Disaster in the Philippines: Why overzealous breastfeeding promotion has no place in relief plans

Dear FFF,

We are based in Manila which, thankfully, was spared from the brunt of typhoon Haiyan. As you may be aware, our fellow Filipinos from the other islands of Leyte and Palawan suffered from this catastrophe. Aid has been slow in coming, and the situation is now miserable and desperate. Donations from all over the world are coming in, but the logistics of getting them to the people who need them are difficult because many of the islands are isolated and cannot be easily reached. Many have not eaten since Saturday. They also do not have clean drinking water and are living in the streets amidst rubble and dead bodies.

Which brings me to my question/issue – What is the best way to feed a baby in a crisis situation like this?

 Our Department of Health has BANNED donations of formula milk – powdered or pre-mix – because of the perils of formula and because it undermines breastfeeding.  According to the Department of Health, the best solution is to breastfeed, or if the mother is no longer breastfeeding, to give support towards re-lactation. If these are not feasible, then the next alternative is wet nursing. I do understand that this is the exact reason why formula has been deemed “dangerous – because preparation of formula in unsafe, unclean conditions (including using unclean water and bottles) can lead to diarrhea and infant mortality.  However, I also believe that the options given by the Department of Health practically require a mother to choose between death of a child by starvation and death by diarrhea.  They say re-lactation as if it was like turning on a switch. Most women who have weaned young babies likely had problems lactating in the first place. How likely is it that she would be able to re-lactate in the midst of the stress, chaos, and misery of a calamity? The Department of Health says that the solution is to provide breastfeeding support, counselling, and breastfeeding-friendly setups where breastfeeding can be encouraged.  In a situation where the most basic of necessities such as water, shelter, and medical care have not even reached the victims, it does not appear that anyone is currently equipped to provide these conditions that would foster breastfeeding in a crisis situation. Wet-nursing or donated milk is the next alternative presented. On wet-nursing, I do wonder if that is really a safe option, since it is possible to also contract disease from tainted breast milk. Again, in a calamity situation, who has the time and resources to check for infectious diseases when looking for a wet nurse?  On donated milk, I concede that this is probably the most viable option, but given the sheer number of people affected, I do not think that it is a sustainable source of nutrition for all the babies affected (given that several hundred thousand homes were affected). Babies need constant nutrition, and while donated milk may augment at the start, is it really sustainable to provide for the nutritional needs of all the victims in the coming days before they are moved to a safe and clean environment? 

And so, I think, banning pre-mix formula donations is a case of letting the principle of promoting breastfeeding defeat the principle of saving as many lives as possible.  Even the American Academy of Pediatrics concedes that pre-mixed formula is the last alternative when the other options are not feasible.  Our government, however, has taken the firm stance against formula and will refuse donations of pre-mixed formula.  Incidentally, pre-mixed is not readily available in the Philippines, but I’m sure it can be procured from other countries or even by local formula manufacturers if only it were allowed.

– S. T.

 

After receiving this email, I logged on to my computer to find several sources reiterating what the author had said. According to Gulf News,

Government and private hospitals in Manila called on nursing mothers nationwide to donate milk for babies in typhoon devastated central Philippines… Explaining the aim of the campaign, (Dr. Jessica Anne Dumalag of Manila’s Philippine General Hospital’s Human Milk Bank) said, “Milk from lactating mothers is preferred over formula milk, which is basically processed cow’s milk.”

The department of health which has been promoting breast feeding has a policy to prohibit the donation of formula milk for babies in temporary shelters, during a calamity….“Children are more exposed to allergy when they consume formula milk. We are also not sure if the water used to prepare formula milk is clean (that is why it is not recommended),” said Dumalag….Government and private hospitals including private organisations were organised to accept donations of human milk. Milk donations will be pasteurised, frozen, and kept in insulated containers before they are sent to evacuation centres in central Philippines, Dumalag said.

 

Concerns over water and sterile preparation of bottle feeds during disaster situations are valid and necessary. Several years ago, we had a lengthy debate here on FFF about this very topic; I’m well aware that if relactation or wet nursing is a possibility, it is without a doubt the safest option in natural disaster settings. Bacteria-filled water, poor sanitation, and lack of resources make formula feeding a deadly proposition; when formula feeding is seen to be “encouraged” in an at-risk population, lactation may be interrupted which can have long-term consequences (i.e., the family would then need formula on an ongoing basis, which could prove difficult if money or resources were an issue). I’m not disputing this, nor am I ignoring the fact that formula marketing in the Philippines is a hot button issue at the moment, and that breastfeeding promotion is in overdrive for reasons that I can’t fully comprehend, as a privileged Western woman.

