 for this “study”. As early on as the introduction, the authors reveal their bias:

“In an emergency situation, infants who are exclusively breastfed have their health and well being protected by the food, water and immune factors provided by breast milk. Breastfeeding also mitigates physiological responses to stress in both infants and their mothers, helping them to cope with the stress of being caught up in an emergency situation… mothers who are exclusively breastfeeding are able to continue to provide food to their infants regardless of the stress they might be experiencing and their own access to food.”

Based on WHAT? They do not cite any studies for the latter claim; as for the one about breastfeeding mitigating stress, the only citation is an e-pub by one of the same authors as this study, in a journal called “Disasters.” I’ll have to track it down, because I’m curious what evidence they have for this dubious statement. Frankly, knowing the trouble most American women have initiating breastfeeding successfully, I kind of doubt a mom with a 5-week-old would find breastfeeding less stressful than trying to prepare formula safely (even if she had to use a knife and liquid petroleum gas, as this paper suggests).

As for the assertion that a mom can produce adequate milk no matter if her own food supply is insufficient or if she is under extreme stress, I again cry bullshit. What about this study, which shows that stress hinders letdown? Or this one, which talks about the effect of dehydration on lactating mothers? (Let me not the scarcity of studies on maternal stores… lots of them on goats, but not so much on human females. Doesn’t seem to matter if the mom drops dead from malnutrition or dehydration as long as the baby is getting enough, apparently.)

Then, the authors begin to delve into what appears to be their real agenda – discouraging formula donations, even from the formula companies themselves. They claim it’s because breastfeeding moms may receive the samples and sabotage their breastfeeding abilities (okay, I will concede that point, but what about the moms who are having trouble keeping up supply for the reasons above?), and also because it might be distributed to those who don’t know how to properly store and prepare it. Bullshit. If it’s between a baby starving to death or taking the risk that the parents don’t know you’re supposed to slice the top of the formula jar with a knife cooked to 100 degrees celsius, well, I think the answer is pretty obvious. A parent will either know this stuff because the message has been adequately imparted, or they won’t. Not having enough formula is not going to change that. The authors recommend that money be given to the “proper” organizations instead, who can correctly distribute the formula. No offense, but UNICEF has not impressed me with their knowledge or concern for formula feeding or non-breastfeeding Western women.

Speaking of non-breastfeeding Western women, I also wanted to know – especially in light of that Tweet about the Japan earthquake I talked about yesterday – what all of this hullabaloo was based on. The authors of this study cite a case (no citation, so I can assume this was something the authors heard word-of-mouth) from Katrina where a 3-week-old baby starved to death after being stranded on a roof with its mother and no formula. Apparently, the woman’s breasts were full of milk, but “initiating breastfeeding had not occured to her.”

Maybe that happened. If it did, that is horribly tragic. But we’re talking about disasters. Disasters. People do not think straight. That woman was stuck on a roof with a baby. Even if she had been successfully breastfeeding, god knows what would have happened. It seems really inhumane to me to take stories like this and turn them into cautionary tales against formula feeding.

The authors claim that “(t)he purpose of this paper is to detail the supplies needed by the caregivers of breastfed and formula fed infants in an emergency situation where essential services such as electricity and clean water supplies are unavailable and to discuss some of the practicalities of caring for infants in emergencies. The amounts provided for each emergency item are based on the clinical experience of the authors’, the author’s trial of the procedures, and the manufacturer’s instructions.” So again, I’m not convinced that any of this is based on actual empirical evidence, but rather assumptions and vague reasoning from people with an obvious axe to grind against formula feeding. Bullshit.

As for practical advice on what should be in your own emergency preparedness kit, I’ll work on it, peeps. Besides the normal emergency stuff (tons of bottled water, etc) I personally have a week’s worth of bottles of RTF formula, a few packs of disposable bottle liners and the bottles you use with them (you know, from that company that rhymes with Shmaytex), and about 10 nipples. I also have antibacterial wipes, in spades. That’s probably not the safest way to go about things, so I will look into the realities of what this paper recommends. Somehow, I don’t think it would cost $550 Australian dollars (about $569 USD) to ensure a formula fed baby’s safety for a week. But I’ll have to look at it more closely, because I seriously know nothing about disaster prep.

Until then, I’d be more concerned with honing your bullshit meter than worrying about a natural disaster. Statistically, it’s a fair assumption that you’ll be needing the former way more than the latter.

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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430 thoughts on “Formula feeding in disaster situations: Is there a dose of reality in your emegency kit?

  1. I was awesome at breastfeeding my daughter when I had easy access to clean water, fresh food, a great support network & a comfortable place to Nurse. Oh wait. Hang on.

    I had no milk. Gee. I wonder how well I would have breastfed in an emergency situation then? I expect about the same.

    Formula emergency supplies – RTF formula, Disposable bottles & nipples. Antibacterial wipes. Gallons of bottled water (which you should already have) and a willingness to face the fact that in an emergency nothing is going to be ideal – and anything is probably better than nothing.

  2. Wow. This has come out of my Alma Mater. Luckily here in Australia we have drs (GPs, OBFYN and Paeds) that wade through this BS and give FF mothers true requirements. Unfortunately militant lactivism is becoming louder in Australia, and so is the revolt. It's becoming more and more the nipple wars in Sydney and this slanted study is just providing fuel to the fire.

  3. Wow. I think I've restarted this sentence four times now, because all I can think is — what, are they serious? Oh, I think they're serious.

    I think every family with a baby ought to have some formula and bottles in their emergency kit, because what if something happens to the breastfeeding mother? I've always thought the idea that the very existence of formula in a home = instant breastfeeding sabotage was some pretty heavy BS, and I'd rather have the formula and not need it than have something happen to me and leave my husband without a method to feed the baby.

    Though if I'm honest, I admit that I do take some disaster assurance from breastfeeding, like — cool, at least there'll be food strapped to my chest.

    Also, I find it hard to believe that a mother on a roof with a starving child and breasts full of milk didn't think to try breastfeeding. If she was formula feeding already, I can't imagine she was exactly

  4. HOLY WOW!!! Yes I am smelling a lot of BULLSHIT on this one. Yes the kit should be different. But I think even a BFing mom should have some bottles and formula in for an emergency situation. What if something (let's not really think about it) happens to the MOM and she is unable to BF. Then there's nothing left.

    Sorry just read Ashley's post and she said the same thing. And I totally agree with her other point about formula samples and instant sabotage. Don't quite get that thought.

  5. AShley: “every family with a baby ought to have some formula and bottles in their emergency kit, because what if something happens to the breastfeeding mother?”

    Ding-ding-ding-ding-ding! EXACTLY.

    And the line, “mothers who are exclusively breastfeeding are able to continue to provide food to their infants regardless of the stress they might be experiencing,” is the biggest load of hogwash I've ever read. Stress can royally screw up people's bodies, that's a fact, but it will magically avoid hindering milk production? Give me a break! (For the record, under stress my body has been known to give me migraines, make me unable to eat without the food immediately exiting, and faint… but these authors are SURE I'd still be able to breast feed)

  6. I call bullshit.

    Under the best “first world” conditions my body was unable to produce milk, even with the aid of teas, oatmeal, fenugreek yada yada yada. SO obviously if there were a major disaster it'd be totally easy right? *rolls eyes*. Here a major earthquake is the greatest threat, so what if I was breastfeeding and away from the house when it happens and just my husband with his vestigal nipples is there to care for my child. What then? Baby starves. Oh heck no. Even if I were BFing I would say feed the baby. I'd rather my supply dwindled/went away than my child die of starvation. These people are morons.

    On another note, thanks for posting this. I never thought about that. I'm going to be buying a few boxes of the premade stuff in the little 2 ounce plastic bottles now and putting some along with sterile bottles and nipples in our disaster kit, as well as putting the same in our vehicles.

  7. I've restarted this three times. I've been in a disaster… houses shooting flames, propane tanks popping, people running, my husband inside a house that would eventually burn down with a cell phone that didn't work, evacuation orders that continually push you back from being able to talk to (or find) your husband. Yeah, emergency. Thankfully my son was safe in my belly at that point, but I definitely have some perspective on the issue.

    First, we are woefully unprepared for emergencies. Let's not talk about what you need as a formula feeding mom. Let's talk about what you need as a family. A PLAN. Please, before you start stocking your house for an emergency to feed your kid, make a plan for being able to locate your family… and a backup plan. Where will you meet if you get separated? What happens if the phones are dead? Where will you keep extra copies of important documents?

    Then you need to realize that even if you have those supplies, it's quite possible that you won't be able to access them unless you have the disaster kit with the baby at all times. If there's an earthquake, you might not be able to get home. If things are on fire, you might not be able to save the disaster kit (and if it's a large emergency, you might still have a difficult time getting more). It truly is hard to prepare for a disaster or emergency… and the best I can do is have a plan to reconvene.

    I think the best option is having RTF in your house and car, which is good anyway in the event you got stranded in a non-national-crisis. It requires the least amount of supplies and will work in the event that there is lack of water. I also always encourage people to have extra bottled water on hand for themselves as well, which works for formula.

    As for the stress and breastfeeding argument, I really have few words. All I know is that breastfeeding did nothing to help relieve the incredible stress I was under, and my milk supply did not hold up, for whatever reason be it stress or just my inability to make milk.

    • If you live in a hot climate, the bottles of RTF can get hot and leach chemicals into the formula. (This often happens to us with the bottled water we keep in the car.) Better to store it somewhere in the house that’s easy to get to, so you can grab it and head to the car if necessary, I think.

  8. Umm.. what?

    What you need in disaster kits for a FF parent (or ANY parent with children under 1 one for this matter becuase if breastfeeding suddenly stops working you can be sure there ain't no shops open): Formula (whether it is RTF or canned stuff), as much bottled water you would think you would need for a week of drinking, cleaning (yourself and other stuff) or as much as you can possibly store :P, bottles and a camping billycan or gas hob type thingy with a pot. Antibacterial wipes would be awesome to go along with the kit.

  9. Ok, as someone who's milk supply completely crashed after a crisis situation, this: “mothers who are exclusively breastfeeding are able to continue to provide food to their infants regardless of the stress they might be experiencing and their own access to food” makes me feel nauseated. What if BFing moms lose their milk supply and then don't have access to formula? What happens then? The baby could starve to death. I remember the nurse in my prenatal class (most useless 150$ I ever spent) saying something similar, that even if you're dehaydrated and starving you'll still make all the milk your baby needs. There is no way that can be true. Yup, my BS-meter is definitely going off.

  10. I can tell you that as someone who was using formula to combofeed for insufficient supply during a disaster (7+ earthquake) it is fucking terrifying not being prepared. I think it's especially hard when you've been a planning on being a breastfeeding mother who is then not-because emergency preparedness and what you'll need now that plans have changed is not as much on your radar. When our disaster hit my baby was 8 weeks old and I was still at the point where I was crying every time I opened the formula tin. How I was going to feed her with no water or power (fresh off a lecture about how I couldn't keep 'just' breastfeeding her because I was starving her) was extra grief.
    I read that study (or rather looked at the pictures 'cause I'm busy) and saw it very much slanted towards a 'why you should breastfeed' argument. Not at all helpful when you are or were intending to breastfeed. The article kind of makes the basic assumption that after the disaster you're going to be living in the woods covered in dirt
    So yes, I agree that all emergency kits should have formula in case of extra emergency loss of the breastfeeding mother. We've had a few formula feeding in emergency situations bulletins here and since RTF bottles aren't available here they recommend feeding cups. Because if water is limited (and power) bottles are harder to clean. We made do with preboiled cooled water for several months. Disasters have different magnitudes as well. Here we are generally recommended to prepare for 3-5 days without outside contact- not the however long in the study.

  11. Because, after all, if mom is injured or separated from her baby, her husband will be able to keep the baby alive on happy thoughts until she can be found and resume breastfeeding. Yup. That's realistic disaster preparedness.

  12. We know that anemia can hinder milk supply…I would imagine that stress, dehydration and/or starvation would also do so. And even if the mother were able to keep up her supply regardless of her state of health, would it eventually kill her (by leaching her of nutrients, and/or energy?)

  13. As someone who spent 5 years involved in post-Katrina recovery in New Orleans, I really hate it when researchers use it to further their own scholarly agendas about topics that are tangentially related. They try to jam their own objectives into the context of Katrina, whether or not it's appropriate or makes sense.

    I am curious how we know this woman was producing milk if she did not even know / realize it. Besides that, there is so much more going on in thst particular anecdote. One of the many interlocking tragedies of Katrina in NO was the demographics of those left behind – the 100,000 or so residents who were poor enough to lack routine access to a vehicle and therefore unable to participate in the voluntary evacuation. Many of these stranded individuals were on public assistance, and with Katrina striking in late August, were at the end of their monthly checks. I have no idea if this particular woman and child fit that profile, but NO was one of the poorest cities in the nation prior to Katrina – in some neighborhoods more than 4 in 10 inhabitants were well below the poverty line, and poverty was highly correlatd with race, i.e., black New Orleanians were much more likely to be poor. They were also much more likely to live in neighborhoods suffering Katrina-relatd damage. So there's a strong likelihood this woman in this scenario was poor and lacking the first necessary resource to avoid this particular disaster – a car to transfer her out of the city before the levees crumbled and flooded the city after the storm struck. After that, as the waters rapidly rose, she suddenly found herself up on her roof for days without much of anything, if I had to imagine.

    In this scenario, would she have even had a disaster kit, and if so, had it handy when the waters started rising? Was she with other family and kin? Who was going to carry the water bottles and formula supplies up to the roof if she had the baby in her arms? Did she have a reasonable supply of formula at that time of the month? Was she adequately feeding her child before the city flooded? People were stranded for days but could an otherwise healthy 3 week old really succumb that quickly? I know very little about child health but if some newborns go 3-4 days without sustenance until their mother's milk comes in, that suggests perhaps something else was going on? And I don't mean that in a blame the victim way at all, but rather just trying to contextualize this specific anecdote if that is indeed what this article is subsequently based on. And if this woman was eventually rescued with a very ill infant in her arms, isn't it the responsibility of the Red Cross and other first line responders to ensure they have formula on hand for babies in this crisis moment who for one reason or another may lack access to breastmilk?

    And why didn't it occur to the mom to try and breastfeed, if that was legitimately an option? Perhaps the authors could back up a couple months or years or a lifetime in this particular woman's circumstances and ask about educational interventions thst would have helped this woman recognize her breasts as a potential health resource for her child, such that she might have tried using them to feed her child at birth, if we are assuming she did not, as her lack of trying to nurse on the rooftop possibly suggests.

    As someone who breastfeeds, pumps and feds expressed milk, and feeds formula, I definitely see how being able to pop the baby on my breast in an emergency circumstance would be the ideal. But I also know that would increase my need for water and sustenance, is it does on a normal day, so breastfeeding during a crisis does sort of demand a healthy mom, just like it does regularly.

    Anyway…my husband just got home from work and distracted me from my internet rant here, so I guess I will stop for now!

  14. Wouldn't those tiny little 8oz bottled waters, black trash bags, and the sun be enough to make warm, safe bottles of formula? Or canned heat instead of anything resembling a gas stove? These people have clearly never actually prepared for an emergency (or camped).

  15. You know, I started crying in the Target parking lot one night shortly after weaning my son when I randomly started thinking that in the event of an emergency I wouldn't be able to feed him. I never even though of just having a stockpile of the little RTF bottles for him. Actually, a disaster would have led to me weaning him anyway because he wouldn't latch without a nipple shield and even that was horribly painful, so the only way for me to get milk for him was to pump (I never got the hang of hand expressing). Even if I stuck to my hand pump, or got past the excruciating pain and exclusively nursed, I would still need enough sanitary water or wipes to keep the bottles and pump parts or at least the nipple shield clean. But at least I would have the happy breastfeeding hormones to get me through the stress of a disaster or emergency. (massive eye roll).

  16. I'm the first author on this paper and I am really glad that the paper is being discussed and some people are thinking about what is needed to prepare for an emergency. I'm curious though about those who think that the recommendations are over the top. What things do you see as being unnecessary?

  17. Two of my concerns (aside from lazy writing, WHO recommendations in intro, is that really necessary or could you just not think of anything to kick off with? ), are that you advise women who breastfeed to have no other emergency resources which could be disastrous if the Mother is not with her child at the time of the emergency. Secondly, you glibly state that stress doesn't matter, although really, we don't know. Here's one paper on that There are numerous other examples but I suspect that the lady who writes this blog will respond to them far more eloquently that I am able.

  18. That's not actually what I meant to say. I think a large flaw of your paper is that whilst the focus of the paper is supposed to be on what you need in case of an emergency, you appear to focus rather too much on the optimality of breastfeeding. There's no need for you to talk about WHO and UNICEF recommendations, you just need to talk about what you need for an emergency. There is the glaring omission that I mentioned before re: breastfeeding women and supplies. Secondly, your paper referenced in [2] irritates me beyond belief as it is entitled '…protecting women's reproductive rights and maternal and infant health.' when actually you are only concerned with protecting *breastfeeding* women's reproductive rights and excluding the reproductive rights of women who have chosen to (or are required to) bottle feed. Another problem is that you state that 'Good feeding practises entail breastfeeding for the first six months of life' which falls into the 'one size fits all' scientific rationalist framework which is a big trap and not altogether true. What about women who are taking medication which causes breastmilk to be less than optimal for their infants, or infants who have severe allergies to breastmilk, or infants of Mothers with HIV, Mothers for whom breastfeeding has caused PND and so on?

  19. Actually, Stephelen, I think you expressed yourself far more eloquently than I will be able to. Excellent breakdown of the criticism I have with this paper.

    Karleeng, I to am glad that your paper got people talking about emergency preparedness for young babies, because it is something that we should all think about. However, I think the paper should express more clearly that you are talking SOLELY about what one would need to FEED a baby. The fact that you say breastfeeding moms need only “nappies and wipes” is oversimplifying a rather serious subject. Breastfeeding moms WILL need more water and food than a non-nursing individual in order to ensure their own health and safety as well as the baby's. You outline what a formula feeding parent would need for one week in a situation where there was no electricity, clean water, etc; but can you imagine what a breastfeeding mom might go through if she was attempting to nurse an infant for a week while braving the elements, with limited water, and extreme stress? We can't take data from women in areas with ongoing sub-par nutrition or women fasting during Ramadan, and extrapolate their experiences to those in the midst of a major natural disaster. I think it is an unfair and dangerous assumption to state that breastfed babies and their mothers will be able to function with just diapers and wipes.

    I also wish this paper had framed itself more honestly…. it reads like a diatribe against the dangers of formula feeding, not like a simple list of disaster preparedness suggestions. The press and other breastfeeding advocates are certainly reading it that way, so it's not a figment of my formula feeding/formula fed imagination.

    There are also simpler ways to formula feed in an emergency. How about those ready-to-feed nursettes that the formula companies give as the dreaded samples in formula freebie hospital bags? They come with disposable nipples. All you would need to do in that case is wipe your hands with one of those nappy wipes, remove the plastic from the nipple, and attach it to the bottle. Done and done. If this is method of feeding is deemed safe enough for full-term babies in hospital, it should probably be sufficient in emergency. Perhaps that would be a better and more politically correct use for those samples. Why can't we suggest that to breastfeeding and formula feeding moms alike? Take those hospital nursette samples and stick them in your earthquake kit. You probably would just need enough to keep a baby from starvation, so a week's supply would be sufficient. Babies over 4 months could be given supplementary foods as well, and under 4 months, most could survive on 20 oz/day. It's not ideal, but we're talking emergency, not Club Med. I did the math, and to do this was 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. The disposable nipples would be about another $30-$40 at the most. Or you could just buy the Similac pack of 48, 2-oz nursers which come with a ready to use nipple and ring – pack of 48 for $41.94 on amazon:

  20. Thank you FFF. I'm an absolute lurker on here and love your site and writing style. I'm supposed to be not commenting as I'm writing a paper on discourse surrounding bf in the UK and may, at some point in the next four years or so, have to use some forums as data and it wont look good if my comments are all over them! However, when 'studies' such as these are published I have a really serious concern that children's lives could actually be lost as a result of the author's (or authors') biased and irresponsible view(s). If you wish to write an article concerning the 'risks' of formula feeding please feel free to do so; do NOT write articles which give absurd and feckless advice.

  21. I find it really interesting that people are so focussed on what is said about breastfeeding. I'm happy to respond to your comments but only if you actually want to hear the answers, as people who are formula feeding I'm wondering why you are so concerned? The answers to many of the questions and comments posed are not necessarily simple and I can't go through point by point, but if you pick out the main ones that you really want to know about I will have a go.
    FFF thanks for your suggestion about using ready to use formula that comes in disposable bottles. That would be a great idea if these products are available where you live and I would hope that anyone reading the paper in locations where these can be purchased would understand that they could use these and that would negate the need for some of the things in the kit (like the knife and bottles or cups). Unfortunately, they are not available in many places (certainly not in Aust, NZ or Japan where the most recent large scale emergencies occurred with large populations of formula fed babies- might only be available in the US?). Believe it or not even liquid ready to use in tetra packs is a fairly new innovation in a lot of places and to get enough packs for the photo shoot involved going to 5 shops because the stock so few of them here. Regardless, depending on the emergency, you still would need to be able to wash your hands. The big deal with washing hands is in emergencies that have involved a lot of water which may result in contaminating most surfaces with sewage containing water. You have to wash carefully in those situations. If you didn't have the water wipes and anti-bacterial wipes might do but you would not recommend that. You must have enough teats for each single feed because washing teats is very difficult without abundant hot water.
    Still wondering what is not needed- giving people information on what they need to prepare for an emergency is the purpose of the paper.

  22. It's interesting that you assume that everyone is formula feeding, I'm not. As a breastfeeder myself who is fully supportive of all families, I am certainly more than happy to see your response. If you would prefer everyone to be formula feeders then I will happily fill that role and tell you that we are concerned because we find your writing disingenuous.

    I would be interested to hear your take on this comment from UNICEF:

    “”I want this message to reach all mothers of young children in Haiti: Please, keep breastfeeding. It may save your baby's life,” stated the Minister of Health, Dr. Alex Larsen. “And for those beyond our borders who want to help, thank you very much for your kindness, but please understand that sending powdered infant formula is not what we need.”

    As compared to this comment from the Minister of Health, Dr. Alex Larsen, Haiti

    “I want this message to reach all mothers of young children in Haiti — Please, keep breastfeeding. It may save your baby's life. And for those beyond our borders who want to help, thank you very much for your kindness, but please understand that sending powdered infant formula is not what we need. For infants who cannot be breastfed, ready-to-use infant formula is best.”

    I like to think that Australian and NZ women are able to order from the internet. Should that fail, it would be fantastic to believe that relevant aid messages could be received by the rest of the world, although thorough comparison of the above two quotes suggests that somewhere along the way messages are lost. If messages fail, I hope that women in Japan, NZ and Aus. have mastered the art of cutting and using cups etc. [“could understand that they could use these and that would negate the need for some of the things in the kit (like the knife and bottles or cups)”].

  23. “Regardless, depending on the emergency, you still would need to be able to wash your hands. The big deal with washing hands is in emergencies that have involved a lot of water which may result in contaminating most surfaces with sewage containing water. You have to wash carefully in those situations.”

