To: Whom it May Concern
Re: Criticism and comments on Karleen D. Gribble and Berry, Nina J.; “Emergency preparedness for those who care for infants in developed country contexts”. International Breastfeeding Journal 2011, 6:16.
From: The collective voices of FearlessFormulaFeeder.com
We the undersigned are gravely concerned with the assumptions, myths, and potentially harmful information presented in the paper, “”Emergency preparedness for those who care for infants in developed country contexts”, appearing in the International Breastfeeding Journal on November 7, 2011 (henceforth referred to as “the paper”).
In the course of the past week, we have been engaged in an online discussion with the lead author of this review, Karleen Gribble. While her intentions are clearly admirable, and her willingness to debate is appreciated, we feel strongly that her paper has the potential to do far more harm than good.
Who we are
This commentary was compiled through the feedback received on a post at FearlessFormulaFeeder.com, a website dedicated to supporting women who have either struggled to breastfeed or have made a well-informed choice to formula feed for a variety of personal reasons. The international readership of this site encompasses a wide range of feeding experiences (many of the readers are/were exclusively breastfeeding mothers or are “combo feeders” who supplement with formula, but primarily breastfeed) as well as ethnic and socioeconomic backgrounds. The author and members of this site are steadfastly in favor of protecting and supporting breastfeeding; however, we are also concerned with the impact the “breast is always best” mentality has had on Western society in terms of both the emotional and physical health of mothers, fathers, and babies; and on public discourse and policy surrounding feeding choices.
This review paper, according to Gribble, is written to give emergency management authorities information to “provide those who care for infants with accurate and detailed information on the supplies necessary to care for them in an emergency, distinguishing between the needs of breastfed infants and the needs of formula fed infants. Those who care for formula fed infants should be provided with detailed information on the supplies necessary for an emergency preparedness kit and with information on how to prepare formula feeds in an emergency.”
We don’t doubt that, provided a mother is physically and emotionally able to breastfeed her infant in the wake of a disaster, breastfeeding is a safer and more economical way to ensure that the nutritional needs of an infant are met. However, rather than simply illustrating this point and providing logistics for those who cannot exercise this option, the authors have offered a biased, embarrassingly inaccurate portrait of what formula feeds should entail in times of disaster. We feel that this paper not only adds to a growing body of breastfeeding literature that relies on a limiting, unrealistic, one-size-fits-all view of infant feeding, but could also 1) lead parents to spend needless money on emergency supplies 2) contribute to the already despicable lack of knowledge surrounding formula feeding and 3) mislead breastfeeding mothers into being ill-prepared for disaster situations.
Lack of impartiality
The paper begins with the WHO recommendations for infant feeding. This frames the remaining information as a diatribe on the dangers and inconvenience of formula, rather than what the paper claims to be (a manual of sorts, providing real, useful, and necessary information for all parents). Instead of explaining the reasoning behind the authors’ recommendations vis-à-vis actual disaster data – possible time frame of being left without aid, clean water, shelter, etc – the message we are left with is “breast is best”, not only in terms of disaster preparation, but “in general”. This seems punitive; while many women in our society do combo-feed (both formula and breastfeeding) and may be able to choose one over the other, women will either be breastfeeding or formula feeding at the time a disaster strikes, many others will have no choice but to continue their previously initiated method of feeding. Relactation is indeed possible (1), and was in fact recommended by UNICEF as a strategy superior to formula donation and distribution during the 2010 disaster in Haiti (2). However, there is no available data on mass, post-disaster relactation that provided evidence for the efficacy of this recommendation, and the experience of the women who frequent this website suggests that relactation is difficult in the best, most privileged of circumstances. Even the WHO document cited above (2) states, “(l)ittle research has been conducted specifically into the physiology of relactation in humans” and later advocates ensuring that a relactating woman should have “enough rest and relief from other jobs while she re-establishes a breastmilk supply.” It seems logical that the reality of a disaster situation might make an already arduous process more difficult, and possibly unrealistic, at least in the short term.
In our online discussion (3) on FearlessFormulaFeeder.com, Gribble infers that the heavy-handed focus on the superiority of breastfeeding was in part a logistical tactic to discourage unnecessary use of formula – a practice which can, in theory, sabotage breastfeeding. Again, we do not argue that breastfeeding should be encouraged and protected during disasters; however, we are concerned that the overwhelming bias of UNICEF and like-minded aid organizations is coloring the determination of what is “unnecessary” or inappropriate. We cannot blur the lines between breastfeeding promotion and post-disaster survival.