But that’s not what this is about.

A policy that forbids powdered formula donations and encourages breastmilk donations is simply replacing one easily contaminated substance with another. Donated breastmilk – and this includes breastmilk procured by breastfeeding-related Facebook pages, speaking of privileged Western women – requires careful packaging, transport and refrigeration, not to mention screening for HIV and hepatitis B (the Philippines still has a low rate of HIV infection, but it’s rapidly increasing – TIME reports that every 3 hours a new case is now being diagnosed). There are still the same risks involved with sterilizing bottles, regardless of what’s filling them; nowhere in these news reports are people discussing the importance of cup feeding, for example – something that can significantly cut the chance of bacterial contamination.

There is, however, a substance that can be easily transported without refrigeration; that has a relatively stable and long shelf life; and which can be fed to babies in a perfectly sterile manner, at least in the short-term. That substance is ready-to-feed, pre-mixed formula, served in “nursette” bottles with pre-sterilized nipples (like these).

Granted, the cost of these supplies is rather high. But while I haven’t done the math, I’d venture to guess that the cost of procuring and safely distributing donor breastmilk would be just as prohibitive. And if people are ready and willing to donate RTF and pre-sterilized nipples, what would be the harm in allowing them to do so?

The answer is none. There would be no harm, except, perhaps, to the “cause” of breastfeeding promotion. That cause may be noble and important, but right now, it’s irrelevant. To put breastfeeding promotion ahead of feeding infants safely and in a timely manner is petty, short-sighted, and cruel. Think about it: would we discourage donations of processed, high-fat canned foods to disaster victims because of concerns over obesity, GMOs, or the environment? Or would we ensure that their immediate needs were met, and worry about preaching better health habits after the roads had been rebuilt and displaced families were settled into safe, warm homes?

The fact that Dr. Dumalog, quoted above, uses “allergies to formula” as a reason for forbidding RTF formula donations speaks to the irrationality of this policy. If a child is allergic to formula, there is also a chance s/he will react to something in a stranger’s milk. A breastfed baby may indeed react poorly to formula at first, but this is a case where the mom should receive plenty of assistance and encouragement to continue breastfeeding – not told to feed her baby via bottle with donated milk. With breastfeeding rates in the Philippines being what they are, it stands to reason that most of the babies without lactating mothers present are already formula fed – therefore they will probably do just fine with donated formula, even if it’s not the same brand. We’re talking about a little gas here, not a full-scale anaphylactic reaction.

Gulf News reports that “groups that promote breast-feeding in six hospitals and in several private clinics are part of the campaign.” A disaster situation is no place for “promotion” of anything but disaster relief. And the scariest thing about this is that the Filipino government isn’t alone in letting a hatred of formula get in the way of ration. The American Academy of Pediatrics also advocates for “screened human donor milk” before RTF (although they do, at least, acknowledge that this is an option). I have yet to see one study or agenda-free policy paper that actually looks at the viability of using donor milk as opposed to RTF formula with pre-sterilized nipples during disasters. If there is a logical reason behind these recommendations, I’d love to see it. All I can find are convoluted references to “breastfeeding being interrupted” (not an issue if we’re talking about babies who are already formula fed) and concerns about sterility and availability (absolutely valid, but just as valid in regards to donated milk, if not more so).

Governments must stop putting ideology above practicality. We are in desperate need of a neutral, informed, and rational voice to come up with better policies for infant feeding – policies that do not throw the cart before the horse, and end up running over its citizens in the process.

The biggest problem with the breastfeeding discourse has nothing to do with breastfeeding

Sometimes, a cigar is just a cigar. And sometimes, it’s not.

As any journalist, blogger, or parenting-forum moderator can attest, merely mentioning the words “breastfeeding” or “formula feeding” will create controversy – or at least a comment thread that derails within the first three posts. It’s virtually impossible for someone not to feel offended. It happens on both sides of the debate; some breastfeeding advocates see red anytime a person writes favorably about formula, while some formula feeding mothers are guilty of taking it all too personally, and assuming that every positive aspect of breastfeeding is dig at their lack of lactation.

This bugs me, being someone who writes about this topic regularly, because it dilutes the conversation. We lose track of what we’re talking about, and lose the chance to understand, to evolve, to connect.