    Really? Really???? So not only could women in Japan, NZ and Aus not manage to purchase things from the internet, even if there were an article on effective infant disaster survival kits, but they would not be able to use disinfectant alcohol wipes etc.? As FFF said, this isn't 5* hotel, this is emergency earthquake, tsunami, nuclear explosion. I LOVE that you follow from a 'washing hands' point immediately into teats. Obviously, breastfeeding women don't need to wash their hands.

  24. “The answers to many of the questions and comments posed are not necessarily simple and I can't go through point by point, but if you pick out the main ones that you really want to know about I will have a go.”

    Speaking for myself, but one key question is your assumption that in a disaster a Mother will always be with their child. If a Mother is not with their child in the case of an emergency, and as a breastfeeding Mother I am not always with my child, what should their care giver do if they have no supplies?

    “Still wondering what is not needed- giving people information on what they need to prepare for an emergency is the purpose of the paper.”

    Perhaps less of the heavy WHO and UNICEF tone and more focus on the task at hand? Why do women not know how to prepare formula safely? Why do organisations not have correct guidelines regarding the safe distribution of formula? What would the correct guidelines be if we take into account cultural differences in breastfeeding practice (i.e., it's not 'one size fits all')?

  25. “…as people who are formula feeding I'm wondering why you are so concerned?”

    I can't believe that someone would write that. I had to do a third post just to address it. The question is structured rhetorically. Yes, that's right, a rhetorical question. In the same way as we would have a rhetorical question like (I'm trying really hard to think of a neutral example here!):

    “Do you really like chocolate ice cream?”
    “Can you really afford a 5* hotel in Dubai?”
    “Is it nice to sleep safely at night knowing that the Eurozone is safe?”


    “As people who are formula feeding, do you really have any legitimate concerns over any child's welfare?”


    “I'm happy to respond to your comments but only if you actually want to hear the answers…The answers to many of the questions and comments posed are not necessarily simple and I can't go through point by point, but if you pick out the main ones that you really want to know about I will have a go.”

    Obviously this site is frequented by simpletons who have problems decifering the “breast is best” message and fall over ourselves the moment we see an artificial teat. You should have SEEN me the other day, saw a MacDonald's advert and went absolutely WILD, seriously! My husband had to restrain me, I was on it, car keys at the ready, taxi if necessary….(I'm British, we do sarcasm here).

    I think several questions have been posed with regards to this article and they are relatively clear from the posts above. I'm assuming that you will be able to read some of the posts above and points in the original blog post. Perhaps you will find at least one or two that would suit you?

  26. I don't have any problem with those statements. I had friends working to support the caregivers of infants in Haiti and was involved in some of the Nutrition Cluster discussions around this.
    Australian mothers could not legally import formula from the US into Australia and it is reasonably likely that this is the case for NZ also. I don't see why a paper like this should be US centric. It is based on what is available in most of the world.

  27. Just found it strange that people on a blog that is about formula made so many comments about breastfeeding.
    OK I've worked out how to reply to individual posts so I will got back and do that.

  28. *The statement from WHO/UNICEF are the starting point.
    *People do not know how to prepare formula safely because health professionals have not been adequately trained in this area. This is a problem just about everywhere- if you go to the Aust national health body the NHMRC you will see a draft of the new infant feeding guidelines for health workers out for comment. 80 pages on breastfeeding and 10 on formula feeding.- completely inadequate. My submission will be telling them that they need to include more info for health profs so that they can help parents better.
    *Some of the aid orgs have excellent guidelines and do a fabulous job in emergencies. Ones I woudl include in this are Save the Children, Care, UNICEF, Action Against Hunger, Concern. Good practice involves assessment on a case by case basis of what is needed and targeted care both to breastfeeding women and to those who are caring for infants who cannot be breastfed. One size fits all helps no one.

  29. *Nope could not purchase these products in Australia.
    * yes use disinfectant wipes by all means but not as a replacement for washing. The recommendations are NOT the ideal, it is about providing “good enough.” Is there a particular reason why you have a problem with the idea of storing water for washing hands?

  30. * FFF the major risk to babies in an emergency is lack of appropriate food. That is why the focus is on proving the food and for the short term (up to 1 week) until external help has come. I do not provide additional material for mothers because I assume that they have this for themselves out of the ordinary disaster kit checklists (which are generally fine for adults and older kids). It is arguable how much extra food a lactating woman needs. Certainly in a week it matters not whether she has extra. Hydration is more important than food but again, a lactating woman with the ordinary ration of 3L per day that is often recommended for adults would be completely fine. What breastfeeding mothers really need in an emergency is support. In the short term that can be hard to come by but it can be done- unfortunately it is often overlooked because organisations see a woman breastfeeding and think that everything is OK and no intervention is needed. That is not so.Can provide more info on what has been found to work if you like. This is not based so much on research (though there is some info from recent emergencies) but on field experience of those who have worked with mothers and babies in the immediate aftermath of an emergency.

  31. *I disagree because breastfeeding itself is an emergency preparedness activity.
    * Do you want the paper, I can send it to you. It might give you a better idea of where I am coming from- you need to understand that very often when there is an emergency the area becomes literally awash with infant formula and powdered milk (during the Balkans crisis it was estimated that 1/3 of all aid brought in by NATA was baby feeding products). In an environment where bottle feeding is an aspirational activity, formula feeding normally completely unaffordable and formula being handed out for free, people use it. They may have no previous experience with formula feeding, they have very limited water and fuel it is disastrous in terms of child mortality. That is the context within which breaches of the reproductive rights of women are discussed. Targeted distribution of formula and associated resources such a fuel and water to those caring for infants who cannot be breastfed is NOT a breach of reproductive rights.

  32. *The WHO recommendations are always the starting point.
    *It's about covering the majority of situations. As someone else pointed out, people might not even be home when an emergency happens- their kit will do them little good if this is the case. Every eventuality cannot be covered.

  33. Well, you and I agree on this point, at least! 🙂 I definitely think there is a lack of good, thorough information given to formula feeding parents. I've discussed this in many posts so I won't rehash, except to say that I believe this is an unfortunate result of WHO and the Baby Friendly Initiative's fear of discussing formula as an option. It makes parents mistrust the healthcare professional who could give them this info, as they have already been made to feel ashamed and like “failures” for not meeting standards; then they are given brochures full of thinly veiled disgust about formula. This is harmful to babies, and I hope the powers that be will take a long hard look at the reality of our world and realize it is unreasonable to assume all mothers can reach the 12-month breastfeeding ideal and start giving practical, judgment-free information.

  34. I have had a few other people talk to me about mums who are exclusively expressing. Perhaps we should have included this in the paper. I would suggest that mums who are exclusively expressing should learn how to hand express and store water for hand washing, detergent, disposable cups or enough bottles to single use.

  35. This blog is not really “about formula”. As it states in the description, is it about “standing up for formula feeders”, most of whom are either partially breastfeeding or feel like they “failed” at breastfeeding even though they desperately wanted to nurse their babies (myself included). We tend to be a rather highly inquisitive group, as the blog focuses on science (and the misinterpretations of that science running rampant in the media) and social issues as well as the “mommy war” stuff. I did start writing about formula recently, as there seemed to be a need for practical information according to my readers, but until then, I'd venture that there was a hell of a lot more about breastmilk/breastfeeding on this blog than formula. But I understand how you might be under that impression if you were simply arriving here via this one post….

  36. Actually, these people have worked with actual breastfeeding and formula feeding women in emergencies, have worked with many others who have worked with actually breastfeeding and formula feeding mothers in emergencies and have trained those working with actual mothers. The biggest deal in terms of stuff for formula feeding is for washing. That's why there is such a big difference between what is needed to use powdered infant formula and RTUF.

  37. But see, that is EXACTLY the problem I have with so much that comes out of UNICEF and world breastfeeding organizations in general… things are so specific to different areas. What might work as emergency protocol in Africa is not going to be the same thing as the US; from what you're saying, there are grave differences between even two westernized nations like the US and Australia. Same goes for health outcomes and social norms. I don't think we should be comparing observational infant feeding studies between Belarus and the US or England. The ethnic groups are different, which means genetics and propensity to certain diseases and conditions are affected; environmental influences are different, and so on.

    As for disasters, I think maybe it would be better for each nation to come up with it's own guidelines. Here in the US, at least, we also have specific issues based on topography – katrina had its own special kind of hell; it would be a different situation if The Big One (earthquake lingo) hit here where I live in LA. Flooding and earthquakes bring different challenges, I would assume? (I honestly don't know much about natural disasters, so I am really out of my league here….) and also socioeconomic clusters (as someone mentioned previously, Katrina took place in a very low income, underprivileged area; there was much anger regarding racial issues in its aftermath – implication being the govt didn't care b/c the majority of those affected were low income minorities – if this storm had hit an affluent suburb in Virginia it would have been a different situation).

    Also, if formula companies were allowed/encouraged to donate formula as you mention they shouldn't be in your paper, perhaps they could specifically donate the nursettes I spoke of? Seems like the best option, although pricey, so the donations would be helpful….

  38. *How do we know about this mum? She sought treatment for engorged breasts after her baby died (which was in hospital after evacuation from Louisiana). And the point of telling this mother's story is not to vilify her in any way but to show just haw hard it can be for mothers to think of solutions to problems in an emergency and how mothers need support. Certainly the population that was caught in New Orleans was very disadvantaged and I have been told that the breastfeeding initiation rates amongst the women trapped may have been less than 10% (this from a local nurse- don't know how accurate it is). That being the case, so many women with so little experience of breastfeeding, no one to help, no knowledge of how to do it, it is not surprise. I certainly do not blame the mother.
    As for how long a baby can go without food or liquid. Newborns can go for a few days (if you go searching for miracle babies mexico earthquake you will find the stories of newborn babies who were buried for 10 days and survived), they are not meant to have a big volume of food in the first few days. After that however, things change a bit and with the heat in New Orleans a few days was too much for this baby.
    Another story, from flooding in Brisbane earlier this year, is a mum who was exclusively breastfeeding but in the aftermath of cleaning out her flooded home she did not feed her baby as frequently as he needed and he ended up dehydrated and hospitalised. Same sort of root problem.
    A story with a better outcome from New Orleans is a pregnant mother who was stranded in the attic of her home in the latter stages of pregnancy. She had no planned on breastfeeding. She gave birth in the attic, cord was cut with a broken bottle. She was holding her baby on her chest immediately after birth when he bobbed himself around onto her breast (google breast crawl) and started braestfeeding. She continued breastfeeding the baby until rescued a few days later. She and baby were perfectly healthy.
    BTW I use what stories I can gather. Not only examples from New Orleans were included in the paper.

  39. Stress does not affect milk production (though it can effect milk ejection), dehydration will affect milk production, moderation malnutrition does not affect milk production, severe will. This paper is just about preparedness for a short term emergency, not long term but even in the long term feeding the mother so she can feed her baby takes less resources than trying to feed the baby directly and ensuring the mother's survival and wellbeing gives her child the best chance of surviving too.

  40. That must have been terrifying. I have heard similar things from mothers in Brisbane and Cairns, just how frightened and stressed they were because they were isolated and all of a sudden were not able to access the supplies they needed to feed their baby. Hearing from these women was why we wrote the paper, so that next time more mothers need not have that happen to them. The whole point of the paper is so that people can be prepared and it's 7 days worth of supplies.
    I'm guessing you're in Christchurch?? How long were you without power for??

  41. It is a physiological impossibility for mothers to lose their milk overnight. There is no mechanism whereby this can happen. What can happen with stress is that the milk ejection reflex can be inhibited. This can result in a change of behaviour in the baby who can be very fussy and upset and mothers can believe that it means that their milk supply has gone. Mothers in this situation need reassurance and support. If babies are encouraged to continue suckling the milk will be released but feeds may be struggle for a while until things settle down a bit. It is an acute response not a long term one.
    Without food for several days and a mum will be fine and continue to feed her baby (anyone remember Katie Kim stuck in the snow in her car?). Dehydration is much more serious, mums need liquid.

  42. Absolutely you are right on the need to be prepared.
    As for breastfeeding relieving stress. It does, there are numerous studies measuring how it does and I can paste in some abstracts if you like. However what you're hoping for in an emergency is helping a mother be able to care for her baby rather than be so catatonic with stress that she can't do anything except sit. Sadly, some babies die in emergencies because their mothers simply cannot care for them. For some mothers whether they are breastfeeding or not they can't care for their babies. For other mothers it makes a difference.

  43. The paper was not about telling people to breastfeed if they can't. It's about encouraging those who can to continue as an emergency preparedness activity and for those who are not to have the relevant supplies for feeding (and despite being called a moron I am glad that you are getting prepared).

  44. Stress does not stop all body functions. It will not shut down your kidneys or stop your temperature regulation etc etc…or stop your breasts making milk.

  45. BFHI requires health professionals to assist parents who are formula feeding on a one to one basis. But you're right, unfortunately it often does not happen.

  46. What is the problem with what was said in relation to Haiti??
    Each country should have its own disaster plan. The guidance on infant feeding in emergencies can be applied in any country/situation because it is based around an assessment of the particular emergency and what works in one setting (eg baby tents in Haiti) may not work at all in another (eg Pakistan flood)

  47. Oh and the issue with donations. Again, this comes from the past 20 years of emergencies the world around. DOnation just come. They do not come where they are needed, in the amount required and of the type required. They are also very often unsuitable for any use (eg out of date, specialty formulas for inborn errors of metabolism, not meeting Codex standards). They cause huge logistical problems in terms of managing them which detracts terribly from the delivery of aid. Furthermore, when a product is donated, especially a very expensive product like formula organisations and individuals are not careful with how they are distributed. They do not provide the careful one on one assessment that is necessary. They also do not provide all of the other things that are necessary to keep formula fed babies safe- because formula is just one thing that is needed. AND because they are donated the organisation who has not budgeted for buying formula does not guarantee to supply the formula for as long as the babies being served need it. Donations are not helpful because in practice they cause harm.If formula is purchased however, organisations are very careful with how it is distributed. They have had to think carefully about how the formula is used and are more likely to provide the support required. They have had to budget to help a certain number of babies and so they are better able to continue to support caregivers. When this happens (as it did with a number of orgs in Haiti) it works extremely well.

  48. I just read the whole article and while a few areas made me chuckle and shake my head – like the suggestion that radio stations advise “mothers considering ceasing breastfeeding should consider waiting until after the
    [bushfire/wildfire/cyclone/hurricane/typhoon/flooding/snowstorm] season”. (I live in a part of the country where we got almost 70 FEET of snow last winter. Even with that ridiculous amount of snow, I don't believe that we've had a shortage of food, water or even formula. Gas and water lines are underground last I checked, so I don't believe that snowstorms could cause community wide water or gas shortages or problems. I would be offended – though possibly amused – if the local radio station went on the air this month and advised breastfeeding moms to not wean until the spring.)

    On the whole, however, the article didn't seem all that offensive to me – especially compared to a lot of the b.s. breastfeeding “studies” that are out there.

    In most cases, I would assume it would be also easier and safer to BF and infant during an emergency than to FF. If the mom is with the baby and is healthy and fairly well hydrated, I assume that it's true that a baby probably only needs mom and diapers. (Mom and other family members, of course, would need a lot more than diapers and wipes.)

    Out of all the crappy studies out there about breastfeeding, this is the only one that I've read that actually kind of rings true to me. I am highly skeptical at this point that if one could somehow do a true double-blind study of FF vs BF babies that there would be a big difference in health, bonding, etc. However, it seems true and obvious that in a real emergency, FF babies will tend to have more challenges.

    In general, what I took from this article and the reaction on this site to it is how dreadfully the “breast is best” movement is failing mothers and babies. The “breast is best” movement has so thoroughly alienated and put FF mothers on the defensive that an article that is basically benign and actually contains information about formula feeding in an emergency is being viewed as an attack against FFers.

    Oh, and if I had read this article in the thick of my “I'm the world's worst mother and my children will hate me and be obese, stupid and probably serial killers because they weren't breastfed” days, I would have been very offended and it probably would have made me cry. Thank god those days are behind me.

  49. I see your point… my anger regarding this study wasn't about the assertion that breastfeeding is safer in emergency situations, though. I think I said it in the post, but if it wasn't clear – I DEFINITELY think breastfeeding is the way to go in an emergency, and I think it is an accurate assessment to say that one could talk up BFing as an emergency preparedness tool. But I felt that this paper did far more lecturing about the dangers of formula and complaining about how not enough people were breastfeeding…. it also felt like it was coming from someone who has not formula fed, and perhaps was basing protocol on UNICEF and WHO recommendations which I do feel are quite colored by a hatred of all things formula. But you're right, that could certainly be my own confirmation bias sneaking in, and I will readily admit that this is a possibility. I am on the defensive, especially when I feel a study (however well intentioned it may be) will feed in to the circular logic so common in breastfeeding science/literature (for more on this, see Jules Law, “The Politics of Breastfeeding”.)

  50. I think you were mentioning the Haiti stuff in response to stephhelen – but I actually wrote quite a few posts on that situation. I link to them above (in the body of the post) if you are interested in what I felt the problem was (and I think stephhelen probably had a similar issue, although I won't speak for her…)

  51. I was responding to you saying that you had a problem with the statements that stephhelen quoted. I don't have a problem with them but wondered why you did.

  52. There is a lot of info in the paper detailing potential risks of formula feeding because we needed to explain just why each item was necessary in the kit, otherwise people would go “OMG, that's a ridiculous amount of stuff” and discount it. We had to justify everything (especially the need to not reuse bottles!! which is quite difficult for many people to comprehend- the final paper will actually have a photo of a bottle taken from a mother after an emergency that has maggots crawling on the side- it was swapped for a cup)

  53. I'm sure that I said in my post that people can't buy RTUIF in bottles and have them sent to Aust because it is illegal to do so….

  54. THere is no problem with your assertion that we need to wash hands. You are right, it is essential that we do that. My particular problem is your somewhat partironising tonem the fact that you then immediately continue to talk about bottle cleaning makes it appear as though this important bit of advice only applies to bottlefeeding women.

  55. Surely that's a pretty basic point to work from? Mothers aren't always with their babies. You should have considered this in much more detail.

  56. “google breast call”…you're patronising again. Even after being told that a lot of the Mothers on here HAVE breastfed and still do, you feel the need to tell us to google breastcrawl.

  57. I don't think the WHO recommendations are the starting point. Surely, when discussing disasters you should start with an overview of the recent natural disasters that you are basing your work on, some statistics on the length of time people were trapped and unaided for and the relevance of writing a paper on this stuff, i.e., confusing and conflicting messages, the threat of climate change increasing the chances of such disasters. Some figures combined with your qualitative data may have gone some way here.

    Yes, people may not even be at home but there are some obvious eventualities, such as, the Father is at home with the baby whilst the Mother is out. The Mother suffers severe injury or death which prevents breastfeeding. That's ONE sentence along the lines of….”Whilst breastfeeding Mothers should not need any extra supplies, it is advisable that they consider keeping RTF Formula and some disposable teats in the event that they are unable to feed their infants.”

  58. Absurd and feckless. Absurd is silly, you've written a paper about disaster preparedness which completely ignores very real possibilities in an apparent bid to frame breastfeeding as a cure-all in a disaster situation. Feckless means, well irresponsible, you don't appear to have any concern for very real and obvious possibilities nor is your advice particualrly thorough in terms of HOW messages re: requirements for formula get out to the rest of the world, or how you can improve methods of distribution of formula during disaster situations.

  59. No we're pretty happy with most of what we've covered. It's not a closed shop though, you and anyone else is welcome to close the gap or even comment on the paper. Comments are added online.

  60. Heck, I can't read minds. Not everyone (even health professionals) know about infant self attachment. I was not being patronising I was trying to help people understand what had happened.

  61. No it is not a matter of contention. They have looked for a mechanism by which stress could stop milk production and have not found one except for the indirect route of retardation of milk ejection resulting in decreased breast emptying resulting in slowing of milk production. As I described elsewhere, this can be overcome (and not everyone experiences it).

  62. Certainly they could be used. YOu would need one for every feed and it would not negate the need for water all together- still need water for washing hands and preparation surface.

  63. When you're writing you own paper you get to decide what the starting point is or your reviewers tell you they want changes. Many who read this paper (policy type people) will know nothing of the recommendations for infant feeding- that where we decided to start.
    As I said, if you feel this strongly about it, consider adding a comment.

  64. Did you read the table at the end, it was full of media messages, there is also a paper in press at the journal DIsasters on media and infant feeding in emergencies (looking at the press from Cyclone Nargis and the Wenchuan earthquake) and there are also discussion papers and guidance on the website of the Emergency Nutrition Network. I suggest you have a ready.

  65. One paper cannot do everything, but you seem to want to insult from the sidelines. There is a whole body of work on infant feeding in emergencies. We have worked to fill one gap, only one. More will be done with time.

  66. We had to provide detail about the risks associated with using infant formula in order that people be able to understand why each item was required in the kit so that they didn't just write items off without understanding why there were included and what the outcome might be of not including them.

  67. Hand washing is most important for those who are bottle feeding infants. It is not necessary for breastfeeding women though if a woman had been immersed in sewage contaminated water (a possibility in some emergencies) then she would need to wash her breasts (and wash her hands to do so).

  68. It's worth pointing out here that the way of feeding infants in an emergency is the same as for any resource poor setting so the requirement for formula feeding and for breastfeeding are the same as what would be required for those in say, urban poor Jakarta or rural poor South Africa.

  69. Why did my IBCLC tell me that stress had a direct negative impact on milk let-down? Who is the “they” you are citing looking for a mechanism by which milk production is stopped for ALL women? Citation, please. I'm willing to bet it's not about as many women as you'd think, but that's a pretty common problem in breastfeeding research.

  70. So breastfeeding relieves stress for 100% of women. You are curiously adamant that all women are 100% cookie-cutter of each other. A cursory examination of the stories of women on this blog will tell you that for some women, breastfeeding does anything BUT relieve stress. In fact, for some women, it exacerbates or even causes post-partum depression, anxiety, PTSD, and more. What do you call the women who experience greater stress breastfeeding because of prior history of sexual assault or abuse, space aliens from Mars?

    I call it more than sad that some babies die in emergencies because their breastfeeding mothers might be so terrified to give formula that they won't even consider it even in the most dire of circumstances. But unlike some militant lactivists I've run into, I have a) a heart, b) enough critical thinking skills to question the “breast is best” mantra, and c) enough respect for the diversity of women and children that one-size-fits-all medicine doesn't sit right with me.

  71. Excuse me, but are you calling Roxane a liar? It's physiologically impossible for milk to dry up overnight? This happened on one side for me. Went from pumping several ounces per session (which I had done for weeks) to nothing. I had a health crisis at the time so perhaps you're calling me a liar too? Or perhaps my doctor?

    But do go on thinking that all women are clones of each other and nothing could ever possibly happen to a woman's supply. You're just further convincing me of how little respect militant lactivists have for little things like the truth and the individuality of women.

  72. So if someone just plain wants to formula feed, they should just be screwed over in a disaster, is that it? They're going against the almighty WHO, and even if formula feeding works better for them given that their lives have been horribly disrupted, they've probably been traumatized, they may be taking care of injured or sick loved ones, searching for loved ones, or mourning the death of loved ones–this is a BAD thing, according to you? Because I don't know about you, but I have family who were in the worst tornado on record in our area, and they all said the only thing they cared about was a) finding loved ones, b) treating injuries, and c) mourning the dead, and d) trying to piece their shattered lives back together.