Gribble admits that UNICEF will not “touch” donations (even of ready-to-feed, single-serve formula containers which would negate the need for washing and sterilizing during the formula prep process – more on this later) from formula companies. “UNICEF’s sponsorship policy places companies that breach the International Code of Marketing of Breastmilk Substitutes as more untouchable than tobacco companies because of the impact of their unethical marketing practices on the wellbeing of children. They purchase what they need at market prices,” she states (3). In our opinion, this speaks to an obvious bias: if the aid organizations in question would refuse help due to moral convictions, what does that say about their worldview? If formula is an instrument of the proverbial devil, then anything formula-related is going to be looked as an avoid-at-all-costs evil. UNICEF does have a large body of research and documentation regarding the unethical promotion of formula in third world countries (4); this is not an argument about their reasoning, but rather the bias inherent in the way they approach infant feeding in every situation, including disasters. We feel that especially in the developed world, where “unethical marketing” of formula is a matter of debate (5) depending on where you stand on the issue of infant feeding choice, it is irresponsible for aid organizations to deny contributions which would help infants and mothers, instead opting to spend precious dollars on buying formula at market price.
Lack of due diligence
The authors spend a good portion of the paper detailing what a formula feeding parent needs for their emergency preparedness kit: A breastfeeding mother needs only “100 nappies and wipes”; in contrast, the formula feeding parent needs “56 serves of ready-to-use liquid infant formula, 84L water, storage container, metal knife, small bowl, 56 feeding bottles and teats/cups, 56 ziplock plastic bags, 220 paper towels, detergent, 120 antiseptic wipes, 100 nappies and 200 nappy wipes. If powdered infant formula is used, an emergency preparedness kit should include: two 900g tins powdered infant formula, 170L drinking water, storage container, large cooking pot with lid, kettle, gas stove, box of matches/ lighter, 14kg liquid petroleum gas, measuring container, metal knife, metal tongs, feeding cup, 300 large sheets paper towel, detergent, 100 nappies and 200 nappy wipes”, which will cost $250 (Australian dollars) for the powdered version, and $550 for the ready-to-use liquid.
We do not disagree that a laboratory-perfect, sterile preparation of formula would be ideal in a situation where sewage is present and resources for hand-washing are scarce; however, we believe that this list of supplies (and the corresponding instructions on how to prepare feeds) is misguided at best; deliberately misleading at worst. Firstly, many of the “dangers” of formula feeding in both disaster situations and resource-poor areas are due to contaminated water sources; using ready-to-feed formula would minimize most of these risks. Gribble also argues that water is needed for cleaning hands (something breastfeeding mothers need not do, apparently, even if they are breaking a latch with a finger; we also question whether a breast could not be similarly germ-ridden as a hand, considering both are covered by the same epidermal layer). Depending on the disaster in question,couldn’t antibacterial wipes (6) be sufficient for cleaning hands prior to preparation of ready-to-feed formula in disposable bottles? Considering many of us were given ready-to-feed nursers in maternity wards with pre-sterilized nipples, and given no instructions except to attach the nipple to the bottle, it seems odd that this would be good enough for an hours-old baby and yet deadly (in a statistically significant regard) for a 5-month-old trapped in his home after an earthquake.
When we presented Gribble with the suggestion of ready-to-feed single-serve nursers (available from all three major formula companies in the United States) and disposable, pre-sterilized nipples, she claimed that these were not available in Australia or Japan, and were in fact illegal to purchase in Australia. A reader of the FFF blog did a few hours of research on this matter, and discovered that in Australia:
“…You can purchase Ready to feed formula in disposable bottles from here: http://www.fishpond.com.au/Lif…. I rang Australian Quarantine and Inspection Services and Steve on the floor in Brisbane said that milk imports from USA are fine at the moment unless the value is over $1000 in which case it maybe looked into but probably passed as long as there is a legit reason for that quantity.” (3)
This is a far cry from “unavailable” or “illegal”; a parent provided with the right resources could easily obtain this much safer and more economical option. Within the United States – one of the countries that this protocol is presumably directed towards – these products are readily available. A baby under 4 months could likely survive on 20 oz/day. To do this with Similac 2-oz nursettes, this would come out to be about $250; with Good Start, which makes 6-oz nursers, it would be under $200. Another option is a pack of 48, 2-oz nursers which come with a ready to use nipple and ring – Similac offers a pack of 48 for $41.94 on Amazon.com (7).