    It seems that all the study of breastfeeding in the world has failed to reveal some key components to proper breastfeeding support: realism and empathy.

  73. Your IBCLC was correct and that is what I described. Stress can have a negative impact on the release of oxytocin which has a negative impact on the milk ejection reflex. If compensation is not made for this (eg more frequent feeds, persisting with fussiness in the baby) then this can result in decreased milk production but there is no direct effect of stress on milk production.

  74. Lactating women are physiologically less responsive to stress. This is not measured in terms of “how stressed are you feeling” but in measures like blood pressure, heart rate and brain function. Of course breastfeeding itself can be stressful for some women but that is not what the paper talks about. It is talking about the stress of an emergency. And in all the stories I have heard from emergencies, many absolutely tragic, I have never heard of anything like what you describe.

  75. No, I'm saying that the interpretation of what is happening can be incorrect. It is not physiologically possible for milk to dry up overnight.

  76. So…when I was breastfeeding, feeling like I had to eat more in order to have the strength to keep up with my baby's demands, all I needed were some kind words and a rah-rah chorus of “just keep nursing, just keep nursing?” I was trying to make breastfeeding work without the hell and chaos of a natural or political disaster. After 5 weeks and change, my own medical situation created its own catastrophe but prior to that, I had all the “just keep nursing” support in the world. I can't imagine struggling through all the difficulties I did in the midst of searching for my loved ones, getting medical treatment, scrounging for food, trying to hide from/fight would-be looters, rapists, murderers, mourning the dead, and figuring out how in the hell I'm going to raise a child in a world gone mad.

    I think the problem with your attitude is that you have no actual concept of what it's like to live through an emergency, and why such a situation might make formula the better choice. As I mentioned above, the family I have who were caught in that tornado had their energy entirely focused on finding loved ones, treating the wounded, mourning the dead, and figuring out what to do now that their entire community was shattered. I cannot imagine trying to maintain my energy to breastfeed with little food and total emotional devastation. If something brings some measure of comfort to a woman who is trying to make the best of a situation surrounded by chaos, despair, injury, death, and potentially the threat of crime like rape, looting, and murder–why is this so horrible? If something brings some measure of comfort to a baby who is already swamped by this world and is even more swamped by the chaos of a crisis, why is this so horrible?

    Can I propose a study on the lack of empathy and realism among some militant lactivists? Because I'm very tired of hearing over and over again that nursing is just so paramount that it trumps every. single. thing. else. about a woman or her baby. Including their well-being, even during a time of great trial.

  77. Of course I am biased and so are you, everyone has their own biases and that's OK. I disagree with what has been suggested, that's my prerogative. Reviewers also made suggestions of changes to the paper, some we agreed with and made the changes, others not. However, as a reader of the paper, the offer is open to you that if you see this as a problem, make a comment- FFF linked to the journal.

  78. And yet each paper is used as arrows against those who can't/shouldn't/don't breastfeed. Including papers that have such inexplicable pro-breastfeeding bias as yours. The parents around here have almost universally had individual studies like yours thrown in our faces to prove that we're horrible parents. Perhaps you can understand why you've got our backs up.

  79. Indeed I have personal experience of exclusively expressing for a period of months for 2 children so I do understand very well.

  80. Perhaps this is a problem because all these world organizations, such as WHO, are so anti-formula that they haven't established good ways to get it where it needs to go? It's sort of like telling women in developed countries formula harms babies when the real issue is that the people who tell women formula is unsafe take an active role in suppressing information about proper bottle preparation (for both formula and expressed breastmilk, I might add).

    It seems that the problems you're citing are problems that could be easily solved if major organizations weren't trying to be so knee-jerk anti-formula in the first place, and would actually be willing to solve the logistical issues that preclude safe formula feeding and thus, true infant feeding choice.

  81. I'm to the point where I am inherently skeptical of any NGO saying anything about formula because as far as I'm concerned, they have destroyed their credibility in their zeal to pidgeonhole all women into breastfeeding. Any study that cites them gets viewed by the same jaundiced eye. So many women who visit this blog have been utterly demonized because infant feeding has been turned into a great moral debate that we have no patience with researchers who start out quoting the very organizations that the people who spit such vile venom at us quote.

  82. If you're going to be a balanced researcher in the realm of breastfeeding, you probably ought to read some of the stories of women on this blog, particularly the FF Fridays. You will have a much better understanding of why so many of us are so skeptical of each study that comes along (it's not just yours) and why this is such a hot-button issue for us. So many of us have been mistreated (that's a BIG understatement) by breastfeeding activists, fed misinformation and outright lies about breastfeeding, and booby trapped not by formula companies, but by the very people who purport to help us breastfeed, that I think a lot of us are very tired of research that only seems to feed into the very abuse that we endured.

  83. I'd love to see some of the risks of breastfeeding outlined in a paper. Things like exacerbating post-partum mental health conditions (depression, anxiety, PTSD), exacerbating chronic disease like auto-immune disorders, BFing being incompatible with medications or conditions like HIV, exacerbating pre-existing issues like trauma from sexual abuse/assault (especially important in this case given that in a political disaster, rape can be terrifyingly prevalent), D-MER that could be exacerbated by the trauma of enduring a horrific disaster in which loved ones (or the mother/baby themselves) are injured, unable to get proper medical care, dying, dead…the list goes on and on.

    If we're going to talk risks and claim to have proper scientific study, I'm sick of seeing researchers feel the need to outline the risks of formula, even out of an obligatory sense, and yet see no need to outline the risks of breastfeeding. How is this unbiased science?

  84. It would be a rare woman who would want to formula feed in an emergency given the information about what this would entail for her (formula feeding long term in an emergency when you don't have abundant water and power is incredibly difficult and time consuming) and her child (stats on mortality rates for formula fed infants in an emergency are frightening) but should there be women who want this then in my experience organisations have supported this.

  85. You are right it is incredibly difficult to care for others when you are shocked, traumatised and grief stricken (I described earlier the catatonic woman who can do nothing but sit because of what has happened to her). But I can't understand why you think that formula feeding somehow makes things easier?? In most emergencies (and I'm talking developing country contexts here), the only formula available is powdered formula. Read the paper and see what is required to feed a baby using PIF in an emergency and tell me how formula feeding could possibly make things easier for any mother caring for her child.

  86. The paper is about *helping* parents so that their suffering during an emergency is less. Other papers are similarly about improving the delivery of aid to infants and young children.

  87. Many organisations are doing the best that they can. Many do a fabulous job of supporting mothers and babies in emergencies (and I have listed some elsewhere) and ensuring that infants who cannot be breastfed for whatever reason get the necessary supplies, education and medical care that they need. I don't know where you get the idea that these orgs suppress informing people about formula feeding. WHO for instance has fabulous publications on safety and preparing formula feeds. In resource poor settings education is just part of the issue with high mortality and morbidity in formula fed infants. There is also the cost of formula that has an impact on families ability to care for all of their children and to supply sufficient formula to the baby, scarcity of resources such as clean water and fuel, the bottles themselves are often a factor, the formula itself that increases vulnerability to infection, the absence of breastfeeding that leads to closely spaced pregnancies a risk factor for child death, scarcity of medical resources to treat infection etc etc. For a decade they tried really really hard to prevent mother to child transmission of HIV in Africa by promoting formula feeding and providing mothers with all of the resources that they could to make formula feeding safe (Something called AFASS). It failed dismally. More babies died because of formula feeding than HIV- the massive experiment was abandoned. These are not philosophical issues, they are very very real.

  88. Those orgs that I mentioned earlier…many of them had programs supporting formula fed infants in Haiti. I've not heard any venom from any of their workers, just compassion and a desire to help mothers and babies.

  89. There are papers published in things like these…lots of them. We only discussed the risks of formula feeding that were directly connected with the practicalities of formula feeding in an emergency and as I said, only to explain why each item was necessary in the kit. It was not gratuitous.

  90. I didn't mean to 'like' that, I was pondering over your last comment. It seems that a lot of these 'FORMULA CAUSES DEATH' comments are based (firstly upon the idea that it is the formula and not the water and sanitation!!!!) on the idea that Bf is a magic cure-all for all illnesses know to man. We can see by patchy and inconsistent data that this is simply not the case. Secondly, people tend to assume that women in third world countries all exclusively breastfeed their children. This assumption masks major differences in feeding practises, one very interesting study is Raphael (1985) who carried out an anthropological study of infant feeding practises in such countries.

    I think it's highly offensive and very questionable to state that Formula causes more deaths than HIV.

  91. Establishing a physiological difference between the behaviours of subjects does not entail a knowledge of how this translates to behaviour. For example, neuro-imaging studies show that bilingual speakers activate different areas of the brain when processing conflicting information (the anterior cigulate cortex found in the frontal lobe, or ACC, in bilingual speakers), however, it is still not understood how this interacts with behaviour. Citing physiological evidence is not robust enough.

  92. What I'm trying to say, in case that is not clear, is that whilst you may well be able to point to a lack of increase in heart rate and blood pressure, you cannot at this point attribute those to activity regarding stress. There could be numerous factors interacting at this point and we can't know which ones.

  93. Out of curiosity, are we to assume that the moment an emergency/disaster strikes women who have been FFing/whose supply has dried up a while ago/never were able to latch etc. will magically see the light and get their bodies to re-lactate? It's confusing to me that this is framed as a choice in an emergency when clearly it depends on what you were doing before said emergency came along. Or is the larger point to say that emergency preparedness is a good reason to choose breastfeeding in the first place?

  94. I think she means that when you're biting your knuckles, stamping your feet, sobbing and hissing statements about mysogyny at your husband whilst your baby's birth wieght drops and they become accustomed to a diet of puss and blood, you should be thinking “But what if there's an earthquake/tsunami/hurricane tomorrow?”

  95. And yet you still advise that breastfeeding women do not need any equipment with which to wash themselves, just 100 nappies and wipes?

  96. OK then that advice seems to apply to people who both a) have the biological and social/economic choice of BFing vs FFing, and b) live in a disaster-prone zone. Not so much to those of us who keep some sort of emergency family plan or kit in case of a tornado or something. It's good to remember the importance of emergency preparedness whether you're a parent or not but I suspect it's not going to be a major factor in feeding choices for most people. As risks go, putting your child in a car is probably statistically riskier than not having backup feeding material in case of a disaster, so while I understand and appreciate that someone has to come up with studies and advice for such situations and protocols in these situations I think it's a fairly specialized concern (all you Californians feel free to correct me!)

    Still scratching my head at the assumption that public health folks can really push everyone to BF on the basis of the odds of natural disasters but glad someone is thinking about it.

  97. OK, reading more I realize that one of the goals is to say that BFing women do not need formula as a backup in case of emergency. While I can see that disaster relief orgs have to apportion resources somehow and don't want to hand out formula making women think that somehow their milk is less safe following a natural disaster, it sounds like a better protocol might be to have formula available for those who need it while being sure to let aid workers give women the right information about their breastmilk being safest IF it is still flowing and stress hasn't reduced their supply a lot. I suspect again that a lot more depends on education, norms and cleanliness of water supply before disaster strikes than on disaster response protocols.

  98. Stephhelen, Karleeng did not state that formula causes more deaths than HIV. She said that “more babies died because of formula feeding than (because) of HIV”. Many people did not expect more babies to die because of unsafe feeding practices when safely prepared formula was recommended for these babies but more babies did die. It was not the formula in and of itself that was the problem here as you have stated in your post. It is the practicalities of using formula in certain settings that increased the risks for these babies.

  99. If you live in Far North Queensland where cyclones are expected every year then it's a big deal. If you live where I do on the temperate East Coast of Australia then it is less of an issue. The recommendation doesn't say that this is for every location but that it should be consideration in locations with seasonal (regular) emergencies.

  100. Some women might consider emergency preparedness as a factor if they encounter challenges with breastfeeding (even extreme ones and that might depend on where you live and your past experience f emergencies) but the suggestion is really about factoring it in to the normal decisions that women make about when to stop which are unrelated to any challenges and are connected to cultural ideas about when to stop. The last time this was looked at in Australia, 1/4 of women stopped breastfeeding because they “felt it was time to stop.” This was unrelated to difficulties with breastfeeding. In times gone by (turn of the 20th century) women were advised by their doctors etc to continue breastfeeding until after the summer so as to avoid the risk of “summer diarrhoea” which was a cause of much mortality in babies. This is kind of the same sort of thing.

  101. Water and sanitation is one issue. The formula itself is another. Yes, it does facilitate and foster infection on it's own regardless of clean water and sanitation. And you are completely right, exclusive breastfeeding rates are low almost everywhere in the world. In many places it is not formula but teas and porridges that are given to young babies and yes, they do harm. One area where we have learn quite a lot about what giving a baby anything except breastmilk does in terms of infection is in Africa in the context of HIV. It took many years but eventually they worked out that babies that were mixed fed with breastmilk an formula or breastmilk and solids where much, much, much more likely to contract HIV than babies who were exclusively breastfed. It's the opposite of what they thought to start with because surely a greater dose of HIV infected breastmilk would mean a greater risk of infection. However, what they discovered is that giving formula or solid food, damaged the protective lining of the intestine of babies and so enabled HIV to more easily infect the baby. Solids were actually much worse for this than formula. Anyway, this demonstrated very clearly one of the ways in which infant formula helps to facilitate all sorts of infections.

  102. In a resource poor setting formula feeding causes more deaths than exclusive breastfeeding. In a resource poor setting mixed breastfeeding/formula feeding causes more deaths than formula feeding alone. What is the problem with saying this? It is not at all controversial. It took a heck of a lot of evidence for organisations and countries to change their infant feeding recommendations. Actually, one of the factors that played into this was an emergency, a flood in Botswana in 2006 (?). Bostwana has a stable government, relatively good infastructure and they had a huge prevention of mother to child transmission of HIV program. They have a pop of about 3 mill and when this flood came they were overwhelmed with cases of diarrhoea in infants and young children. Somewhere between 500 and 1000 died. The CDC was sent in to gather data on what had happened and the biggest factor was babies who were not breastfed. Other factors such as HIV status of the mother, piped water in the home etc were much, much less of an issue.

  103. I see those points but I think more care needs to be taken when talking about these issues because it often does feel like an attack. I'm someone who has had a fantastic breastfeeding experience (after the first bit) but feel really strongly for women who are constantly attacked for their choice/need to formula feed. I've seen lots of pain and tears over the issue and get on the defensive when comments which are clumsy appear to undermine these women's confidence. It wasn't the case that 'more babies died because of formula feeding than HIV' it was that more babies died through inappropriate feeding methods, including the premature introduction of solid food and infant formul as combined with poor sanitation and general malnutrition.

  104. So is this business about BFing being safer in disasters/emergencies something that you want to promote as a reason to BF or is it a reason not to routinely offer formula along with relief supplies? Sounds like a number of different policy recommendations going on. It sounds like the percentage of women in disaster-prone zones who might happen to be considering weaning during, say, tornado season is a small one. Probably more important is the percentage of women who are at any time BF or FFing infants in that zone. I would imagine the first job of public health or disaster relief persons would be to have a sense of what rates are in that region and whether to encourage people to stock formula or offer it in disaster relief kits themselves. The least charitable interpretation of some of your recommendations is the rice Christian one, i.e. don't come asking for formula if a disaster strikes we told you to keep BFing and that formula would kill your child in a disaster anyway. In a country like Australia I assume there are resources to provide clean water to those affected by natural disasters. So I wonder why pick on formula as something to avoid encouraging?

  105. If a woman has multiple personal, health and job-related reasons to not continue breastfeeding, then the idea that she should do so just in case disaster strikes, well that strikes me as a bit of scaremongering on the part of BF proponents. Perhaps it's because I've never lived in a place where it was seriously a possibility that there could be no water the next day…but it sounds like a fairly important burden to place on women (bearing in mind that whether or not they BF may not be something in their control!) for questionable benefits.

  106. “it does facilitate and foster infection on it's own regardless of clean water and sanitation”: is “it” here “formula”? If so then all of science would like to know what your evidence is for that statement I'm sure. If not, could you explain?

  107. Why are formula donations “huge logistical problems” and why should ongoing supply vs one-time donation be any more of a problem with formula than with any donated medical supplies for disaster relief? Of course orgs will be more careful about budgeting when they have limited resources to spend on something but resources are fungible – money not spent on formula if formula is donated can go elsewhere. Many of these arguments against formula as a factor in emergency relief sound really minor when weighed against the risk of not supplying needed food for the “undeserving poor” who did not have the good sense or ability to BF their way through it.

  108. I have explained one way (ie via damaging the protective lining of the intestine). There are more in the following article but please be aware that you will not like what it says. This article was not written for parents but for emergency workers responsible for infant feeding in emergencies.

  109. Actually donations of any good has the potential to cause problems. Medical donations can be just as problematic as donations of infant formula or powdered milk. Some of the reasons why donations of stuff (of any kind) is a problem is described by this article from the Logistics Cluster.
    To understand why donations of infant formula are such a problem you need to understand the scale of donations. I've mentioned before the experience in the Balkans where 1/3 of all aid flown in by NATO was baby feeding products. Another example is from the Yogyakarta earthquake where a survey found that 70-80% of households with infants had received donated infant formula. There was an association between having received donations and diarrhoea. And remember again these donations are distributed WITHOUT water, WITHOUT fuel, WITHOUT access to health care, sometimes WITH bottles. They are catastrophic in terms of infant mortality. I (and everyone I know involved in infant feeding in emergencies) am not against distribution of formula to the caregivers of babies who need it. But it must be targeted to only these infants, it must be accompanied by the other supplies that are needed to formula feed and it must be accompanies by educational support and medical care.
    For an example of the overwhelming nature of donations of infant formula I will provide you with an American example. Some years ago there was a Hurricane that affected Harrattas Island (may have the spelling wrong) on which lived 3 infants. Donations of infant formula arrived….lots of formula, a semi-trailer load in fact. Not only was the formula not needed but it cause a huge headache for those providing the aid.

  110. We've been having lots of interesting conversations about aspects of infant feeding in emergencies. I'd be really interested though to hear more about what you think about the emergency kits described in the paper. Are there things that you think should be added or subtracted from the formula feeding kits? Are the instructions clear? Do you think that it would be helpful to have a flow chart, cartoon illustration type thing on how to formula feed in an emergency? If a brochure on formula feeding in an emergency was being put together what would you like to see in it?

  111. The author of this study seems to disagree. Quite pertinent, too, as the case concerns two women in a disaster situation:

    Ruvalcaba RH. West J. Med 1987;146:228–230.

    “Paper shares the case studies of two women following the Mexico earthquake in 1985. Both had successfully breastfed their other children. The first was exclusively breastfeeding her 3 month old child, the second lady was pregnant but producing colostrum before birth. In both cases the milk production stopped immediately. The first lady her milk had not started again a week later and she formula fed (no mention of breastfeeding support), the second lady went on to give birth but no follow-up of breastmilk production following birth. Refers to animal and lab studies.”

  112. Please see above citation regarding stress affecting breastfeeding; also, how could it be overcome if the stressors which incited the issue have not abated? For example, let's say there's a woman whose family has perished in an earthquake. She's lost her home, living day to day, trying to put the pieces of her life together.Her grief and stress has impaired letdown, which leads to understimulation and hence reduced supply. How is she supposed to find the strength, resources and time to sit on her behind and cluster feed so that she can increase her supply, and possibly counter the effects of dehydration on a baby who has been deprived of adequate nutrition due to this “temporary” dip in milk supply?

  113. This review –” found that “lactation in women, in contrast to lactating rats, does not seem to result in a general restraint of the endocrine stress response during the whole period of lactation. Recent data strongly suggest that the blunted HPA axis response to stress in women seems to be counterbalanced if the acute stressor, at least when of a psychosocial nature, occurs later than 1 h after suckling.”

    Also, this study – – states that “results indicate that…stress to the mother and fetus during labor and delivery… (is a) risk factor for delayed lactogenesis. Although this stress is occurring during labor, I do think it is an important contribution to the conversation. There will be women who are in the early stages of lactogenesis in disaster situations – perhaps they should be advised to have formula at the ready?

  114. Please see study above on the two Mexican women after the earthquake… sounds like this is something that could, and possibly does, happen.

  115. Again, I think this is unfortunately a matter of not being familiar with this blog (not your fault, of course – why would you be reading something about formula feeding??); the majority of us are pretty well versed in lactation lingo and breastfeeding fact and fiction.

  116. It's just a factor to consider. If you live in an emergency prone area, you will give it more weight than if you don't. It's the individual mother and family who decide. People who live in emergency prone areas tend to take preparedness pretty seriously.

  117. The cases here are not in conflict with what I have said. I will dig out the research for you (will try to be as comprehensive as I can) but it will probably not be until Wed in order for me to do it properly.

  118. Just surviving an emergency is difficult. It is hard to care for a baby in an emergency and no, it is not easier. I ask the same question though that I asked before, how would formula feeding be easier?? Especially using powdered infant formula.

  119. Actually I don't need abstracts. My house burned down. I have a pretty clear picture of how my body responds in stressful situations, and I can absolutely assure you that breastfeeding did not reduce stress. I'm sorry. You can argue *your* studies all you want, but they won't diminish my reality.

  120. I'm responding to the paper you cited below – this thread has gotten so long that the box to type in is invisible, so please excuse that this response is out of order.

    The paper you use as “proof” of the mechanisms that make combo fed babies more prone to HIV is your own (which seems a bit odd, but maybe this is more “done” in research circles than I'm aware). In it, you make statements like “Without the external immune support provided by breastmilk infants are effectively immunocompromised”. I think we were all more curious to see an actual lab study or even a case study which illustrates your point that babies can more easily acquire HIV because formula damages the gut?

  121. But again, what I don't understand is the aside that donations from the formula companies themselves are unwelcome? Couldn't the aid orgs work with Enfamil, Nestle, Similac, etc, and have them donate RTF nursettes and pre-sterilized nipples? In the social media age, it seems like it would be a HUGE boon for these companies' PR departments, so I'm sure they'd be more than willing. I assume it's b/c UNICEF would rather be caught dead than deal with formula companies?

  122. That article is a review paper and it summarises the research. Yes, I wrote it and I linked to it because it was easily accessible. Unfortunately the source documents are not easy to get unless you have university library access. I will add some in for you though Coutsoudis, A., K. Pillay, et al. (1999). “Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study.” The Lancet 354(9177): 471-476.
    Ferguson A 1995, The gastrointestinal tract. Allergy 50(s20): 33-40.

  123. I think the instructions are very clear. If I were designing a brochure for formula feeding parents about emergency preparedness (which I think is a wonderful idea), I'd like it to

    a. Refrain from any discussion of breastfeeding, as this is irrelevant. If they are already formula feeding or combo feeding, the point is moot.

    b. Cartoon imagery would be good, but I think a clear step-by-step list of instructions would work as well.

    c. I would either tailor these documents to the country in question, or include caveats about what might or might not be readily available in different parts of the world. Here in the States, parents should be informed about the nursette option, and of RTF in general. That stuff takes water out of the equation, which is HUGE.

    d. Just as you can't include every conceivable situation for breastfeeding mothers (if they are stressed, injured, struggling w/breastfeeding, on contraindicated meds, etc, all the things we've discussed here which are viable scenarios), it seems extraneous (and perhaps even punitive) to make the instructions so wordy and precise. There are shortcuts here, at least in Western nations, so let's make sure we tell parents the easiest and safest way to do things.

  124. I've read the entire paper as research for my book. It gives two examples of milk production that stopped overnight, or at least very, very quickly, if I remember correctly…. no? It was about a year ago that I read it but I recall being surprised, as I'd always heard the same arguments about lactation/stress that you've been making…

  125. Just to clarify once again, I am assuming you are asking what I personally thought of the statements Stephhelen was discussing in her post, correct? I'm a bit confused as I don't think I made any comment about these statements within this thread; my sentence “that is exactly the problem with…” was not about the statements she C&P'd; I was referring to the conversation at large and what I felt was a blatant disregard for differences between countries. That really has nothing to do with Alex Larsen's quotes.

  126. No, it could be describing inhibition of milk ejection not milk production. It's really hard with descriptive case studies to determine just exactly what is happening. I'm not saying that inhibition of oxytocin release is not a serious problem but it is one that can be overcome with assistance.

  127. Yes, you're pretty close to right. 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.

  128. Thanks FFF! Yes, each country/state/province should develop their own publications so as to make it applicable to local circumstances.
    Can you give me some examples about the kind of details in the instructions that might be deleted?

  129. Sure thing! It's rather late here at the moment; give me a few days to go through the paper and think on this.
    Also- just wanted to say I appreciate your willingness to converse about these things. I know things get heated around here and I respect that you have stuck around to debate and explain where you are coming from.

  130. Do you mean to suggest that aid organizations should pay full price for formula instead of letting formula companies donate it to them (because the formula companies might gain some sort of influence)?

    I know that's UNICEF's position. But I've must say I find the whole idea fiscally irresponsible… if not downright crazy. These agencies need to make the best possible use of their cash. Why on earth would they insist on paying full price for formula if they could get it for free? To me, this is just as absurd as making sure they paid enough for medical supplies, clothes, other food, shelter, or anything else victims might need.

    Suppose a high- end sporting goods company approached a relief organization after an earthquake (that left thousands of families homeless) and offered to donate some easy- to- set-up tents with their logos printed on them. I'm going to go out on a limb here and say the organization would accept them. They would not respond saying things like, “We can't accept those; they might be a marketing tactic on your part. The people we serve would never be able to afford your products. What will they do when these tents wear out? *Same worker picks up the phone again and orders blue tarps for makeshift shelters* Nor would this organization hold a meeting and say things like, “I don't know about all these fancy tents. Our aid workers on the ground might start giving them away left and right. And what if people set them up wrong?”

    The above scenario is inconceivable. The more supplies these agencies have in an emergency, and the more they can stretch their funds, the better. What makes formula so different?

  131. Thanks, that would be great. The paper was honestly written to help people and part of future efforts in the area will be helped if I have a better understanding of not only what people feel is important but also how it is understood and where more info is required to explain things better. I am appreciative of the willingness of posters to engage with me on this. Despite what some may believe many who do research in infant feeding do not make judgements about women based on how they feed their babies and do really want to help but it is an area that is so fraught with emotion. I know that many mothers struggle with the idea of being a “good mother.” My personal opinion is that this is a idea that no one can win with. I recently heard someone describe how in days gone by (like 50 years ago) women were very caught up with the idea of needing to be a “good wife,” now that's a terminology and idea that no one thinks of anymore and it would be lovely if the “good mother” could go the same way.I have plans to write about that sometime!!

  132. I've read the blog on Haiti now….UNICEF deleted that section in order to attempt to stop donations of RUIF. I don't think that anyone would apologise for that preventing and then managing donations is such a huge problem. Haiti really suffered from being so close to the US, every man and his dog was sending stuff and people who didn't know what they were doing (heck I'm sure you heard of the breastmilk donation it was a debacle and took so much time and effort to deal with I personally spent hours on the phone including in the middle of the night attempting to sort it). It made a coordinated response very difficult.

  133. I missed this post before so am answering now. No, clean water was not easy to come by for many communities affected by our most recent spate of natural disasters for several+ days. Providing formula to communities and isolated families was also an issue. This also came through as a big problem after Hurricane Katrina. Emergency response will always do the best that they can to assist the most vulnerable and babies are high on that list. If the emergency is large enough (and with Australia's last summer, NZ earthquake hell and the Tsunami in Japan) we saw large emergencies in which providing aid quickly enough to all those who needed it was difficult. Breastfed babies with their mothers will be fine for several days provided their mum is OK. Formula fed babies need supplies to keep them OK until external help can come. A few years ago I was at a training meeting for Asia on infant feeding in emergencies. One of the exercises was looking scenarios for different emergencies and planning a response for delivering aid to babies. One scenario involved a large scale emergency with a large whack of the population of babies formula fed. No one wanted to go near it in terms of planning a response because it is so bloody difficult to do. That is the end point of the paper, the more babies breastfed when an emergency happens the easier it is to provide effective assistance to those babies who cannot be breastfed.

  134. That scenario does not fit. A better one would be if an alcohol company wanted to sponsor AA. Organisations serving children in the developing world see formula companies that use exploitative and unethical marketingof their products for profit and as a result kill many children as untouchable. Some talk about “blood money.” Have you seen the video on youtube about marketingin the Philippines “Formula for Disaster”

  135. Should that not be addressed? I've been wondering that for a while. If it's illegal to send RTF formula into Australia even in spite of disaster preparation should whatever law this is be evaluated?

  136. My comment is going to be brief, because this is not something I want to spend a long time thinking about? What kind of university funds these “studies” and academic papers? I can't believe that there aren't more pressing issues for public money to be spent on. Has anybody seen any news reports in the last 20 years that are covering natural disasters and keeping a tally of the babies who have died because they're not being fed? Wait till the lactivists get hold of this paper. They'll dine out on this horse shit for months. I can see it now… Big Pharmy… political conspiracies… you can get a university degree in breastfeeding now, didn't you know. Good grief.

  137. Having engaged in discussion with you I do see that this paper was written in good faith and that the intention is not to lambast formula feeding women. I admire you for defending your paper on here and some of the comments have been heated and strongly worded.

    I think it's important for people who write papers on bf/ff to understand that formula feeding women constantly feel the need to defend their feeding choices. This is evidenced by the way in which when you see someone comment on their decision to FF usually there is a long list of 'acceptable reasons', often followed by expressions of guilt and shame at their choice. This should not be the case as there is enough pressure on Mothers as it is!

    Formula feeding women are also frequently subject to harsh judgements such as 'If you don't want to breastfeed you shouldn't have children' or 'I had mastitus too but I was strong enough to carry on'. Add this to the feelings of guilt and you have a really hurtful combination. Below are a two comments from my corpus:

    “Breast is best, and unless there is a medical condition is is SELFISH not to breastfeed. I think it goes a long way in showing what type of mother someone is. “

    “Breastfeeding was so terrible I dreaded everytime my son woke up to feed, I couldn't stand to look at him, and I kept asking myself, how am I supposed to bond when I am despising the experience? Not to mention being exhausted and with post partum depression. I kid you not, the word suicide crossed my mind more than once. But the most painful thing out of this experience is the judgement that followed. I even lost one of my best friends because she has this holier than thou attitude because she has been breastfeeding for 2 years. Not only has she implied I am lazy, selfish and I didn't try hard enough (her nipples never bled, she's had a wonderful experience), she has always implied I don't love my son enough.”

    Papers published with comments such as 'good feeding practises are exclusively breastfeeding for the first six months….' fall into the hands of the idea that to be a good mother you need to take full responsibility for the nutrition of your child (see first quote). This appears to entail that if you decide against 'good' feeding practises you are a less than 'good' mother and therefore irrational and bad. This may not be the intention but is how it is read and sadly used against women who have decided to formula feed. There are a few papers which discuss this and I will try to find the links (can't at the moment and shouldn't be on here anyway…should be working!!!).

    These points should always be considers so as to prevent any papers being misinterpreted and later used as amunition. For example, although it may not be your intention, this paper could be seen as saying:

    “Well you should have been breastfeeding anyway”

    This paper appears to ignore the fact that it is simply not the case that all women breastfeed/are able to breastfeed/want to breastfeed. Whilst I understand that perhaps journals like you to put WHO recommendations in, you could perhaps counterbalance this a little by just saying something like “…worldwide, fluctuations in breastfeeding rates demonstrate that the optimal feeding practises are not currently achievable”, I personally would prefer it if you also put some reasons as to why women don't breastfeed, i.e., PND, recurring bouts of mastitus etc.

    I agree with everything FFF said re: what should be included in the paper. Especially the need to taylor advice for women of different countries. I would also like to make it clear that a lot of the things we're saying aren't levelled solely against your paper, but breastfeeding literature in general. Thank you again for engaging in a debate here, I've learnt some things.

  138. I do live in a disaster prone area (North East Queensland) and it didn't make my breasts work anymore then if I lived elsewhere in the world. If it is a case of “you should keep breastfeeding just incase their is a cyclone” then when should a mother stop breastfeeding? When her child is 5? 10? All people in a disaster need clean water and eating/drinking equipment. It really (I know cause I have had to do it) is not hard or unsafe to formula feed during a natural disaster. Breastfeeding mothers need to be supported during those times but telling formula feeding mothers “sorry – you get no help cause you should be breastfeeding” is most probably the reason that people in those situations make mistakes in bottle feeding safety. As usual bottle feeding parents are given no support or decent information that doesn't have a 'breast is best' message attached.

  139. Sorry to respond far below but no more space above – when you say that formula “damages the protective lining of the intestine” and therefore makes children generally more prone to illness including HIV infection, that is not scientifically proven. Bad water may make children sick. Formula doesn't. You specifically state that formula makes children sick regardless of the availability of clean water. This and several other comments make it sound like your organizational or research perspective is not objective but rather aimed at painting formula as dangerous and taking a “well using formula will kill children anyway so why send it to help them” position.

  140. Kerleeng, first of all, I did not say that my “milk dried up overnight”. I said it crashed, but not that it was completely gone.

    Second, let me tell you a story. One night, at about 11:30PM, an 11-week-old baby, exclusively breastfed, who's pediatrician keeps telling the mother he's not gaining enough weight, suddenly wakes up, screaming him head off. He suddenly has a fever, so his mother takes him to the ER. They run a gazillion tests, including a lumbar puncture. To perform this lumbar puncture, they give the baby morphine and he stops breathing. In the aftermath, the baby is unconscious for 12 hours. The baby is finally diagnosed with a UTI and is hospitalized for the next 7 days, on an IV drip. The mother keeps nursing him on demand. And then, they go home. The mother keeps nursing as usual, and something strange starts happening. The baby, who is usually a calm, happy baby who sleeps very well, has become impossible to soothe. The mother starts nursing more often, to no avail. The baby eventually starts refusing to latch. After 3 weeks of watching his 3-month-old scream his head off and his severely sleep-deprived wife nurse around the clock, the father decides to make a bottle of formula. The mother says the baby must not be hungry if he's not latching, but surprise! he gulps down the 4oz of formula in under a minute and finally falls blissfully asleep.

    So let me tell you something. Don't tell me it's impossible for a mother to lose her milk, I did. I wasn't making enough. My son was starving. Don't tell me I should have tried harder or longer, I nursed around the clock for 3 WEEKS. Don't you dare judge me and assume I didn't know what was going on with MY body and MY baby, when you have NO IDEA what we went through. Don't you dare.

  141. This sounds like an argument for better logistical coordination in disaster relief rather than an argument for why women should breastfeed in case aid agencies can't get their shit together to supply water along with formula in case of war or disaster

  142. This is false. As a biologist (or are you?), you should know better. Not all body functions are equal. Stress will not stop *vital* body functions. *Your* body is concerned with *your own* survival, not anyone else's. You need your kidneys or temperature regulation to survive. Breastfeeding? Not so much. Breastfeeding requires a lot of resources and energy, if your body needs that energy for other purposes, it will shut down this *non-vital* function and use the energy for a *vital* function.

  143. And when you compare formula donations in emergencies to alcohol being donated to an AA meeting, you suggest that formula is just a Bad Thing overall and that does not sound objective or scientific at all. All those women who were formula feeding earlier or lose their supply or all those children whose mothers may have died in a disaster don't seem to matter so much as fighting the big bad wolf of the Formula Problem.

  144. For one, because a FF mother can rely on friends and family to help her feed the baby through the crisis, so she can search for bodies, materials, resources, whatever.

    Telling a mother to keep breastfeeding in case of emergency is patronizing and scare-mongering. I don't care what kind of natural disaster zone you live in (and I live in one), this rhetoric is designed to motivate mother from a place of fear.

    Whole-family health should be our priority, as healthcare advocates and researchers. Certainly you have the right to limit the scope of your paper to one facet of baby-feeding, but for what purpose? This adds so little to the discussion about baby-feeding (“breast is best!”) and emergency preparedness (“clean water is hard to find!”) that I'm surprised it's gotten the attention it has.

  145. OK, I certainly see the point that it's *easier* to have good outcomes when more people BF. But we live in a less than perfect world and one in which disasters happen and people need formula. So when you say “no-one wanted to go near that scenario because it was so difficult” that suggests it's simply not worth planning for the reality that BFing may not be a large-scale reality. Denial isn't helpful IMHO

  146. Yes, I think the number one recommendation for disaster relief for FFing parents should be to encourage the storage/provision of RTF bottles. Sounds like that would take a lot of the risk of sanitary disaster out of the equation. And perhaps urge formula companies to supply only RTF and not cans?

  147. Hand expressing is not nearly as effective as pumping with the kind of pumps EP-ing mothers use. An EP-ing mother would most likely not be able to keep up with her baby's needs this way. Once again, your advice is flawed – and dangerous.

  148. I think the paper is well intentioned and written for policy advisory purposes – disaster relief agencies need some guidelines on infant feeding – but suffers from a blind spot in that it pins its hopes on getting BFing rates up before disaster strikes and kind of throwing its hands up about the possibility of helping those who don't BF, or rather, suggesting that this is so difficult or has such negative consequences that it's something to be discouraged. it's biased but I don't think it's all BS.

  149. Right. I feel like you have to meet people where they're at and not massage the research to promote wishful thinking on behalf of disaster relief and/or breastfeeding promotion. There are going to be women who can't or won't breastfeed no matter what research we browbeat them with, and their babies are worth saving too. Disaster areas are individualized and complex. So are women, children, and their families. Meet them where they are.

    The first change I would suggest is a more realistic assessment of what is needed for formula fed and breastfed babies; the current list in this paper is so hyperbolic it's anti-reality.

    My second suggested change would be to rethink using the personal, individual tragedies of parents who have lost their children in a disaster as an object lesson to scare the rest of us into today's parenting method of choice. Not to mention that it's gross to suggest that the babies that died in Katrina, for example, would have lived if only their moms had had the education, support and good sense to breastfeed. Rhetoric like this is patronizing, reductive, circular, and so baldly biased it verges on unethical.

    My last suggested change is a pragmatic reassessment of how corporate money and energy can be harnessed in disaster relief. Comparing RTF formula donations to sponsoring an AA meeting with booze is offensive and harmful to babies and their families, not to mention emotionally punitive to moms. “Sponsorship” is different than charity, charity is different than self-promotion, and one doesn't have to love a company to take their products or money. Conflating these things is super-fun for an argument on the internet, but it's terrible for social policy.

    Look, we can have our righteous anger about formula companies' (and any corporate entity's) underhanded business practices, but let's keep our eye on the ball when it comes to babies' and families' well-being. Get the baby fed by any means, and don't starve them to satisfy your own moral edification and/or boycott.

  150. Agree completely. I found the weakest parts of the paper/author's argument here were the uncited urban-legend sounding scare quotes about the Katrina mother and misguided “aspirational” formula feeding by women in natural disasters who were lured into a less healthy feeding practice by the availability of alluring formula. Those throwaway examples don't say much about real disaster preparedness and just rehash tired old paternalistic arguments about free formula messing with the brains of dark-skinned or less-educated folks.

    I totally support the message of encouraging women who ARE BFing and can continue to do so in an emergency to do so, but to suggest that planning to supply formula in case women cannot BF or never did or may be separated from their children is tantamount to booby-trapping…well that sounds like a lactivist is projecting his or her general agenda onto disaster victims. Start with what the victims need, be sure you are getting them the right info along with the right supplies, and give them the support they need – that's what aid agencies should be focusing on. NOT turning disaster relief into a breast vs bottle battleground. Anyone who has worked in development assistance knows that you have to be sure that knowhow and information and proper distributional networks accompany aid supplies. It's not the fault of the supplies if there isn't a reliable network on the ground to be sure they are properly used.

  151. What did someone mention re-lactating?! A re-lactator here! LOL. Guess what I live in an earthquake prone area. Guess what happens after a major earthquake? No water no electricity. Guess what I needed to re-lactate? Bingo! Yes, I keep ready to feed formula at all times not mention my milk supply will never be the same as it was the beginning.

  152. It'll be YEARS before I get anything done on this, at least two and that's just an initial deadline, we all know what happens to those! I'm interested in the ways in which women are silenced through discourse and breastfeeding seemed a good subject to start with. There are so many examples even within this thread, i.e., (paraphrase) I've been in a disaster and my milk dried up. Vs. It's not physiologically possible. A very common one is “I didn't have enough milk” pretty much uniformly followed by “Only 1% of women don't have enough milk” [where that number comes from I don't know!].

    Sadly, over the course of beginning this research I interviewed a former breastfeeding counsellor who was so shocked by some of the training she received she no longer wishes to be associated with the field. Even more tragically, I heard of a woman who conceived through IVF and had a terrible battle with breastfeeding. Despite telling bf counsellors, health visitors and MOther and baby groups she was not listened to. She put the baby to bed one lunchtime, phoned her husband to come home and hung herself. It's one of the most awful things I've ever heard.

    When I started work on this I had no idea of the sorts of comments and experiences that I'd come across and I now feel very passionately about the whole thing.

  153. Wow. We should talk. Sounds like we've been doing similar resarch and feeling similarly disgusted by our findings.

  154. In terms of the sponsorship/AA analogy, I want to echo Lauren's comments. There is a big difference between formula companies providing charity and an alcohol company sponsoring an AA meeting, and suggesting the two are even remotely the same goes beyond hyperbolic to a point that it nearly discredits any other, potentially reasonable, issues brought up here. I think the tent analogy above was actually very accurate.

    Our fire was a big deal. It wasn't a house fire; it was a brush fire, took out 10 homes and killed a woman. The entire community stepped up to help, so while it isn't the same as a large scale natural disaster, there are some parallels. When you are dealing with a disaster, you take help where you can get it, and ethics tend to be trumped by need. I don't, as a rule, shop at Wal-Mart, but I still used Wal-Mart gift cards because we needed assistance, and that was what was available. I didn't ask for a breakdown of donation origin when the firefighters showed up at our door with monetary assistance. I think it is a cynical response to assume that all formula companies are evil and any donation must be an underhanded attempt at interfering with breastfeeding rates. Why can't we look at formula donations as charity the same way nearly every other donated resource is?

    *Also, as an aside, I do have some sympathy for trying to sort through donations. We got to the point where numerous other people were involved because there was so much for our small family, and we couldn't possibly use everything.

  155. All very good points. I would add that citing WHO recommendations or unnamed grassroots NGOs who “see formula donations as blood money” is a kind of cop-out that masks the real judgement. Are your local partners in disaster relief the ones refusing formula donations, is the WHO/UNICEF refusing such donations, who is making this judgement call? I wouldn't claim to speak for all disaster victims and their needs on the basis of a lactivist YouTube video and it sounds a bit like pulling random anecdotes together to confirm one's own agenda. I sincerely hope that this kind of advice will start with the needs of people affected by disasters and not be used as a mission civilisatrice by lactivists.

  156. I will say this much about the issue. No matter what type of infant feeding you are doing you should be prepared for a natural disaster no matter what. Always keep in mind Murphy's law. Breastfeeding may work in favor for some women in a natural disaster. It may even help many feel more secure and empowered, but lets consider all scenarios first. Instead of fretting on the could've, would've, should'ves it would be better to actually focus on what is the most safest and best way to help breastfeeding AND formula feeding women to feed their babies in the event of a natural disaster. Some woman are breastfeeding, but due to complicated issues may require a pump and be Exclusively expressing breastmilk. I have known many in this situation BTW. Reading through FFF's blog, we can find a plethora of reasons why a woman may be formula feeding. So instead of just going on the premises “you should breastfeed in case of a natural disaster” why not lets consider all scenarios first and figure out the best way for both moms to be prepared. That also means being prepared for the fact that you may be breastfeeding, but the disaster caused you to somehow no longer be able to BF or EBF. There is a safe way to formula feed in the event of a natural disaster why not educate mother's on that as well as educating them on breastfeeding?

  157. I most certainly did not say that formula feeding mothers should get not help, quite the opposite in fact! And as to when to stop, that's up to the mother and her child but the WHO recommendations are not a bad ball park. That said, the younger the baby the more vulnerable they are.

  158. Actually the response on here has led me to believe that it is a very useful paper. If it gets people talking about what they need to do to be prepared then it is doing a good job.

  159. It's really hard to get data from emergencies. I linked before to the Botswana tragedy. That got press because they were calling for changes in HIV policy. Another paper is Hipgrave, D. B., F. Assefa, et al. (2011). “Donated breast milk substitutes and incidence of diarrhoea among infants and young children after the May 2006 earthquake in Yogyakarta and Central Java.” Public Health Nutrition FirstView: 1-9….there are a few other bits and pieces but nothing other than anecdote from developed countries.

  160. Thanks for this feedback. Can you provide me an example of where we didn't meet people where they were at? I thought that we gave information for women/families in all different places (except for the EEs- which we should have added in).
    Can you tell me what is hyperbolic in the kit? WHat should be left out and why?
    Oh, I see my analogy has been misunderstood!!!! I was not talking about alcohol companies sponsoring AA with alcohol but with $$. AA would not take it. Children's aid orgs will not take money (or anything else) from infant formula manufacturers who breach the Code because of the harm that they do to children via their unethical practices.

  161. With as much respect as this defensive answer calls for, that's a cop-out response. If your job was to start a discussion by inflaming the breast vs. bottle war, you've done your job. If your intent was to help design social policies that help families feed babies in a disaster, your paper has failed for the variety of contrary bullet points that have been laid out in these comments.

  162. We didn't provide any examples of donations causing problems in the paper. We did provide a small number of examples from recent, developed country contexts in order to show that this is a real problem. I think that they achieved that goal.
    If you feel strongly that breastfeeding women should store formula then comment on the paper, as I've said before it is not a closed shop..

  163. Sorry but it is the case. It is the “foreign proteins” in formula that damages the lining of the intestine. I did provide a couple of refs before about that. That wasn't an issue in the paper but was brought out in discussions about what the problems are with formula. Unclean water magnifies the risk of illness. But this is not about no helping children. If breastmilk is not available then providing formula is what should be done but provided along with other physical resources like water, fuel, cooking pot etc, education for the caregiver, medical support.