Even if a mother is relegated to using ready-to-feed formula which does not come in serving-size nursers, the same Australian mother did a breakdown of costs for this method and found the following:
A five month old will need approximately 42 250ml RTF cartons. The standard way to calculate how much formula a baby needs is 150mls – 200mls of formula x body weight of baby. According to my Queensland government personal health record chart by the National Center of health Statistics a 5 month old averages about 7kgs. 7kgs x 200mls (to be on the safe side) equals 1400 mls per 24 hours or 6 250ml cartons/day (again to be on the safe side) x 7 days equals – 42 cartons.
COST: $41.75 from Chemist warehouse. (this cost is based on buying them in lots of 6 – I am sure you maybe able to find them cheaper in bulk.)
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 $11.00 (crazy clarks)
50 Large Zip lock bags – $5 (Coles)
Paper towels – 400 $4.70 (Coles)
Detergent – 1L $1.06 (Coles)
Antiseptic Wipes – 80 pack – $10.68 (Coles)
Packet of strong sharp disposable knives – 50 pack – $3.20
TOTAL COST: $132.13
This is based on one mother’s research, and we are concerned that if her cost assessment was significantly different than Gribble’s (both women are from the same country), something is amiss. Perhaps a little non-biased, real-world perspective might go a long way in honing these recommendations. We wonder if formula feeding recommendation written by admitted breastfeeding activists is really the way to go?
Lack of adequate information
As many of us are, or have been breastfeeding mothers, we are also concerned with what we feel is a lack of information (and a lack of realism) about breastfeeding in the developed world. Many women have a steep learning curve with breastfeeding; it is often a learned skill (8). Some of us have struggled with insufficient supply in the best of situations; we wonder how a brand new mother, possibly dealing with the death of loved ones, a loss of a home, etc, would be able to handle successful breastfeeding in the worst of situations? Furthermore, what would happen if an exclusively breastfeeding mother were at work or out at the time the disaster hits? Or if the mother is severely injured or killed? If a baby is separated from its mother, an alternative food supply will be needed; it seems that it would be far safer to suggest that even breastfeeding families have a supply of formula on hand.
Dehydration and stress can also have a deleterious effect on breastfeeding. While stress has not been shown to impede milk production, as Gribble points out in our discussion, it has been shown to cease lactation in a few documented cases (9) and has been proven to inhibit letdown response (10); by Gribble’s own account, handling this problem requires support from those knowledgeable in lactation. Regardless of the mechanics involved, if the milk is not flowing, a baby is not getting fed. Considering the amount of psychological and physical stress in times of disaster (11)(12), we wonder: how many lactation professionals will need to be deployed to meet the needs of every struggling lactating mother? It may be true that for a mother who has already established breastfeeding, even times of extreme stress and lack of food and water will not affect the nursing dyad; we are concerned with the new mothers who suddenly find themselves trapped in their homes, and who are struggling to breastfeed in the way we all have (13) in much more comfortable situations (and our experiences run the gamut). If these mothers have been told not to have an emergency stash of formula in case of disaster, what will happen? It is a well-known argument that having formula in the home can discourage breastfeeding (14), but we feel that a paper focusing on disaster prep, not breastfeeding promotion, should look beyond a few self-reported studies and concentrate on the worst-case scenarios.
Ultimately, while no one here is arguing the fundamental point of this paper – that breastfeeding is a better disaster preparedness strategy – we feel it is obscenely dismissive of the lived realities of most women in “developed” nations. To suggest that a woman delays weaning in case of emergency is inane. To ignore the possibility that a breastfeeding mother may not be able to breastfeed her baby, either due to injury, emotional state or separation/death, is unrealistic. To ignore the options available to formula feeding parents, and to the aid organizations themselves, out of a disgust for formula companies or formula feeding as a practice, is irresponsible.
We ask that this paper be amended to include better, less biased information that is truly concerned with helping all babies rather than presenting yet another reason why breastfeeding is best. If nothing else, we hope that government agencies dealing with disaster preparedness will think seriously about the points we have illustrated, and refrain from using this biased, poorly-researched paper as a reference for recommendations.
The Readers and Author of FearlessFormulaFeeder.com