  164. Actually I don't think that you've got my entire publication record there but that's neither here nor there. And you are correct there are so many nuances in research- it makes it really difficult to communicate about and sometimes the picture is very muddy.
    But I think that you are deliberately misinterpreting what I was saying about organisations and donations/sponsorship. Can you show where I suggested that women were addicts?
    With regards UNICEF, I have done some work for them but I certainly do not speak for the organisation.

  165. I mentioned UNICEF's policy which is an official one. I know that many other orgs are the same but I have not seen their actual policies. The reasoning behind why they do not accept money or anything else from infant formula manufacturers who breach the Code is accurate though. An example of evidence of this is at
    I was suggesting that people have a look at the Formula for Disaster which is actually not about emergencies but about the reasons for the International Code and one country's experience of attempting to enforce it. I know that the WHO Code is something that many people have difficulty understanding the need for.

  166. I think that you could all see why AA would not accept funds from an alcohol company so it's not useless in that sense but it clearly was offensive (not my intention I was not comparing formula to alcohol!) Can you suggest another one? One that is not offensive but in which a potential sponsor is inimical to the organisation and so sponsorship was refused.

  167. Really? Hand expressing is as effective as a double electric pump? Again, I don't buy it.

    As for what I would suggest instead, well, Stephhelen said it. RTF formula and disposable teats.

  168. Even though I planned on breast feeding exclusively, I kept the sample can that Enfamil or similac (can't remember which) had sent me on hand along with 3 gallons of distilled bottled water until I had pumped enough to feed my kid for 48 hours in my deep freeze . JUST IN CASE something happened to me. JUST IN CASE we got snowed in or something. I never needed it, OR my pumping stash but I felt good knowing I had it “just in case”.

    I've also heard “survivalists” suggesting to keep formula on hand because I guess its a food that's life sustaining and has pretty much every thing necessary for living in it (obviously as it has to feed babies) so in an extreme emergency, adults can consume it to survive as well if there are no babies who need it.

    Here's the other sticky thing folks, ready to eat formula doesn't go bad as long as its still sealed. Unrefrigerated breast milk? Oh my oh my does it go bad, and spectacularly so.

  169. The analogy is offensive. Formula feeds babies and helps them grow. Formula is a valid and medically appropriate choice for many babies and their families for a slew of reasons we all know. Alcoholism is a serious disease that requires complete abstinence from alcohol to have a functional, happy life. So, not even comparable. Already kind of offensive that you drew the parallel. (And FYI, AA is a self-supporting group that doesn't take donations anyway.)

    All around this is a really terrible analogy because alcohol is actively harmful to alcoholics while baby formula is (sorry, it hurts) good for babies! Making a comparison like this and then following up with “Ha ha! You didn't understand!” is disingenuous. This kind of flip response happens to be salt in the open wounds of nearly the entire readership of this blog.

    So, an example of not “meeting people where they're at.” That's one. How about this entire comment thread? Or your paper? How about you start with, “This is a piece promoting breastfeeding as emergency preparedness.” I mean, it's not an empirical piece. Your paper is designed to make formula feeding look overwhelming in or out of a disaster. I'm flummoxed that the paper didn't even consider what would happen to a breastfed baby if she was separated from her mother for any length of time. The number one thing a baby needs to get fed in a time of disaster is access to the food source!

    So let's be real: state your biases up front and stop with the feigned obtuseness. You wanted to promote breastfeeding, that's great. But the problems with that promotion all over this page. Noone here is pulling a gotcha, you came along to respond to this criticism personally. Meet these responses as they are and be willing to accept valid criticism without patronizing us for being angry or insinuating that formula feeders are feckless idiots, or be willing to live with criticism of your research that calls your policy recommendations irresponsible. Your call.

  170. You have missed the point. It is not the product (formula) that is the problem and why organisations will not accept money from infant formula manufacturers it is the unethical marketing of their products that results in serious illness and death in contexts where there is already high infant mortality. Read the letter I linked to with the list of 20 child aid orgs working in Laos on why they don't want the money that Nestle was offering them.
    My response was not disingenuous. I have responded to people's posts all through this with respect for opinions despite being personally attacked on a number of occasions. I do so because I am wanting to hear what people have to say. I have taken the time to try to explain things that people have said that they did not understand. As I said before, I am sorry that my analogy was offensive. I have been trying to think of a better one but have yet to. If you can come up with a different scenario of where an organisation would not accept funding from a business because their actions were inimical to the aims of that organisation then I would appreciated it greatly. I would be very grateful in fact, I would like to be able to do a better job of explaining why many aid orgs have a problem with accepting in kind or monetary donations from the infant formula industry.
    So what is the problem with the list of supplies for a formula feeding kit and the accompanying instructions??

  171. So by introducing MORE stress, we're supposed to create LESS stress and just somehow magically “get over” anything that gets in the way of breastfeeding, like, say, losing your family in a disaster, the threat of terrorism, picking through the soggy/shattered/windswept/snow-covered/whatever remains of your home, trying to find medical care for your injuries or your child's injuries…riiiiight. And you, like so many other lactivists with no concept of the real world, make curiously no mention of what you're supposed to do with a child who might be so injured that sucking isn't working for them.

    I remain steadfast in my assertion that you have absolutely NO concept of what a real emergency is like, and that therefore your research is in fact harmful to all women, breastfeeding or not. We don't need people who don't bother to understand the real needs of women in the midst of catastrophe trying to make more unrealistic policies actively prevent women in crisis from getting the help they REALLY need.

  172. What if the baby cannot suck? What if the mother doesn't have the ability to cluster feed as you seem to think every woman in crisis just has the resources to sit around and do? What if the mother has been injured, assaulted, raped? Do you have any concept of the psychological trauma that accompanies a disaster? I strongly suspect not. Perhaps instead of sitting around talking about how formula as we currently distribute it in times of disaster won't work, you could write a paper about how to effectively distribute formula so it's safe instead. Ah wait, that would go against the groupthink that is currently so pervasive in academia, can't have that now can we…

  173. There is quite a bit of information available on how to effectively distribute aid and what is needed to support babies needing to be formula fed. Making it happen is the difficult thing and that is where donations are such a big problem. I have written about this issue, have a paper in press at the journal Disasters on the media and emergencies.
    I didn't say that breastfeeding would make things easy or that every woman will be able to breastfeed. There are no easy solutions to the situation that many women find themselves in in emergencies. The premise of the paper was simple, how to prepare for an emergency. The detail you are asking for is simply outside of the scope of the paper. That's not to say that they are not worth dealing with but just not in this paper.

  174. If the milk isn't coming, do you really think that people in the midst of disaster have the resources to determine what their oxytocin levels are? Overcome it with assistance. Right. I'll get right on that, right after I slog through the devastated, charred/flooded/buried/ash-covered/shattered town, dodging downed power lines, broken glass, dangerous debris, looters, rapists, people fighting over scarce supplies, etc. to sit down with someone who has the time and energy to be with me round the clock to get me through whatever cluster feeding you have determined sight-unseen and with no regard for my or my child's medical history is guaranteed to work.

    Assuming that I had no problems with breastfeeding before hand, which is another dangerously harmful assumption to make, one that booby traps more women than formula companies in my opinion (which is about as valid as your “study” I might add–perhaps moreso, as I've at least bothered to TALK to women with children to learn the things that hindered their breastfeeding their children). If my ability to nurse was somehow not in great shape before the disaster (and a lot of breastfeeding activists contradict themselves here–breastfeeding is natural so it must be possible for everyone, yet they maintain that no one can breastfeed without lots of support and knowledge which means it must not be all that naturally occurring…) what makes you think that all the support in the world–in the midst of a disaster–would somehow improve my situation?

    You say with enough support people can breastfeed thru whatever milk production issues they have due to stress. You seem to think that formula should be considered a poor option because you deem it inherently unsafe, yet the reasons that it may be unsafe are partly because some lactivists have made it impossible for formula companies to do anything without being demonized and seem to want to stop any woman's ability to get formula at any time regardless of her situation. But what about breastfeeding? I can't imagine there being the kind of resources you describe in the middle of a disaster. Medical personnel are going to triage people according to their severity. Having leagues of breastfeeding counselors sitting around willingly in a disaster sounds more unrealistic to me than proper distribution of formula. Unless you'd like to volunteer your time, and get the ball rolling?

  175. Your idea of what constitutes conclusive research seems to be about on par with other breastfeeding researchers', which continues to make me suspect the credibility of much of the pro-breastfeeding research out there.

  176. Yes, it's very difficult.
    NO, I have said repeatedly that it is really, really important to get targeted aid to babies who are not able to be breastfed that includes everything that they need.
    And yes, a cascading program of breastfeeding support and support for formula feeding was deployed in both Yogyakarta Indonesia (by UNICEF and the INdonesian Breastfeeding Center) and in Myanmar (by Save the Children) after the earthquake and Cyclone emergencies in those countries. This was not immediate so would not affect infants who were in a bad way in the first few weeks after the emergency but it was still in the scute phase and they did make a difference to child health.

  177. And this is precisely the problem with much of the breastfeeding literature out there. The ideals they're trying to shove down everyone's throats so forcefully are the unstoppable force meeting the immovable object that is the reality for many women who cannot/should not/do not breastfeed. It's all the more sickening when people who are already victims of a major catastrophe–whether it's an illness, life situation, or disaster–become victims twice when others not only expect them to breastfeed beyond all reason, but actively work to hinder their ability to access formula.

    Brooke, I am so sorry to hear about what happened to your home. My family's stories of their experiences with natural disaster make me appreciate just how much fortitude it takes to get through a disaster in which your home is destroyed. People who don't know what that's like can sometimes be very cruel, not to mention unrealistic. You're a strong person and whether you breastfeed or not, that doesn't change that fact at all.

  178. So, your interpretation, which is made without ever looking at me, my child, my chart, her chart, by someone who obviously has an agenda, trumps all. Whether the milk has ceased production or the milk simply isn't coming out is rather academic to a woman struggling to make breastfeeding work, and points out just how out of touch you are with the reality that so many women experience.

    Go on, tell me how one-size-fits-all medicine prescribed by total strangers promotes more respect and better health for women and babies in ANY situation, including disaster zones. Or do they not encourage such critical thinking in the ivory tower in which you perch?

  179. I'm beyond furious at seeing the real-life experiences of real women being dismissed as impossible by a lofty academic simply because they don't seem to fit her world view.

  180. If I have misrepresented your publication record, then please accept my sincere apologies.

    This statement: “A better one would be if an alcohol company wanted to sponsor AA. ” came from one of your posts, I believe? If not, then I apologize again, however, I believe I am correct.

    AA is an organization devoted to helping people who have made serious mistakes, or shall we say have a real behavioral problem, change their lives around. The implication is that women cannot be tempted by formula, that they have made serious mistakes in their choice of infant feeding, and that we cannot trust them to make the right decision when confronted with two possibilities: formula or breastmilk. If that was not what you intended, well, then you should think more carefully.

    Although to be honest, the statement doesn't really make much sense anyway. Exactly what would be the problem if Jose Cuervo sponsored an AA meeting? Should we not accept funding or donations from corporations that have questionable practices? Wouldn't that pretty much eliminate all corporate funding for nonprofits?

  181. I won't ask, then, what your preparations were for disaster. But I'm willing to bet that a lot of moms who EP know that hand-expressing is not going to maintain supply, and may be afraid of hindering supply if they try. Certainly I was told by different IBCLCs that even with a double electric pump there was no way to maintain exclusive pumping, all in the name of not booby trapping me. I was told that anything other than exclusively breastfeeding “from the tap” would mean the death of my supply from the IBCLCs and the militant lactivist pediatrician I took my daughter to before I wised up and found a medical professional who practiced medicine appropriately. Again, I find the advice unrealistic.

  182. In response to Teri's comment and in order to keep it readable…

    The psychological stress is what I find most often overlooked. I was amazed after the fire to realize how little resources were available in terms of dealing with the psychological issues of losing one's home and because of that, I suspect there is very little training for those on the front line of a crisis. When we told the Red Cross I was having nightmares and needed a counselor, it took over a month for someone to contact us, and that was only after someone complained about the response.

    And in terms of the cluster feeding, I actually think that the nature of our life at the time (in addition to the stress contributing to a very serious chronic illness – yeah, my life was pretty much a winner that year) made it impossible to make breastfeeding successful. I had low supply as it was, and in order to combat that, I would have needed to be home nursing around the clock. Instead, we were meeting with contractors and counselors, trying to rebuild our home and get our life back to some degree of normal. Even though I felt guilt at the time, breastfeeding was not my first priority, nor should it have been. My experience is not that unique in terms of the psychological stress and the realities of rebuilding a life and I think one would be remiss not to take these stories seriously and learn how to better serve women and babies in a non-idyllic world.

  183. And sadly, being on the front lines of a disaster as an aid worker, I've found, does not make you understand truly what it's like to be the one enduring. It's one thing to say that you've been there during a natural disaster. It's quite another to say that you've sifted through your leveled house, saving about five items which really aren't even salvageable and then trying to pick up from nothing and figure out how to start over, not to mention things like nightmares and the fact that you now feel like you are no longer safe, may never feel safe again. I believe if you look at Maslow's Hierarchy of Needs safety and shelter are pretty critical. Food is too, but I was under the assumption that formula and breastmilk both satisfied that condition.

  184. I cannot believe that someone who claims to be a researcher, someone who is supposed to be trained to look for creative solutions to problems, would not possibly see the obvious solution to the powdered formula problem:

    Get ready-to-feed formula stockpiled in disaster-prone areas! Disaster-prone countries! Work WITH the formula companies instead of against them!

    Saying that you cannot imagine how formula feeding would possibly be easier amounts to a dangerous amount of naiveté as to why people formula feed in the first place. Even if formula was as arduous and difficult to obtain and prepare as some lactivists want it to be (prescription-only, massively taxed, etc.), it is STILL easier and healthier for some moms and some babies. A natural disaster is not necessarily going to change that.

  185. Statements like your AA comparison just blew you out of the water–permanently–as any kind of credible researcher in my book.

    You may be acting like you're a reasonable person, but you're actively advocating for the maltreatment of women and children in a disaster zone simply because you don't like how they feed their children. People like you want to be right more than you want to actually help any woman or any baby improve their health.

  186. You proclaim formula doesn't work in a disaster zone. It doesn't work because people like you MAKE it not work. Your disgusting attitudes are exactly what is wrong with breastfeeding activism. You do a horrible disservice to the many breastfeeding women who would rather see a baby survive on formula than die just to make breastfeeding somehow more valid.

  187. Statements like yours above: “A better one would be if an alcohol company wanted to sponsor AA.” do nothing to convince me of this. You are only becoming more alienating of many women the more you speak.

  188. Interesting that yet another researcher has been unable to find a good study that backs up the “only [insert tiny number here]%” of women cannot breastfeed.

  189. Where did I advocate for maltreatment of women?? I have repeatedly said that in an emergency breastfeeding women need support, babies that cannot be breastfed need targeted, comprehensive aid (quickly).
    And, please, if you have a better analogy, of an organisation refusing sponsorship because the sponsor was acting in ways inimical to the organisations aims, I'd love to hear it.

  190. Unfortunately, disaster prone countries are amongst the poorest in the world. Storing food for a future emergency that might not happen before product would have to be repurchased is difficult. There have been discussions around whether WFP should have a central supply but I don't know where that is up to.
    People keep saying to work with the formula companies but in poor countries their actions kill a lot of babies. Why is no one upset about this?

  191. Where did I say that?? I said that in a large scale emergency ensuring the safety of formula fed babies is difficult. I've said that they need a package of care targeted to them quickly. I've said the more breastfed babies there are the easier it is to target aid to the formula fed infants. What is wrong with any of that?

  192. Certainly I cannot back that up because there is no such study. We do not know what % of women are physiologically incapable of producing enough milk for their baby.

  193. Just for your info: in Australia you can purchase Ready to feed formula in disposable bottles from here:
    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.
    So ummmm… yeah, I am no researcher, just a mum with the internet and a phone but you might want to check your facts before being so black and white in your responses cause “*Nope could not purchase these products in Australia” is not entirely true.

  194. Yes, that was one of my posts. I was providing an example where an organisation might refuse sponsorship because the actions of the business were inimical to the aims of the organisation. That was my only point from the analogy. I think that many people would understand why organisations might make decisions like this.

  195. Wow, that's great to know Ann. I was basing my advice on the info on the AQUIS website. I will follow up further to get some official confirmation. So glad that you did this. It's important to know that this option is available because it would make things easier. Can someone tell me about how these RUIF in bottles work?? Do you have to put the teat on or is it already there? How do you open it?

  196. I read your paper. Yes, you do provide tips for safely formula feeding. Thank you. Although I did not see anything mentioned about the read-to-feed formula already in disposable bottles, many of the supplies you mention would not be necessary if this were made readily available, but that's fine lets assume they are not. I did not find however anything about women who exclusively pump. They would be a breastfeeding mom in danger. I will tell you as someone like myself who decided to re-lactate I needed a hospital grade double pump, certain foods, water, and a quiet low-stress environment to get things started. Hand expression does not work for many women to get the supply they need to properly feed their baby. The information also conflicts with many books that I read on breastfeeding. It is almost always mentioned that a breastfeeding mom should have a good diet, lots of hydration, and even prenatal vitamins. If you even go to kellymom they will tell you a breastfeeding mom should have a good diet and plenty of water. Even anemia is mentioned as something that can hamper breastfeeding. I had hyperemesis during both of my pregnancies for 9 months. Both times I went into labor I was malnutritioned and I miraculously have large healthy babies over 8lbs, but these babies eat a lot. While many lactivist have argued that my milk was just fine, I will say that I had 2 well-versed veteran LC's and 2 Pediatricians who told me that it is taking me longer than normal for my fatty milk to come in and thus my babies always loose +10% of their weight in the beginning. I solve this problem by combo feeding. Thank goodness for formula! Pediatricians always tell to give me my babies vitamin D and iron supplements since breastmilk and possibly mine is deficient in these nutrients. Besides all this, many woman have claimed stress does indeed affect their supply. A breastfeeding mom should really be prepared in the event that breastfeeding does not work out. It gives a false sense of security to just say breastfeeding will be the best thing you can do in the event of a natural disaster. There are dangers such as your milk supply becoming depleted. You can also end up in a situation where you cannot BF because you are too ill or injured to do so and now your baby will not take a bottle. A very knowledgable LC with 20+ years of experience I met told us in a meeting once if you are going to bottle feed (whether it be Expressed BM or formula) don't wait too long to do so as she had seen her fair share of babies in the ICU with dehydration because they will not take a bottle.Ideally breastfeeding would work out great in a natural disaster and I am sure it actually has many times. However, a breastfeeding mom should always be prepared a be open-minded and realize you may need other means to feed your baby. Painting formula in a such a negative picture like FFF described in her post does nothing to help any mom.

  197. I have been thinking on it and I have a better analogy. How about if BHP or Rio Tinto wanted to sponsor Greenpeace?? Or if the Battery Hen Association (no such thing exists as far as I know but you get the drift) wanted to sponsor PETA. They would not accept funds because they are acting against the core business of the organisation. Aid organisations specialising in the well being of children act similarly. I refer again to one example involving 20 aid orgs (many well known and respected)

  198. Hey Michelle,I have only just discovered (thanks to this blog) that it is possible to obtain the ready to feed in disposable bottles here and probably in many other places. I will be talking to the editor of the journal about adding an addendum. I need some more info about how they work which I hope someone on here will be able to give me some pointers on before I investigate further.
    It's interesting that you mention relactation because that is what got me into this work to start with. Relactation was my first area of research in infant feeding and I help a lot of mums who are relactating and mums to be who are relactating or inducing lactation. A surprising amount of the work that has been published on relactation is in an emergency context. If you are interested I can provide you with more info on this.
    As for nutrition and lactation. There is some really robust research. Oftentimes mothers are presented with what should be ideal in terms of diet as being the baseline necessity and it is not so. My favourite work in this area comes from the Prentices who worked for many years in the Gambia where women have quite marginal nutrition for significant portions of the year. Prentice, A. M., S. B. Roberts, et al. (1983). “Dietary supplementation of lactating Gambian women. I. Effect on breast-milk volume and quality.” Human Nutrition – Clinical Nutrition 37(1): 53-64.

  199. Firstly because, as numrous posters have pointed out, we don't buy this “formula kills” and “Nestle did it and ran away” stuff wholesale like some bf advocates, the situation is a lot more complex. Secondly, because the problems that have been caused by inefficient formula supplies in every-day distribution are not relevant here. Thirdly because a number of the posters on here have a deep mistrust of UNICEF and WHO for all sorts of reasons. Finally, because this really isn't relevant to your points, we're talking about emergencies and disaster sitations in highly developed countries.

    Of course everyone cares about babies dying but we're not simpletons.

  200. In the niceset possible way of saying this, but you've just published a paper on disaster/emergency supplies. You absolutely without a doubt should have checked this MORE THOROUGHLY than looking at one website. Are you the kind of researcher who thinks wikipedia is a go-to? Ann is NOT your research assistant, she should not be doing your job for you.

    For all your enthusiastic response, this grates.

  201. But below are extremely revealing comments which demonstrate clearly that you did not even do the research that is apparently within the scope of this paper. I'm completely shocked that a Mother was able, with the phone and the internet, who wasn't being paid to research this, was able to discover that RTF formula and reusable teats ARE available in Australia and are importable. It's a damning indictment of your research practices and this paper.

  202. haha – I have no idea why that came up as Ann….. my only thought is that I was feeding my baby who likes to kick the keyboard….. Yea, my name is Lisa 🙂

  203. But you've repeated in the comments on these threads that formula donations are a bad thing and make it harder to respond to those in need. When it seems like what makes it hardest is the MIS-use or planning or distribution of said donations. It's kind of like (sorry for the tasteless analogy) throwing the baby out with the (bad) bathwater

  204. Which of these children's aid orgs don't take formula? I could ask my friends who work with the ICRC and Red Crescent and WFP in Somalia too, but I get the impression they take what they can use.

  205. So we're going around in circles – you cite the WHO and UNICEF codes, and WHO and UNICEF claim they are doing it for the well-being of people in poor countries without good water supply, so they won't even accept RTF formula out of their refusal to budge from their (not always applicable) assumptions? Let's just say I will never trust UNICEF in a disaster zone again…

  206. it was the “foreign proteins” in my milk that damaged my child's intestines and formula that helped him recover and stop being sick. If you're going to insist that formula per se – and NOT the water it is mixed in – increases HIV vulnerability, that's a huge claim that I have never seen scientific evidence for and would pretty much negate all science I've seen on formula feeding so excuse me for being sceptical. I'll check with a friend who is a public health researcher on women and children's health in West Africa (she worked on HIV for years) and ask what she thinks, but it sounds really implausible.

  207. That's the problem with donations, they just turn up. Very difficult logistically in practice. As I mentioned, donations will not be accepted by many organisations from infant formula manufacturers that breach the Code because of their actions to undermine child health. But refusal of these donations is not a barrier to providing aid.

  208. And what is “mixed feeding”? I know about bad water causing illness and infection, but Karleen's claim above was that it was formula per se, regardless of the water it is mixed in, that increased HIV risk.

  209. Takeaway conclusions from this paper: “There
    appears to have been no attempt to limit the distribution of BMS according to the pre-existing feeding practices of the caregivers surveyed, or to households with older infants, or to those in which infants were no longer being breast-fed but with extra attention given to hygiene in such households.These findings confirm our observation and communications that many agencies active in the relief effort prioritised BMS distribution(21–23), usually without regard to these and other recommended practices.” AND “The high overall 1-week incidence of diarrhoea identified also suggests that all children in surveyed areas were at risk, probably because of lack of clean water and/or poor sanitation.” And note that this is a UNICEF policy paper. They are not saying formula (“breast milk substitute” in their phrasing) is the problem, they recognize that it is simply difficult to distribute properly. And honestly RTF would solve many of these problems. Plus getting their own act together with distribution instead of whining about “donated” supplies.

  210. I'm glad that I've found that it's a possibility. It will be added to the paper (one reason why I chose this journal- such things are possible). It will reduce the need (I think) for having a knife and a bowl and antiseptic wipes and plastic bags and some water so not a huge difference in terms of what to store…but cheaper than having to buy bottles and formula separately and not much more expensive than using tetra packs and disposable cups.

  211. I can give you some (not comprehensive). Some are reviews, others actual studies but these should give you what you are looking for.

    Coovadia, H. M., N. C. Rollins, et al. (2007). “Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study.” The Lancet 369(9567): 1107-1116.
    Coutsoudis, A., H. M. Coovadia, et al. (2008). “HIV, infant feeding and more perils for poor people: new WHO guidelines encourage review of formula milk policies.” Bulletin of the World Health Organization. 86(3): 210-214.
    Coutsoudis, A., K. Pillay, et al. (1999). “Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study.” The Lancet 354(9177): 471-476.
    Coutsoudis, A. (2005). “Breastfeeding and HIV.” Best Practice & Research in Clinical Obstetrics & Gynaecology. 19(2): 185-196.
    Iliff PJ, Piwoz EG, Tavengwa NV, Zunguza CD, Marinda ET, Nathoo KJ, Moulton LH, Ward BJ, the ZVITAMBO study group and Humphrey JH. Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival. AIDS 2005, 19:699–708
    Kuhn, L. and G. Aldrovandi (2010). “Survival and health benefits of breastfeeding versus artificial feeding in infants of HIV-infected women: developing versus developed world.” Clinics in Perinatology 37(4): 843-862.

  212. Yes, there are very many. This was just providing you with an example of a host of child focussed aid orgs explaining why they will not take money viewed as tainted by child deaths. The International Code Documentation Centre puts out publications every few years showing how the Code is breached all over the world.

  213. lol – nope not a research assistant but in the hope that formula feeding mothers in Australia are supplied better information than the normal and overdone “Breast is best” no matter what the situation and formula will surely kill your baby in some way: Doing a quick search I found, on the Similac Website this information ” Just twist off the cap — no powder mixing or measuring — and the formula is ready for your baby. Nipple might not be included. See package for details.”
    Doing a quick google search I found that you could also buy a case of 48 nipples and rings

    It really makes me quite sad that 1. Australia doesn't stoke pile these essential emergency items and 2. that in case of a natural disaster the WHO code and red tape would get in the way of potential saving babies lives (if it really is so difficult to prepare safe formula using powder and water) by accepting and providing sterile formula from formula companies to parents who need it.

    Maybe in the times that disasters happen people could put down the swords and think about the babies?

    PS – if you need an address to send my 'assistant fees' too I will happily email that to you. 😉 lol.

  214. I really think that you would find it difficult to locate any organization who would not take donations of a life giving substance (in emergency situations) for many babies from any company – no matter what their problem was with them. For most intelligent organizations it would only stand to reason that even if the devil himself said “you don't have enough safe food to feed these babies, I will give enough too you” that they would put their differences aside and accept it for the health of babies in that situation.

  215. Contaminants in water can also be a factor but even with clean water the foreign proteins in formula damage the lining of the intestine.

  216. I only breastfed for a few months max in one way or another (mostly via SNS – but lets not go there with disaster feeding – OMG) but early on (when babies are small and most vulnerable) most women touch their breast to help latch the baby (especially when baby isn't latched properly and she has to basically stick her finger in the babies mouth to break suction). I don't really understand why a formula feeding mother touching a bottle nipple with dirty hands (I have never had to stick my finger in my babies mouth to break suction off the bottle BTW) is any different from touching her own nipple with dirty hands? It does seem to me that most of the information on bottle feeding VS breast feeding aims to make breastfeeding seem to be as uncomplicated as possible while making bottle feeding be as complicated as possible. It shouldn't be about making one way seem prettier then the other – it should be about the health of the baby. Common sense tells me that if you hands are going to come in contact with anything the baby is going to put their mouth on or near you need to wash your hands. But I guess common sense is not so common anymore 🙁

  217. Count my son in as another whose intestines were damaged by the domestic terrorist proteins. If it weren't for the foreign aid of hypoallergenic formula, he would have been one sick little guy.

  218. I was wondering the same thing, Lisa. With all the skin to skin contact, what about washing the breast itself? Surely in a flood situation, if a woman were doused in dirty flood water, there could be the same contaminants on her breast as on her hands?

  219. Yes, because they received formula WITHOUT access to clean water. That's it. Nothing about formula being bad in and of itself. Do learn to distinguish between formula and water. Most of us here have.

  220. But you're the one writing the papers which could influence policy! You're wilfully missing these opportunities to address these problems through your bias and inability to research or critically review research papers. (Sorry FFF, I promised i wouldn't write anymore comments!)

  221. (Sorry FFF, sorry, I'm going to stop…after this one!!!!!)

    That is also a useless analogy, as commented below, you cannot sponsor a disaster.

    IF you restructured your examples such that a ship full of Greenpeace protesters had run into difficulty (fire in the engine room, titanic style iceberg?) and the crew and passengers were out of food/water/in freezing cold water and in danger of death, if the only ship around to rescue them was a BP ship, would Greenpeace let the greenpeace people die or would they let the BP ship take them to safety?

  222. What do you think? Should aid agencies accept RTF formula donations? Should the code be changed, and would that make it easier to reach those in disaster situations?

  223. Everyone, I am just about to head to the nation's capital for a few days of meetings (maybe I'll see Barak!) and won't be able to engage for a few days. I have valued greatly you sharing with me. I have learnt a lot from you all. I realised last night that the conversation had moved well away from the emergency preparedness/response stuff when we started talking about the impact of formula on the intestinal mucosa of infants and I'd moved into academic “argue my point” mode as opposed to explaining. I apologise for this. It was not appropriate. So I will leave that discussion where it is. I'm happy however, to have more comments about what people would like to see in terms of communicating the information about emergency preparedness to mother and to answer questions about emergency preparedness and response. I will get to them when I return.

  224. In response to Karleeng about the 1% statistic…
    Then why are so many studies and lactivists so quick to point out that only 1% or so of women are physically unable to breastfeed as though it is some magic standard and if we could only get the rest of the 99%, we'd be golden?! Since we can't actually study this, maybe *someone* should write a paper about why we should get rid of this statistic in breastfeeding literature. (I nominate Lisa!)

  225. I think most here are knowledgeable about the fact that the reason behind it is the concern over formula marketing (though I find it ironic that we have no issue with any version of breastfeeding marketing even if it endangers babies' health – and yes, low supply and fear to the point of starvation endangers a child's life). I still find it disturbing that in the event of a disaster where it is a child's life or formula donation from a manufacturer, somehow the disgust over marketing wins.

  226. Roxane – first off, I am so sorry to hear what a distressing experience you went through.

    But… I think you and Karleen may be talking apples and oranges here, and that a lot of other people in this debate are doing the same thing. I think people are losing sight of the fact that the issue isn't whether a mother's milk could dry up, but whether that could happen so suddenly and completely as to make a woman immediately unable to produce enough to keep her child alive for even the next few days.

    Yes, your milk dropped and eventually dried up – but you still had enough to keep your baby going for three weeks. In a disaster situation, that would most likely have been enough to get through until clean water was available again. So, yes, you *would* have been able to continue to provide food for your baby. Not the ideal amount, no… but enough to get by in an emergency. And, bearing in mind that available formula milk might well also be in very short supply *and* would have the added disadvantage of the risk of contaminated water in such a situation, I think breastfeeding with a poor supply would be the better of two very non-ideal choices.

  227. Haha Brooke, yeah thanks, maybe when the kids are a bit older…….
    From all my own research into that stat all I could find was one study that found 15% of women (in a very supportive setting – who were very motivated) couldn't physically breastfeed and one other that showed (and I am going from memory here) around 5%. I have NO IDEA where people seem to get all these various stats from???

  228. O no. And here I was all 'benefit of the doubt' thinking, maybe she just doesn't know, maybe she just needs abit of help and guidance. The whole 'breast is best' push is so strong in Australia maybe she just got given bad information. But with comments from Karleeng like:
    “it costs significant amounts of $$ in medical care to treat formula fed babies- the numbers requiring care is large. The social cost to families having sick babies is also significant.” I think she is just another typical Aussie breastfeeding bully 🙁 It makes me sad that someone has paid a person who obviously has such a strong bias against formula feeding to write a paper that should be about helping ALL parents in horrible situations but instead is simple an avenue to push her 'breast is best' agenda (or if you agree with 'Marie' the “infant formula is deficient” agenda) :/

  229. Here is my list and costs: (from Queensland Australia)

    (ignoring that you are able to get ready-to-feed in bottles from the USA)

    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.)

    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)

    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 (as explained in this paper) $11.00 (crazy clarks)

    50 Large Zip lock bags – $5 (Coles)

    Paper towels – 400 (let's go crazy) $4.70 (Coles)

    Detergent – 1L $1.06 (Coles)

    Antiseptic Wipes – 80 pack – $10.68 (Coles)

    Packet of strong sharp disposable knives (here is the thing – the packet of RTF I used already have a tear section – so for me a knife is not needed at all, but some do not so guess what I did? Got a plastic knife out and tried to open to carton with that – guess what? It worked with no problems! This part eliminates all that extra cleaning of the metal knife, the bowl, the extra water etc cause you can use the plastic one and throw it away per feed!) 50 pack – $3.20

    TOTAL COST: $132.13


  230. The difference is that I'm not applying my biases in such a way that they're going to cause real harm to women who won't get formula in disaster zones because people read research like yours, think “formula = too hard” and as you pointed out later on this post, just give up on trying to provide it in a disaster.

  231. Their actions kill a lot of babies. So the formula companies are personally responsible for the craptastic water supplies these countries have? Perhaps these companies could contribute to making the water supplies safer if they were, y'know, invited to do so, instead of being shunned.

    Out of curiosity, is there anything folks like you DON'T blame the formula companies for? I've heard global warming, I'm just wondering if Nestle would have been responsible if, say, the world had ended on May 21.

  232. Yeah what is wrong with me! I guess what I should REALLY do is just not have any more children, in case there's an emergency and I couldn't breastfeed them.


    This paper suggest making infant powdered formula by following the WHO's guidelines of always boiling any water to mix the powder and adding the powder at 70 degrees Celsius. As I do not agree with adding the powder to near boiling water (as it can kill important vitamins and minerals in the powdered formula – which the baby needs and to me is MUCH more of a risk then the 0.01% of infants affected by the bacteria which MAYBE found in the powder) I would not do this. (Sorry – can't be bothered linking all the info on that – if I REALLY have to I will, but I am not being paid for this 😉 In the same instances – if you and baby have been happily using bottled water without boiling it under normal circumstances then you would probably not change to suddenly boiling bottled water under extreme circumstances.

    At under $200 you are probably better off having RTF formula in your emergency kit.

    Anyway – here is my list:

    2 Tins of powdered infant formula (makes 48 230ml bottles) Cost appox. $36.00 depending on brand and age group you are buying for.

    WATER: 200mls/feed for washing (see RTF list) and 200mls/feed for powder equals 400mls per feed. 400 x 6 equals 2.4L x 7 (for a 5 month old – see RTF list) equals 16.8L COST 20L water (Coles) $12.18

    Storage Container – $11.00 (crazy clarks)

    Metal kettle for boiling bottled water (if applicable) $15 (crazy clarks)

    Small gas stove to boil kettle $26 (crazy clarks)

    Gas for stove – 16.8L over the week will be the max amount of water you would have to boil over the week. Cause I really suck at math I am not going to figure this out using the equation as is in this paper but I am going to say that a 8.4 kg bottle of LPG would be more than enough. COST – $24.95

    Bottles (as per RTF list) COST $48.65 for 42

    Large Zip lock bags – 50 for $5

    Paper towels $4.70 for 400

    Detergent – 1L – $1.06

    Antiseptic wipes (cause they are good to have anyway) $10.68

    Baby Wipes – 480 pack – $10.70

    Nappies – 100 about $35 (depending on brand and sizes)

    (If you use a knife to level to powdered formula off then a packed of plastic throw away knives (about $4) is smarted then a metal one – good plastic ones can be put through the dishwasher to sterilize before packing, however I use the lip of the formula can – which is what it is there for.)

    TOTAL COST FOR KIT: $240.94

  234. Whoops – forgot to add the all important Nappies and wipes 😉

    WIPES – 480 pack (some extra incase you need to wipe your babies nose – after all they are formula fed and will probably be sick at the time 😉 haha. – $10.70 (Coles)
    NAPPIES – 100 – around $35 depending on brand and size)

    Makes the total $177.83

  235. I have read this comment thread way more times than I should, and I keep coming back to this quote: “…as people who are formula feeding I'm wondering why you are so concerned?” It's totally reasonable for lactivists to be concerned with those who formula feed because I'm sure [and I quote a previous comment thread] of the “societal costs” and yet, it is so impossible to see (prior to it being pointed out) how formula feeders could possibly be concerned with anything remotely connected to breastfeeding?!? Amazing.

  236. It boggles my mind, is what it does. This does not inspire confidence in the other infant feeding research papers out there. Too bad most lactivists never see blatant errors like this. It might reduce some of the bullying that routinely goes on against formula/bottle-feeding parents in the name of being “evidence-based” or “just stating facts.”

  237. I don't like to unleash my anger at a lactivist because I feel there's enough doors slammed shut in peoples' faces in this debate as it is. But some folks just get my back up immediately and stay that way. Usually they're the insidious militants, the ones who pretend to be all understanding, reasonable, rational, but who eventually reveal their true selves. In some ways, I'd rather the militants just call me an weak, stupid, inferior person to my face, rather like my daughter's first pediatrician did, than sneak around like some of them do.

  238. Karleeng, here's really easy question: if formula is so impossible to use without state-of-the-art sanitation, how come people routinely take formula-fed children camping? Willingly? Without outbreaks of HIV or whatever else you contend formula causes?

  239. Do you all think that we should compose some sort of letter/grand posting as a response. Karleeng has mentioned that it is possible to make comments about her original paper (although I haven't checked where and how this is done), perhaps we could put our heads together and create something fully referenced and with Lisa's fantastic research? I feel that as we've given so much time to discussing the falws in this paper it would be sensible for us to do something like that. How does everyone else feel?

  240. Karleeng, just a question: I found it strange that under the powdered infant formula section it says “Neither a feeding bottle nor a spouted cup is appropriate for feeding an infant in an emergency….” but under the section on Ready-to-feed formula you recommend one use bottles. Why the difference? Wouldn't it stand to reason that if you recommend one use bottles for RTF formula you would also recommend one use bottles for powdered formula? Of course it would make it more expensive (by about $50au) but would be much easier for an infant used to bottles and mothers used to bottle feeding to use bottles in that situation as opposed to using a cup feeding method which would be foreign to most formula feeders. It would also seem to eliminate alot of your steps to safely feed formula…..

  241. Wow. Sorry to go off-topic in what is already such a long, complex thread – but, yes, Karleen, I certainly would like to see the evidence that 'if we talk about breastfeeding as bes and the benefits of breastfeeding that we fail to effectively communicate the importance of breastfeeding and the risks of formula feeding- we actually assist in the promotion of formula feeding' (quote from the thread on the Ben Goldacre blog). This is an area of considerable concern to me, and I've blogged about it already at So, if you've got some evidence in favour of the 'artificial feeding is risky and dangerous' approach, I'd love to hear it. (Leave it in a comment on that blog post, if you like – that'd avoid sidetracking the debate here, which is quite complicated enough already.) Thanks.

  242. The first part of your question is good, Teri, but the HIV bit is just totally off base. Diarrhea would be more appropriate in this context. Or maybe you were being deliberately ironic? 😉

  243. Rina, see above (way up in the thread) where Karleen contends that formula fed babies are more vulnerable to HIV transmission because of foreign proteins affecting the intestines, rather than anything to do with the water formula is mixed in. Yes, she really does.

  244. Will have to wait till I get back up to campus as some of these don't link where I am now! Sent them on to friend who is public health researcher at Brown/Harvard though at some level seems pointless since K seems to believe that if you repeat something that is not actually stated as a finding in a paper often enough it will be true

  245. Yep, it's totally off base. Karleeng seems to disagree. By her logic, no one should take a formula fed baby camping because it makes them more vulnerable to HIV.

  246. So many people do, it REALLY frustrates me. I found this amazing quote by a UK journalist (Monbiot) and I try my hardest to live by it:

    “We have a duty to base our judgments on the best available information. This is not only because we owe it to other people to represent the issues fairly, but also because we owe it to ourselves not to squander our lives on fairytales.” George Monbiot in The Guardian today (5th April 2011).

  247. “….UNICEF deleted that section in order to attempt to stop donations of RUIF”

    So they purposely misrepresented what the minister of health said, as he said that ready-to-feed formula would be appreciated. I don't think that is honest, and I think it was serving their own agenda. Ready to use formula would have been far easier (and safer!) than donated breastmilk.

  248. I hope Karleeng does understand that the only people who cannot catch HIV are those with 2 copies of the Delta-32 gene (BTW, they not 100% immune to certain types). This is less than 3% of the European population. Everyone else is vulnerable to HIV through the known ways of transmission formula fed or not. I read about that part that just leaves me at an utter loss for words.

  249. Right – Women have breastfed through war and famine. The body will make milk even at the expense of the mother's own nutrition. That being said, one needs to have the breastfeeding relationship well-established to count on this. And many moms today are, obviously, opting out of giving their babies breastmilk.

  250. Many moms also have difficulty establishing supply. And many moms experience stressors in the initiation stage of breastfeeding. Are their (MY) experiences not valid?

  251. I have heard, and don't know the source, that formula companies dump expired formula in such situations.

    In a disaster, where will the clean water be? One reason that formula feeding is a leading cause of death of infants is that when sanitation is inadequate, the bottles of formula become carriers of disease. If feeding bottles and formula preparation can't be clean, then the baby is at risk of pneumonia, diarrhea, and death.

    In a disaster, there will be no infrastructure. The breastfeeding mother carries her own infrastructure.

    As for other history, here's a story about stress. During World War II, Hitler laid siege to the city of Leningrad. For 2 years, nothing went into that city, nor came out. All the food was eaten. Then folks ate all the pets. They ate rats. By the end of the siege, people were eating bread made of sawdust.

    Many died of starvation, including pregnant mothers. The babies that were born were smaller, and weaker.

    The mothers that survived made so much milk that a milk bank was started to feed the babies whose mothers had died. My colleague, Lois Arnold, tells about a discussion she had with a translator in Leningrad (again St. Petersburg). Lois was on a People to People tour in St. Petersberg and asked if there were any milk banks in that City. She was told no, that there were none at this time, but then was told of the war-time milk bank.

    Stress makes learning to breastfeed more difficult; once lactation is established, breastfeeding can survive war and earthquake and other disasters.

    Human history is about surviving adverse events: famine, war, floods and earthquakes. Formula feeding requires an infrastructure (plumbing, an energy source, clean water, preparation mechanisms, manufacture and distribution) that is easily disrupted. When a baby becomes sick, there is no sufficient way to provide medical services. There are no stores to purchase things. A breastfeeding mother IS the infrastructure for the survival of her baby. Her baby has a better chance of being healthy and of living.

  252. But nobody is arguing that formula is the answer. All we are saying is that this particular paper- one that claims to be giving information for formula feeding parents- is misguided. Have you read the discussion or our summary of issues?

  253. OK, here is what my friend the researcher says (FWIW she BFed her two till they were toddlers, in case someone wants to call bias!)

    “That is a big debate re: formula feeding in developing world. The problem w/ formula is often clean water, but shouldn't be b/c there are relatively easy solutions and people are quick to say that “poor women don't have access” and leave it at that. People should be advocating for education of women who choose to use formula (most of whom would probably be HIV+ given cost of formula). The risk of HIV transmission via breast milk is significant. Some ministries of health will not allow formula feeding to be put into guidelines for treatment of infants born to HIV+ mothers b/c of high risk of diarrheal disease. They probably also don't want US companies like Nestle barging into their economies. At [her org] we advocated (and I use advocate w/ capital A b/c we really took a firm stance) that formula should be used in the presence of “accompaniment”, or education and support from community health workers, for HIV+ women who were pregnant or post-partum. Transmission rate of HIV via breastfeeding is extremely high (I'd have to check but I think it's in the range of 40%). Safe use of formula feeding has very low HIV transmission rate. Community health workers can provide supplies (containers, stoves, free formula) and teach mothers how to boil and store clean water, and leftover formula can be drunk by the woman or given to other children. Mixed feeding (breast and formula) should NEVER be done b/c formula actually can irritate digestive tract and allow HIV in breastmilk to pass intestinal lining, into bloodstream, but if not doing mixed feeding, transmission risk would be nil.

    You could tell this person to see bulletin in WHO:

    The mixed feeding question seems to have something to do with the formula-based irritation making the HIV-positive mother's virus more likely to be transmitted with the baby. I will ask for clarification. The WHO document she sent me seems quite sensible actually.

  254. I lived through a few minor emergencies, like power outages for a week which means no stove, no water, no heat. I can tell you that we barely survived with breastfeeding. At least it was one thing I didn't have to worry about. I had to think about taking care of myself, feeding myself, having water for myself, but the wellbeing of two of my kids was covered hands down. The author of the article did a good job describing the practicalities of infant care taking in an emergency. I as a mother can say that breastfeeding is a life saver during disasters. I was stressed but not nearly as I would have been had I been formula feeding.

  255. Again, I don't have a problem with what she says about breastfeeding in an emergency as the best protocol. Can you tell me what you disagree with regarding the point of this post? I.e., the best way to formula feed in a disaster; the refusal of UNICEF to accept formula donations of RTF or the recommendation to parents to keep RTF on hand in case a mother is separated from her infant?

  256. That's great for you and your family that you were able to do that Karmait58. And I don't think anyone here is saying that in a disaster you should stop breastfeeding and start using formula. But for me breastfeeding during a disaster would be about as 'life saving' as it was when my baby was almost admitted to hospital from dehydration because I medically do not produce enough (no where near enough) breastmilk. Relaction in these situations maybe possible but for me relactation is about as practical as asking my husband to relactate.
    As a formula feeding mother who goes camping quite often (no power, clean water, heat and most of the lack of amenities which would be similar to an emergency situation) I do not think the author of this paper described the practicalities of formula feeding in that situation without the hidden agenda of breastfeeding promotion. Promote breastfeeding, sure – but just leave it out of a paper which is meant to be providing life saving information to parents in a practice way. It would be a much more stressful situation if a formula feeding mother was discouraged to prepare an emergency kit for her baby because she read that it was going to cost over $500 to do so when it has been proven here that it can be done for under $150.

  257. Over the course of this discussion of more than 300 comments we have discussed all of the points in your post and so this is becoming somewhat circular. We agree that breastfeeding is a great method of infant feeding IF you can do it. We agree that contaminated water sources are a majour issue. I'm not really sure that I understand the relevence of anecdotal WWII and unsourced 'stories' are?

  258. We all thoroughly agree that breastfeeding is optimal in a disaster situation, however, there are major oversights in this paper which concerns far worse disasters than a power cut, (have you read any of the survival stories discussed?!) such as when a Mother becomes separated from her child. Also, the research that has gone into this paper is severly lacking. I'm really pleased that breastfeeding worked out for you and your family and it would be lovely if every woman was able to do this but sadly this is not the case.

  259. Well, after listening to and reading some other information from Karleen as well as some comments about this thread in which she basically said that many of our experiences, particularly those we have had with health care professionals, have probably been twisted into something they were not (in other words she doesn't believe we have had horrible experiences with health care professionals, it was just all in our heads?) and where in the same line of comments the 'lactivist' there were all commenting on how bitter, angry, hurt, desperate and heartbroken we all are, I fear our comments, suggestions and efforts to really help will probably fall on deaf ears. Karleen also said that this discussion has “yielded some useful information, but not quite perhaps in the ways that the responders think they have been useful” I was wondering then what it is it that she has gotten out of this discussion?

    I am not bitter, angry, hurt and definitely not desperate or heartbroken. I am a proud formula feeder because for us formula was 'best' and is the reason my children are alive (and happy, healthy and smart). I am, however, sad that we can not take a stand against something we feel could hurt other formula feeding parents without being seen as those things.

    I would also be very angry if access to formula was denied to me and my family by any means (formula company donation, Aid worker distribution, army personal etc) during a natural disaster because of red tape put up by people who are much more concerned about breastfeeding rates then feeding babies.

  260. I'm so pleased that I don't know what site that's on. It's incredible that they only appear to hear what they want to hear. We have repeatedly stated that we all believe that breastfeeding is best when possible in an emergency, we've also mentioned a few times that a number of us have/still do breastfeed. It's clearly just the case that they want to 'win' the argument and will stop at no lengths. They will use any vehicle to showcase their ideology, even that of disaster preparation and even if that vehicle is so inappropriate that it could potentially cause death.

    I feel very very lucky to be on this side of the debate where the lack of bitterness, resentment and anger mean that there is reason and ethical thinking.

  261. They are not appropriate if you are attempting to re-use. We should have been clearer there. If you are attempting to re-use a feeding implement, then a cup that is easier to clean is what is recommended.

  262. Yes, I stated that the formula itself can assist in facilitating the transmission of HIV if a baby is mixed (breast/formula fed). However, I also stated that other substances in the water used to reconstitute formula can also assist with this.

  263. Thankyou. Your friend might like to have a look to see what the consensus is on the transmission of HIV via breastmilk and compare exclusive breastfeeding (with antiretrovirals) vs mixed breast/formula feeding vs mixed breast/solid food. Her estimate of 40% transmission rate is greatly inflated- I have already supplied citations that provide this information. The current recommendations on HIV and infant feeding are in the document at Under these recommendations it is up to national governments to decide what the recommendations (EBF with anti-retrovirals or exclusive formula feeding) on the circumstances in their country. It will vary between country to country. I would hope that her organisation would follow the recommendations of the country in which they are working. She is completely right though, if exclusive formula feeding is being recommended it must be ensured that support like water, fuel, education, medical support is supplied.
    Anyway, your friend supported the point that brought us into discussing HIV and infant feeding in the first place and that is that that formula helps facilitate infection via its impact on the gut of babies- the reason why mixed feeding in the context of HIV is so dangerous.

  264. Lisa, I am very impressed by the price you were able to find for the RUIF. What brand was it? We based our costings on buying the supplies at Woolies and there you are looking at about $9 for 4 serves. The amounts of formula are not based solely on the amount consumed but on the number of feeds because once opened the RUIF must be used immediately or discarded (or consumed by the mum or younger sib for eg). It will vary greatly depending on the age and feedng habits of a particular baby.
    With the amounts, of water I disagree on how much is required to wash hands and prep area adequately.
    Your idea of the plastic knives is a great one. It saves water and would reduce the amount needed to serve. Thanks very much for this suggestion.

  265. Some interesting ideas here too Lisa. This is exactly the sort of feedback that we wanted. Thankyou. It is possible to obtain sterile water in some locations and if you are not too worried about intrinsic contamination of powdered infant formula then it would be possible to do (and I personally wouldn't be too worried if the baby is 2 months or older- government recommendations are something slightly different). There are some other issues to consider which we are investigating.

  266. There is no best way to formula feed during disaster. During disaster survival gets down to whatever you can do. There are no vast resources available. I would NEVER want my children, separated from me or not, to be formula fed during disaster. If there was a kid separated from mom and I was around, I would put that child to my breast to give it a chance. I would hope another woman reciprocates should my child be separated from me.

  267. If I had no breasts or no milk, I would want my child to get breastmilk from a family member, a friend, or a neighbor. Why would I want my child to get formula if I am unable to produce milk?

  268. This is good you are proud. I would be devastated if I could not nurse my children, and I would not want them to be fed formula if I did not have milk. My inability to nurse them would not be reason for my babies to be deprived of at least the milk, if not the nursing relationship. I would be very angry if nobody was willing to give my children human milk offering them formula.

  269. I am not doing the best for my children by nursing them. I am providing the basics, the normal. It is not best or extraordinary. God forbid disaster management agencies decide that breastfeeding is best downgrading my children to normal formula feeding. Thank you, I do not need that.

  270. But what happens if there are no lactating women around? Wouldn't you rather the neglible risk of dying from rtf formula/disposable nipples than certain death from dehydration/starvation? We're talking just in case, not instead of breastfeeding.

  271. I understand if you would prefer breast milk over formula. If you were unable to breast feed and were able to get enough milk through donor milk and/or milk sharing (provided you were sure the moms sharing their milk were healthy and not on any harmful drugs) to make up your child's entire diet, great.

    But from what I'm told, that is seldom the case. Donor milk is generally available in small quantities, if at all. And buying milk from a milk bank can be very– sometimes prohibitively– expensive. I don't know whether these milk banks would remain open and in stock during an emergency, either. You'd also have to be able to store (i.e. freeze, or at least chill) any milk you couldn't use within a few hours. And in an emergency, you can't count on having electricity. The same thing goes for milk sharing. You would be very lucky to find one or more lactating women who were willing and able to supply all the milk your baby would need. Nursing around the clock– for a child that isn't even yours– would be quite a sacrifice. Also, lactating women generally have babies of their own to feed. Not everybody can make enough milk for two babies, particularly on short notice and following a natural disaster. Again, if you were able to find “a family member, a friend, or a neighbor” to supply your child with adequate breast milk, awesome, really. And I don't mean that in a snarky way.

    For many moms who don't have breasts or milk or for babies whose moms are deceased, severely injured or separated from them, donor milk and/or milk sharing are not options. The question then becomes not “Breast milk or formula?”, but “Formula or nothing?”.

    I understand the tendency to be idealistic and want exclusive breastfeeding, or at least breast milk, for your child. Some situations, however, force parents to be more realistic. The question then is not, as you put it, “Why would I want my child to have formula…” It's “Do I want my child to eat?”

  272. I am going to check on that price. I called Chemist Warehouse and she gave me that price but it does seem low, so I will do a double check and get back to you.
    I was also very surprised in how little water it took for me to clean my hands and the prep service but I did it adequately. I should also mention that our 'emergency water' that we have stored is our normal tap water placed in large containers. Doing it this way for us was much cheaper (as the water was free – just the cost of the storage containers) so that maybe something to consider too.

  273. We have written a little on this. Berry, N. J. and K. D. Gribble (2008). “Breast is no longer best: promoting normal infant feeding.” Maternal and Child Nutrition 4(1): 74-79.

  274. And yet for some reason I don't understand some people here appear to be in favour of such untargeted and resource limited distributions and against aid orgs that provide targeted and appropriately resourced distributions.

  275. No, I do not think that that is a good analogy. It is more like should Greenpeace accept funds from BP to buy the boat in the first place?

  276. When my family lived in California, during all the wild fires in SoCal, we had to get out of there fast. I did a combination of breastfeeding and formula feeding. My supply didn't suffer. Now, we live in Japan. In Okinawa, we have had quite a few tsunami warnings (including the one that swept away some cities in northern Japan), strong typhoons, and several very strong earthquakes. The most recent was a couple of weeks ago, and measured 6.9. It has all stressed me out, but I have always taken comfort in knowing that I can breastfeed my baby, should the water become non-potable. None of these stressors have negatively impacted my supply. However, I do feel it is important for parents to have an emergency supply of formula (ready-to-feed) in case something happens to the mom. Just 3 weeks ago, I had an emergency appendectomy. I wasn't able to feed my 6 month old for 24 hours. He was used to taking the occassional bottle, and handled the situation well. As soon as I was able, I resumed breastfeeding, and my supply was normal. The same thing happened back in 2010. I had to have my gallbladder removed, but my supply wasn't affected negatively. Having said this, I've never had issues, and I have been able to breastfeed all five of my children from the start. I have been very fortunate. I have to say, also that nothing is more nerve calming than nursing a baby in the middle of a catergory 4+ super typhoon that is threatening to rip your windows and doors from your house. Most of the Japanese that I speek to here will agree that it is good to breastfeed during a disaster (if you are able). Those who can, seem to fare better than the mother who has to worry about water contamination and availability. I think it goes without saying that being prepared in the first place is key, and having easy access to such emergency supplies.

  277. Oh, hadn't realised you were the author of that paper! Been a while since I read it so hadn't made the link with your name.

    Of the three papers you cite to back up your point, two are cross-sectional surveys of public opinion concerning breastfeeding – these tell us *what* people think at a particular point in time, but nothing about *why* they think it, or about what approaches might work better or less well in persuading them to a different opinion. The third is a paper looking at experiences of women who were persuaded to change their initial decision to formula-feed as a result of individual discussions with medical staff – who did use the approach of presenting breastfeeding as better rather than formula feeding as disadvantageous. In other words, the very approach you're objecting to actually worked in these women. Of course, that pretty much boils down to anecdotal evidence and doesn't prove that another approach might not have a higher chance of convincing people… but, still, it's hardly evidence in favour of the approach you're advocating.

    My impression from the paper was that you were lumping two separate issues together – whether women should be given more detailed information about the differences between breast and formula feeding than simply the rather vague and unhelpful 'breast is best', and whether this information should be framed in terms of positives of breastfeeding or negatives of formula. I agree with you on the first point, but not on the second. Are you actually aware of any studies that have compared an advantages-of-breastfeeding with a disadvantages-of-formula-feeding approach and found the latter to be better? If not, then I remain very concerned that you're promoting an approach with a lot of potential downsides (as detailed in the post of mine that I linked to, above) in the absence of any supporting evidence.

  278. Karleen, I get that unethical formula promotion is a huge problem worldwide, and I share your strong disapproval of that. But I am STUNNED that you would actually support the idea of a disaster aid organisation turning away donations that might save the life of children in emergencies because they don't approve of the policies of the organisation.

    If getting sufficient formula to feed the non-breastfed infants in a disaster-struck area is so difficult, shouldn't aid organisations be accepting help wherever the hell they can get it? We're talking about an *emergency situation* here. It's the difference between not buying Nestlé's products on a day-to-day basis, and declaring that if the only food available for my children in an emergency was being handed out by Nestlé then I'd rather let them starve.

    Do you really see nothing at all screwed up in the priorities of aid organisations who would rather go short on life-saving donations than accept help from someone who behaves unethically in other situations?

  279. Lisa, I think you've (unintentionally) put your finger on one of the problems with the paper – it seemed to be assuming that all breastfeeders were well-established in breastfeeding. The issue is not just that some mothers formula-feed, but that, at any given time, the group of women breastfeeding is going to include a lot of women who are struggling to get breastfeeding established, may not be able to do so even under the best of circumstances, and may be even less able to do so in the added stress of an emergency situation. Blanket advice to all breastfeeders to continue breastfeeding is therefore not going to be very helpful in the case of this group of women, and I'm concerned that Karleen's recommendations could lead to women who really aren't able to get breastfeeding established being denied formula as they're lumped in with the 'breastfeeding' category.

  280. It seems completely potty to me. Basing your child's survival in a worst-case scenario on a wing and a prayer that there'll be someone lactating nearby who will be able to take on the responsibility of feeding your child as well as however many of their own they are nurturing at the same time. If 'disaster survival gets down to whatever you can do' wouldn't something really very simple be to have a supply of RTF formula and bottles and a workable policy with regards to safe and ethical distribution of formula worked out beforehand?

  281. So if you don't want/need the donated formula in an emergency, don't take any. Let me say that again–Don't. Take. Any. Problem solved.

  282. No, nothing happened to my children because of formula. I could have, because formula is so acceptable. I am not angry either. I am indignant, just like I would be if you were suggesting my children could walk on crutches when there would be a possibility of walking.

  283. Would you be working on provision of cross-nursing during emergencies? Or are you advocating other people's children are endangered by an unsustainable model of feeding during emergencies?

  284. I am not talking donor milk. Donor milk is Western play milk vs. formula. Expensive, prohibitive, unsustainable. I am an avid anti-breast milk sentiment mother. I am talking putting other children directly to the breast of any women who have milk. Channeling food and water to sustain the women who can sustain children in dire circumstances.

    When you see death looking into your eyes, putting another child to your breast is not sacrifice. Westerners are too concerned with what they do for others. It is a simple act of kindness to another human being. It is not a heroic deed, not sacrifice. It is what being human is about. Helping another person when they need it is graceful, ethical, neighborly, not sacrificial and heroic.

    When I ask myself do I want my child to make it, I assume that my child gets the breast. Not milk. I think that other children are worthy of the same thing. Unfortunately, people in the West do not have a concept of treating others like they would like to be treated themselves.

    Let me tell you, I can make milk for two children. I tandem nursed. I bet I could make milk for four kids. I would give your children my breast so they will have a chance. And I would not be a martyr or a saint for doing it. I would be a mother who is concerned about another mothers children.

  285. If I found your child or any child separated from you or anybody else, I would do everything in my power to find another woman to care for it as well as focus my energies on sustaining the women who do good for others until a child can be traced back to any surviving family members who can feed their children whatever they please.

  286. Sourcing formula is not a big problem. Why accept donations if you already have what you need?? Distributing it (and everything else that is difficult) is difficult just because of what is required.
    The problem in emergencies is not too little formula it is generally way, way too much that is the problem and it is also of the wrong sort in the wrong place in the wrong amount etc etc…still don't get why people are so keen on untargeted, dangerous distributions of formula.

  287. Karmait58, I have to say I'm finding your indignation on this particular topic a bit incomprehensible. Nobody has suggested that you start formula feeding your own children, and I think every single person on here would completely support your wish to continue breastfeeding and feel happy for you that you're able to do so. What exactly are you so indignant about?

  288. Huh? Are you saying that cross-nursing is more sustainable than supplying formula? I recognise the problems with getting ready-to-use formula into a disaster zone in sufficient numbers, but that's surely got to be a piece of cake compared to finding sufficient lactating women who are happy to be separated from their own children for days or possibly weeks and bringing them along.

  289. I think you might be missing the point a little her and so we're talking at crossed purposes. If a child is happily breastfed and the Mother is happy with this situation/child is thriving then absolutely, stick with it. Nobody on here is suggesting anything other than continuing to breastfeed for as long as you are comfortable and happy to do so. The concern comes from the idea that within disaster situations a Mother may well be separate from her child or harmed, or worse – dead and so there should be some form of sustinance available/sensible methods for distribution of infant feeding solutions.

    I think I speak for most of the women on here when I say that this is essentially a pro-breastfeeding site, however, we do not agree that disaster situations should be used as a vehicle for discussion on breast vs. formula. We feel that this paper is inadequate in its consideration of women who have already chosen to formula feed and potentially misleading to breastfeeding women. We also believe that means of distribution of breast milk substitutes needs to be addressed so that in the event of an emergency the milk will get to the right babies and save lives.

    It is excellent that you are such a happy breastfeeder, as I was and many other women on here were/are, but that in itself isn't a solution to disaster preparation in developed country contexts.

  290. Yes, I would agree with this assessment. I'm also confused by the sentiments you're expressing, especially considering we've been pretty clear that our main issue is with the way this is framed for women who are already formula feeding. We are also concerned with breastfeeders who may die or become separated from their babies, in cases where there is not a woman like you around who is willing to wet nurse.

  291. I would like to know how a baby who has never nursed is going to suddenly know how to suck on a breast in the middle of an emergency situation? How about an premmie baby who has no suck reflex or a baby who has milk protein allergies? Is the mother of that baby going to be able to find a lactating mother who is willing to breastfeed another baby (something many breastfeeding mothers find an intimate act) also on a milk free diet during an emergency situation? I just don't understand these extremist attitudes.
    For me and my babies Formula is a VERY substantial feeding method and would be during an emergency as well because I am prepared.

    I get it Karamait58 – you hate formula, you think that parents who formula feed are horrible people who are endangering their children's lives. You think all babies should be fed from the breast only and that anything else is not good enough. Nothing new – we come up against people like you all the time. It's just that we know at times it is not practical to breastfeed from the breast. We understand that formula is not evil nor poison and most of us have healthy, beautiful, intelligent children who lack nothing and are in no way deprived of love or bond with their parents which sort of flies in the face of all the claims presented by those who have your sort of attitude.

    You will not see reason on this matter so there really is no use in speaking to you but good luck in your breastfeeding extremism, if that is what you think is important.

  292. Not if children have food allergies. Which 1 in 13 children do, at least in the States. Unless you're personally willing to provide me with a wet nurse who has scrupulously avoided all the myriad ways milk can be snuck into every food imaginable (everything from bread to meat to packaged vegetables), I will tell you that cross-nursing is NOT sustainable for my child, and 7.6% of other children her age (many of whom are, in fact, breastfed). So…try again.

  293. Many of the people who have shared their stories on FFF had every intention of nursing, in many cases for the 2 years WHO recommends. It was simply not possible for them, and there are many reasons donor milk may not be a good option (food allergies being just one example off the top of my head; FFF herself experienced this with her child who is allergic to human milk protein). If you can breastfeed your child, great! But people who have access to clean water and good formula and who cannot or choose not to don't need pity.

    What we need is for people to stop condemning us as stupid, ill-informed, selfish, emotionally detached from our children, or bad mothers. Something that Karleeng's colleagues seem completely unable to grasp. They may have lots of nice letters after their names, but all the letters in the world don't mean you have the common sense, capacity for critical thinking, or sense of ethics to publish breastfeeding research that is truly useful instead of another flimsy excuse to denigrate people like us. That's something useful that I wish Karleeng's colleagues could take to heart, except that it's quite apparent to me that a lot of the breastfeeding research out there is written by people with the emotional depth of a teaspoon.

  294. Okay, and during the 12 hours or 2 days or whatever it takes you to find another breastfeeding mom who hasn't consumed anything that a child is allergic to, I could be popping open a container of ready-to-feed formula and ensuring that child is fed. Problem solved. Breastfeeding can resume if possible, and if not, the child doesn't die of starvation, anaphylaxis, water-borne illness, or whatever. Flexibility is going to help someone survive a disaster a hell of a lot more than blind ideology.

  295. And I'm sure the people who would benefit from your actions would appreciate it. However, unless you have a cloning machine at your disposal so that we can just install copies of you in every disaster-prone area, what you're saying may be more infeasible than people assert getting ready-to-feed formula supplies to disasters may be. It's not a matter of simple willingness. It's a matter of finding the breastfeeding moms. Getting them enough food and water to maintain their supplies. Dealing with children who physically can't nurse (e.g. preemies, cleft palate, etc.). Dealing with children who shouldn't nurse (e.g. kids who are allergic to human milk protein, children who are allergic to so many foods that an elimination diet is not logistically possible, and especially isn't possible in emergency).

    The rest of your statements are just blatant bigotry and say a hell of a lot more about you than you seem to think your snide comments say about Westerners. On behalf of all the nice breastfeeding women out there, I am facepalming as I read your statements, which do not make breastfeeding women as a whole look more intelligent, reasonable, or kind than the rest of us.

  296. You really have to wonder about the ethics of some of the breastfeeding promotion if the result is people who are taught to think that it is acceptable to literally sacrifice children on the altar of breastfeeding. How is it ethical to essentially say a child is better off dead than formula fed? How is it ethical to willfully tell families to deliberately not stockpile emergency formula, knowing that some babies will die as a result?

    People rail about Nestle sending around bogus information and booby trapping people in developing countries. How is what people like Karmait58, or hell, Karleeng, are saying any different? Deliberate misinformation to stop people from stockpiling a life-saving alternative to breastfeeding. This is what gets me so angry about this paper. It is the ugly flip side of Nestle, and no less unethical.

  297. Lisa, Did you see my post asking about the formula you found at Chemist's Warehouse?? What brand was it? And what price per pack? I have been unable to find anything that matches your description.

  298. But the carrier of HIV in this case is…breast milk. And breastfed babies are more vulnerable to dying of HIV/AIDS. Small fact you missed out on discussing.

  299. Mixed feeding is dangerous and straight BFing is dangerous too, which makes sense given that we're trying to avoid HIV transmission. RTF may actually be a saviour in these cases. No?

  300. The goal is to maximise HIV free survival. A baby who is HIV negative and dies from diarrhoea is still a dead baby. In some contexts exclusive formula feeding maximises HIV free survival in other contexts exclusive breastfeeding maximises HIV free survival. I have been quite clear about this. Read some of the papers and the WHO guidance I linked to.

  301. No, that is incorrect. In many instances exclusive breastfeeding with antiretrovirals maximises the rates of HIV free survival. They tried really hard to make exclusive formula feeding for HIV positive women work for a decade. Bucketloads of $$ and resources were thrown at the endeavour. They discovered that it was very difficult to do and that in many contexts HIV free survival was lower in cases where exclusive formula feeding was being supported.

  302. You have discounted cross nursing for your child and your particular situation. My post was not meant to be a commentary about individual situations. But, since you brought it up, there are also many families and babies who cannot use formula because it is, for them, for various reasons, “unsustainable”.

  303. I'll concede that if you were to happen upon a baby whose mom were unavailable, injured, deceased or unable to breastfeed and there was no formula to be had, then yes, nursing another woman's child would be worth a try. I would be forever grateful to to somebody who did this for my child.

    On the other hand, if an organization (even a formula company) offered formula and somebody breastfed my child instead, I'd have mixed feelings about it. I'd be grateful, but I'd also be concerned. How can I be sure this woman is free from communicable diseases and drugs that might harm my child? Are they underfeeding their own child(ren) to do so? Yes, I know some moms successfully tandem nurse or breastfeed multiples. At the risk of being redundant, that's great, really. But not ALL moms can supply enough breast milk for two or more babies. A family friend had twins and gave BFing the old college try and did lots of pumping, but she just couldn't meet her girls' needs. And I don't know, but might you have a better chance of nursing multiple kids if you gave birth to all of them, thus signaling your body to make more milk (as opposed to breastfeeding somebody else's)?

    Regarding your suggestion that a woman who was not breastfeeding at the time re-lactate or induce lactation, I would again say that if there was no formula around, it's worth a try. But it doesn't always work. Even if this previously non-lactating woman does pull of breastfeeding, how long will that take? Days? Weeks?

    I'll admit that milk sharing can and does work out in some cases. But I definitely wouldn't count on it, especially in an emergency. Like it or not, some babies are going to need formula following a natural disaster. For them, emergency stockpiles and/ or donations of formula are essential. As a couple people have said, you must really hate formula. You're entitled to your opinion. The trouble is, not everybody can breastfeed their child or arrange for another woman to do so. They can't afford to be so principled… regardless of where they stand in the breast vs. bottle debate.

  304. I would hope Lisa that those delivering aid would ensure that you received the aid that you needed in any emergency. I hope too that you read what I wrote on Lactnet in the context of the discussion on this thread where statements have been attributed to me that are nothing like what I said. I don't think that you have done this but others certainly have.

  305. “Unfortunately, people in the West do not have a concept of treating others like they would like to be treated themselves.”

    Interesting that you should feel qualified to hurl this at people reading this blog many of whom are suffering from great feelings of guilt, shame, inadequacy and hurt with regards to breastfeeding.

    I would like to give you this:

    “Atticus was right. One time he said you never really know a man until you stand in his shoes and walk around in them. “

    Secondly, you assume that eveyone has the same views towards breastfeeding in emergencies as you do. I'm not convinced that had I died in an emergency, my husband would particularly enjoy giving our baby to another woman to feed, or if my baby was old enough to understand that I wasn't there anymore, she would enjoy that.

    You're not being neighbourly at all, just extreme.

  306. I should add, that I don't feel that formula is in any way a bad option or harmful. I think it's a fantastic scientific intervention which allows women control over their reproductive organs in much the same way as the contraceptive pill. Also, there are numerous occasions (which you would see if you read some of this blog) where it has saved a child's life.

  307. I know, I also find it unbelievable. Imagine if it were the other way round, someone didn't want to feed formula and said to the big formula company “But I have plenty of milk and my child likes it” only to have the formula company turn round and say “now now dear, only 1% of women have enough milk and children are sometimes allergic to breastmilk”. It's exactly the same as a mother who wants to formula feed saying “I don't think I have enough milk and my child is reacting badly to what he does get” and the breastfeeding mafia responding with “now now dear, only 1% of women don't have enough milk and it's not possible for a child to be allergic to it”. Madness.

  308. In a disaster situation I would rather you spent your energy on helping to find me and any other families who had become separated. I would also rather significant energy was poured into making suitable shelter and getting everyone enough food/clothing/medical attention. My child would do fine on formula.

  309. You wrote of this thread that it revealed to you that :”anything negative ascribed to formula feeding must be hunted down and shown to be false and hyperbole seems to assist in demonstrating absurdity.” You insist that you were insulted, your words twisted and radically misinterpreted, yet you have responded to facts that counter your research only by restating what you had already said.

    I fully support BFing activists encouraging people to BF when possible and frankly wish it WERE possible for everyone to BF in disaster situations, but it isn't and all the wishing in the world isn't going to change that. And we should keep our eyes on the ultimate goal, which is keeping babies alive. Everyone here recognizes that impure water is a huge problem with FFing in many areas and wants to find a solution to that whether through the use of RTF or cost-effective water purification techniques – a far cry from your whinging that no-one wants to believe anything could go wrong with FFing (trust me – we've boiled enough bottles to know what's entailed).

    I'm a pragmatist and I did breastfeed my child when I could and did combo feeding when I went back to work. I think most people here are upset that lactivist blinders may stop people from getting the help they need. (Wo)man up and take the constructive criticisms you're getting here instead of whining.

  310. I would do everything in my power to ensure that your wishes on how to feed your children in an emergency were respected, and I trust you have done your advance planning to identify what you would do in such a situation. Conversely, I would hope that you would respect the wishes of parents who have identified what they believe to be the best options for caring for their own children in an emergency.

  311. I dunno – I can't think of any lactating women who live around me and assume that I could rely on someone to find/feed my child in an emergency. What would you suggest to make this a sustainable project?

  312. If your children could walk/nurse in emergency situations, of course they should. Not a bad idea to keep crutches/formula around when the roof is falling down and people are breaking bones, though.

  313. You're jumping from one scenario to another without following through on the point in question. Babies dying of diarrhea is completely unrelated to HIV transmission (and yes, of course impure water can kill more than HIV can, you won't find anyone disagreeing with you on that!) Let's focus on HIV transmission. You said before: 'Contaminants in water can also be a factor but even with clean water the foreign proteins in formula damage the lining of the intestine.” This was with regard to HIV transmission via mixed feeding, i believe, but then you used this fact to say FFIng was just generally bad for reducing HIV transmission rates even with clean water. Then you said “I also stated that other substances in the water used to reconstitute formula can also assist with this” (sounds like “this” = HIV transmission – but then you don't back up your statement with evidence). The WHO papers don't actually support your point as far as I can see, but do show me why you think they do.

  314. BTW, that WHO study is excellent and nuanced and seems to support assessing trade-offs between risks of death from bad water with the risk of transmission in the absence of ART/ARV availability. I don't think it generally contradicts anything that has been said on this blog, and certainly doesn't suggest that formula per se is the problem

  315. Well, at the failure rates of Western women there would be no lactating women around. In general, in a population, if there are women with small children, there are lactating women. You are correct that it's next to impossible to find a lactating woman in the US.

    When you have just in case scenarios, these just in cases happen. Just in case cesareans that are over 30-70%. Just in case failure to breastfeed in a whole population.

  316. All over the world there are MILLIONS of women who breastfeed who don't have issues nursing other people's children. You don't have to clone me. People are replaceable fairly easily.

    I am afraid most children who require measures above and beyond will die in most emergencies. You simply won't have the resources to keep them alive.

  317. Do you keep crutches at home just in case you break your legs? Do you keep infant child crutches around just in case your child is crippled?

    I suspect you get them only when you have undeniable reality of broken legs. Not in anticipation of handicap.

  318. I think you are extrapolating and interpreting what I said. I did not say anything about what you personally do. I have feelings about general public health policy that sets up formula feeding as the norm. These policies will endanger my children.

    I have handicaps in my life, but never would it occur to me to tell other people that it is ok to have these handicaps and that this should be portrayed as the norm. Nor do I have to justify my handicaps to others and write how beautiful it is to be handicapped in any area. Nor does it occur to me to let my handicaps affect other people to make me feel better. If I know how to overcome or prevent a handicap, I will be the first one to tell you how to do it, so that you will not be suffering how I suffer.

    Formula extremism creates suffering for many women who fail to nurse as a direct result of formula promotion and marketing through public health agencies and media outlets.

  319. So just to get my head around this Perfessor…

    There is around a 40% transmission rate of HIV to babies through breastfeeding (significant and not just scientifically speaking I'd say). IF we work on the assumption that if 100% of babies were breastfed NONE would get a dirreah infection, which we know not to be the case (PROBIT), but for the sake of argument lets go with it. Some people would rather 40% of babies contract HIV, nearly half, than work on getting proper sanitation and education to new Mothers in the developing world? Even though better sanitation and education would be beneficial to everyone who inhabits that world?

  320. I read the two WHO studies in detail and it sounds like actually the transmission rate in utero is about 15-20% while in first 6 mths BFing is a further 15-20% so it's cumulative; the longer you BF the higher the odds of transmission etc. But the papers are nuanced and quite sensible, in that they look at trade-offs between risk of transmission vs risk of baby dying from things like diarrhea due to impure water. Agencies like WHO and govt health agencies have to make decisions on whether or not to spend resources on formula and the education/clean preparation support systems that go with it, or on HIV meds that control infection in mothers and reduce the risk of transmission via BFing to one that is very low. It looks like in places where there is clean water like Cote d'ivoire or in some parts of S. Africa studies find that formula use cut infection transmission; in other areas with less clean water, babies who were not BFed for fear of HIV transmission actually had higher odds of contracting other fatal illnesses through bad water when very young. So it looks like a case by case decision. This all makes good sense to me, though one would hope govts would account for the women who cannot BF for biological and other reasons no matter what. My question for Karleen was concerning an earlier assertion she seemed to make that formula per se actually increased the risk of HIV transmission. Hence the passing back and forth of studies. It looks like mixed feeding increases transmission risks IF the child is already being BFed by an HIV+ mother.

  321. PS The policy trade-off seems to be cost of HIV drugs vs cost of clean water and formula and HIV drugs work out cheaper (again, mothers who are on aggressive meds don't transmit to nursing infants unless they have sores/mastisis/a viral outbreak at the time, per the studies). And drugs + BFing is assessed to be safer in contexts where BFing is cultural norm and knowledge about preparing safe formula feeds is questionable. Then there's the fear that people will thing formula is medicine or something which of course it is not but that's a matter of education, as much as getting women to take their meds correctly is, I would assume.

  322. THanks Perfessor, I read bits of the paper Karleeng posted but didn't have time for all. It appeared to me that the paper was saying that you need to take a look at every situation and work out what is likely to get best results, based on factors like access to sanitation, drugs that prevent transmission etc. It seems a long way from K's advice.

  323. Your summary is not one that I would necessarily disagree. The reason why I brought up HIV to start with was to explain how we know that infant formula helps to facilitate infection. I explained that formula can damage the lining of the intestine in such a way as to make it easier for any pathogen that the baby is exposed to to infect the baby. If the mother is HIV positive then it makes it easier for HIV to get in, if the pathogen is something else (eg rotavirus) same deal.

  324. It would be good if you read some of the papers I provided citations for. Everyone I know who works in the area of PMTCT HIV works to maximise HIV free survival- however that might look.

  325. I think that they have given you the price for stick packs of PIF. The cost of RUIF in our estimation was $120.
    Yes, absolutely, storing tap water for washing is perfectly adequate. The hand washing I don't agree on. Try with obviously dirty hands (after gardening for a bit) so you can see the dirt that needs to be removed (as opposed to the stuff that you cannot see but is there none-the-less).

  326. I don't disagree with what he says. I disagree with studies purporting to issue advice on how to deal with infant feeding which are shockingly badly researched and clouded by bias.

  327. You've sunk to a whole new level and one which I have rarely had the misfortune to see. I can't see any point in engaging with you at all. I hope you're much nicer in real life, although it pains me to do so I'm going to give the benefit of the doubt and say that anonymous internet comments can bring out the very worst in people.

  328. We keep paracetemol in case of a headache, piriton in case of allergic reactions, a first aid kit with slings and plasters etc. They're all in anticipation of a handicap no?

  329. Amazing, what should be understood is that our paper is the first ever written on the subject of preparedness in infant feeding in emergencies in developed countries. No first piece of writing on any subject will be without problems in any field. We didn't expect that we would get it all right and the reason why I came here was to pick your brains and to find weaknesses and errors so as to be able to make it better.I don't have a problem with making mistakes, no researcher worth their salt would. It takes time and the input of many to sort things out. I have found some very useful things as a result of being here and listening to what people have had to say. I don't think that anything earth-shattering has been shared that would negate the usefulness of the paper but some tweaks here and there are warranted.

  330. Thanks. Something more detailed on supporting breastfeeding women in emergencies is in the offing but it will take quite some time for anything to be published.

  331. This is where I apologise to FFF and everyone else including Karleeng *hangs head in shame* I went to Chemist Warehouse this morning and they do not sell RUIF, she did indeed give me the price for PIF…. grrr (note to self: don't trust a young girl on the phone to know what formula you are asking for)
    I was able to find 6 packs of RUIF (checked and double checked) at another chemist for $11.98. Also reading the packages it says that a baby who is 4-6 months would have 5 250ml feeds a day so if you go off the packages recommendations that would be 35 servings – so that would be 6x$11.98 – $71.88. So yes you would need somewhere between $70 and $120 of formula depending on how much your baby has. Obviously you would be better off importing the Ready to feed in disposable bottles.
    But still, my costs (with the adjusted amount for the RUIF) still comes in at $207.96.

    Even if you said you need $120 worth of RUIF and 1 liter of water (which still seems so much to me) per feed at 54 feeds – At wooloworths 10L is $4.40 so 60L would be $26.40

    That means that the formula and water based on 54 feeds would be $146.40 add nappies and wipes at around $50 (max) and that would still be under $200

    Where then does the other $350 come from? Were the bottles you found very expensive? That is all I can think of? As I said you can buy cheap bottles and if the bottles are going to cost that much then why not advise of cup feeding as you do with Powdered formula?

    What I worry about is that your paper could either turn formula feeding parents off preparing for a natural disaster because they will see $550 and decided they can’t afford it or they will look at the powdered formula section and think because it is so much cheaper it is better to stock powdered formula in case of emergency which is not the best formula feeding situation in those circumstances. If your paper was consistent: either recommending one use bottles for both methods of feeding or recommending NO bottles be used and cup feeding only be used then the costs would work out similar.

    Again, I apologize to everyone for my error and I am feeling adequately silly. 🙁

  332. I am sure I am just feeding a lactivist troll, but here goes nothing.

    We are not talking about setting up policies that make formula feeding the norm. We are talking about having safe options during a disaster for babies who are already formula fed, or who become separated from their mothers. Your decision to put philosophy over survival is your decision alone–having formula available does not have an impact on your baby. Breastfeed to your heart's content and don't accept any formula. But to make formula unavailable during a disaster would absolutely cause suffering to babies.

    I am going to need an example of how formula feeding endangers your children. Are they harmed by merely being near formula?

    If I know how to overcome or prevent a handicap, I will be the first one to tell you how to do it, so that you will not be suffering how I suffer.
    It's funny you should mention that. Hypoallergenic formula fixed my baby's health issues so fast that it amazed me. And I have mentioned it to everyone I know. You know, so their babies won't suffer as mine did.

    You are getting progressively more offensive on this thread. I really appreciate hearing that babies like mine will just die in an emergency–if you have your way, that is.

    I am fairly new to the formula feeding game, but I am pretty sure that breastfeeding as a cause is more damaged by lactivists like you than by any form of “formula extremism.”

  333. When has anyone here ever said they were in favour of untargeted distributions? Most of us here have said that formula should be provided in case there are mothers who are not BFing and in case mothers are separated from babies, with adequate education and hygiene-supporting equipment. Can you cite me one example of anyone on this thread who has called for untargeted distributions? It's a big thread at this point and I have missed some comments but I cannot remember anyone saying just send formula to every home.

  334. People have spoken repeatedly in favour of sending donations of formula to disaster areas which invariably results in untargeted distribution (data from Yogyakarta provided- the experience from many, many other emergencies) and against aid orgs budgeting, purchasing and distributing in a targeted and supported way the distribution of formula to those who need it. Is that an incorrect interpretation?

  335. I've just spoken to my coauthor and in fact, although we discussed calculating $2 for each bottle (based on the cheapest we could find in a discount shop) we decided in the end to use the cost of buying all the products at Woolworths and so it was $5 per bottle which accounts for nearly half of the cost of the RUIF kit. Really should have provided the cost breakdown for the kits because it even got me confused!

  336. Even if you decided to base all your purchases in one store Woolworths sells Happy Baby bottles in a two pack for $4.29 which makes them an average of $2.15 each. 2.15 x 54 (if we go with your figure) equals $116.10. Five dollars each is a bit rich…… $270 for bottles is more than most people could afford. As I said the real danger is turning formula feeding parents off preparing which is dangerous. A break down of costs and maybe alternatives would be a good idea cause then people could see where the prices maybe different from what they could find.

  337. That is incorrect. The general idea is that it is crazy for aid organisations to pay full price for RTF in emergencies WHERE IT HAS BEEN REQUESTED. This means that on occasions where it has been requested it should be accepted in the form of a donation rather than paying full price with people's monetary donations which could go elsewhere. The second suggestion is that there needs to be some sort of sensibly policy with regards to distribution as there clearly has been problems here in past emergencies. For example, is there breastfeeding support for women on the ground? Do aid workers know how to assess a breastfeeding Mother's situation and advise accordingly? Are Mothers of infants actually listened to with regards to their feeding choices? Thirdly, in developed contexts, all Mothers should have some sort of RTF in the eventuality that they are separated from their infants or injured/killed during a disaster, this could mean that Grandparents and nursery schools should hold stores of RTF formula or that parents keep a supply of equipment in their car or home.

  338. THIS sort of thing is what we agree with: “There
    appears to have been no attempt to limit the distribution of BMS according to the pre-existing feeding practices of the caregivers surveyed, or to households with older infants, or to those in which infants were no longer being breast-fed but with extra attention given to hygiene in such households.These findings confirm our observation and communications that many agencies active in the relief effort prioritised BMS distribution(21–23), usually without regard to these and other recommended practices.” I may have missed something but NOBODY is in favour of untargeted distribution….I posted about this underneath here as well….

  339. Oh, and when I say accepted as donations I don't mean people just sending it in, I mean accepting help from formula companies and not conflating the issues of unacceptable third world advertising with developed nation emergency aid.

  340. Perfessor states further down this thread:

    “I would do everything in my power to ensure that your wishes on how to feed your children in an emergency were respected, and I trust you have done your advance planning to identify what you would do in such a situation.”

  341. If I live in an earthquake prone area I would certainly hope relief agencies would have crutches available instead of tsk-tsking about how I could always be carried around by my family and it shows a lack of faith in humanity to provide crutches 😉

  342. Oh, I get it! You're angry because you know your child would most likely get formula if you were dead, you don't like that idea, and you think this thread/our beliefs are in some way contributing to that? Is that what you're angry about? Or am I misunderstanding you?

    And, out of curiosity – in the unlikely event of you dying and me somehow ending up responsible for your child, what would you want me to feed them? I mean, you've said you don't like the idea of donor milk either. I'm not lactating and very much doubt I'd be able to relactate rapidly and fully enough to breastfeed your baby. I don't know anyone with a baby offhand that I could ask for milk, and, even if I did, I doubt they'd be willing/able to suddenly double their milk supply to feed another baby (not to mention the practicalities – it would basically require this hypothetical wet nurse also taking on most of the care of the baby, at the same time as caring for her own baby). Just wondering what you would actually want someone to do in that situation that you think we could do but aren't willing to?

  343. Thankyou ladies for engaging with me in this discussion. I appreciate it very much. It feels like we're going over ground we have already been over in the last day or so and other things beckon so I will have to leave it here. I hope that you do send a comment about the paper to the journal some time. Certainly we will be writing some amendments to the paper as well as doing some further work in related areas as a result of the conversation here.

  344. In MOST emergencies (barring a world-wide catastrophe), very few children, even those who need specialised formula, would die without access to lactating women, as long as there are good preventative measures and aid in place. As a mother who breastfed my children (including whilst pregnant and tandem nursing) for a total of nearly 15 consecutive years, I have to say that you need to look at what you've written here and think about the implications. It makes me just as horrified as statements I've read by extreme environmentalists who think that the deaths of billions of people are acceptable as long as society goes back to the state it was 4 000 years ago. Maybe you don't mean to come across like that, but that's how your statement appears to me.

    I have been very short-sighted for most of my life and I am very grateful for modern advances and I would be disgusted if someone were to suggest that it was ok for me to die because I didn't have access to certain resources. I would like nothing better than to pick up a baby and relactate, but the thought that this would be in the event of a loss makes it an unacceptable fantasy for this ardent ex-breastfeeder (my youngest weaned himself over 6 years ago.)

  345. You need to experience winter in Leningrad, Teri and you'd realise that you could put the milk outdoors there and it would keep for months. I'm joking – you know that I don't mean that you should experience it yourself 😉

    In seriousness, I thought that this was a story lacking verification, so I did some research. The only reference I could find online to a milkbank during the siege of Leningrad was in an article by the aforementioned Lois Arnold. This doesn't necessarily mean that it didn't exist and that the story isn't true, but you need more evidence than one anecdotal source. In contrast to this, there were several stories of lactation failure (whether this was just because the shocking stories of breastfed babies starving tended to be the ones that were told, or whether this was common, I can't say.

    Various scientific articles support the idea that a short-term famine (which the Leningrad famine went beyond, as it lasted for nearly 3 years and the people were undernourished before and after it) does not have much effect on milk supply, particularly for babies under 6 months to a year.

    From an article written in 1947:
    “9.The capacity for breast feeding remained even in severe degrees ofhunger, but less milk was produced and the breast feeding period was considerably shorter.”

    This study is cited by Jelliffe and Jelliffe, who say that “in the earlier stages of communal starvation, human lactation appears to be relatively little affected…” (it's on pg 56 and cites examples from various famines, but I can't copy and paste, so here's the link:

    This article, discussing the Dutch famine at the end of WWII (which my father-in-law lived through as a young boy) says “The percentage of babies who were exclusively breast-fed in the first weeks after birth tended to be (slightly) higher for those babies exposed during mid or early gestation” (as opposed to babies whose mothers starved late in pregnancy).

    Here's another possibly interesting article that I'm too tired to read and comment on properly:

    Here are some of the anecdotes I found:

    “Infants officially received only 3 1/2 ounces of soy milk
    a day. Mothers like Elena Kochina drank a pot of water every night to try to keep their milk flowing, but it rarely helped. Kochina's baby daughter screamed
    and tore at her dry breasts.25 Here is how Lidia Okhapkina nourished her baby:
    My Ninochka cried all the time, long and drawn out, and she couldn't go to sleep. Her crying, like moaning, drove me out of my mind. So to help her fall asleep, I gave her my blood to suck. I hadn't had milk in my breasts for a long time, in fact I didn't have any breasts left, everything had just disappeared. I pricked my arm with a needle just above my elbow and placed my daughter on this spot. She sucked noiselessly and fell asleep. But I couldn't fall asleep for a long time…”

    Page 5 of the book (can be read on google books) The Psychological effects of war and violence on children
    By Lewis A. Leavitt, Nathan A. Fox describes babies being lethargic and not being able to suck and decreased quantities of breastmilk.

    “Here is a rather typical story:
    She had a baby that was born in ’41. She had no breast milk. She got a ration card for the baby. And when the baby died, she kept the body, as I was told, between the window frames. But she still kept hold of the baby’s ration card. Later, in spring, she had to bury her (Igor L., m., age 18).”

  346. I'm too tired to read your response properly Perfesser, so forgive me if I missed something and am misinterpreting what you've written.

    However, what is meant here is that( for mothers in the third world where HIV leveles are high) is that formula fed babies are at higher risk of dying (fullstop). If they are purely formula fed, they are at higher risk of dying from diarrhoea and if they are mixed fed where the mother is HIV positive, they are at higher risk of dying as a result of contracting HIV. I'm not arguing whether this is the case in this posting (although I've discussed this at length on the FFF facebook page before) but rather the semantics of what Karleen Gibbs is referring to. Perhaps she expressed it rather unclearly, thus giving the wrong impression, but that is what she means.

  347. Thank you so much to all for the information in the comments – I can’t wait to get home so that I can add some formula to my emergency kit!

  348. Pingback: Disaster in the Philippines: Why overzealous breastfeeding promotion has no place in relief plans - Fearless Formula Feeder

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