Of course, this problem is endemic to any hot-button parenting issue. Circumcision, sleep training, working vs. staying at home, vaccinations… But when it comes to breastfeeding, what I’m talking about goes far beyond the mommy war bullshit. We’ve apparently lost the ability to discuss anything to do with breastfeeding and formula without heaping layers of preconceived notions, philosophical ideals, and emotional reactions onto whatever’s being discussed. Even if the conversation takes place in a respected medical journal, the halls of a hospital, or a human rights nonprofit.

With that said, I want to make something clear: this post is not about breastfeeding. It is not about the benefits of breastfeeding. It is not about a woman’s right to breastfeed or formula feed. It is not about you, or me, or your sister-in-law. It’s about language, interpretation, and bias. If it helps, substitute the word “breastfeeding” for something less emotionally loaded. “Drinking coffee”. “Wearing palazzo pants.” Whatever.

In the past month, two stories popped up, buried so deep in the news that only someone who obsessively googles terms like “infant feeding” and “lactation” would have seen them. They were about studies showing negative associations with breastfeeding (see? Didn’t your heart start beating a bit faster? …Negative associations with palazzo pants. That’s better, right?) The first one found that longer durations of breastfeeding (past 12 months) were associated with higher rates of a specific form of breast cancer in Mexican and Mexican-American women. The evidence was based on subject recall of breastfeeding history, in a specific population. All I will say about the study itself is that it is one, isolated result; more research must be done before anyone can make proclamations about whether women of Mexican descent might want to wean after a year.

Which is basically what I say about every infant feeding study. These results do not prove a causal relationship. It would be patently false and extremely irresponsible to have headlines screeching “breastfeeding causes breast cancer!”

Luckily, there were no such headlines. The story didn’t receive much coverage in major news outlets, but here were the headlines I did find:

Breastfeeding May Increase Cancer Risk for Mexican-American Moms (http://www.nbcsandiego.com/news/health/Breastfeeding–Cancer-Rules-May-Not-Apply-to-Some-226050001.html)

Lactation may be linked to aggressive cancer in Mexican women

http://health.ucsd.edu/news/releases/Pages/2013-10-01-lactation-linked-to-cancer-in-Mexican-women.aspx

Women of Mexican descent more likely to be diagnosed with aggressive form of breast cancer http://www.news-medical.net/news/20131002/Women-of-Mexican-descent-more-likely-to-be-diagnosed-with-aggressive-form-of-breast-cancer.aspx

Mexican Women’s Breast Cancer Risk Tied to Breast-Feeding? http://healthcare.utah.edu/womenshealth/healthlibrary/doc.php?type=6&id=680757

Notice all the qualifiers. May be linked. More likely. And my favorite example, the question mark at the end of the last headline.

Now, let’s compare these measured, accurate headlines with those that stemmed from similar studies (self-reported data, specific populations, single studies rather than meta-analyses) that showed a positive effect of breastfeeding:

Breastfeeding reduces cancer risk http://www.dailymail.co.uk/news/article-88785/Breast-feeding-reduces-cancer-risk.html

Breastfeeding Cuts Breast Cancer Risk http://www.webmd.com/breast-cancer/news/20070417/breastfeeding-cuts-breast-cancer-risk

Study: Breastfeeding Decreases Cancer Risk http://www.npr.org/templates/story/story.php?storyId=9656285

Breastfeeding Protects Against Breast Cancer http://www.reuters.com/article/2009/08/10/us-breastfeeding-cancer-idUSTRE5795CZ20090810

Not one qualifier to be found.

But FFF, you’re arguing semantics, you say. Perhaps. But how can we argue that subliminal messages that come through the advertising of formula or bottles can so greatly affect a woman’s breastfeeding intention, and then argue that the language used in widely-read headlines doesn’t make an impact?

Not convinced? Let’s go beyond the headlines. The one quote from the lead researcher of the breastfeeding/cancer in Mexican women study used in the media was this:

“Our results are both puzzling and disconcerting because we do not want to give the wrong message about breastfeeding…If you treat breast cancer as one disease, breastfeeding is beneficial to both mother and baby. That should not be dismissed.”

Puzzling? Disconcerting? Science needs to be free of bias. It’s perfectly acceptable to be “surprised” by findings, but “disconcerted”? And as for the point about “breast cancer as one disease“, this is not the sentiment expressed in the quotes from articles reporting a positive effect, many of which proudly extrapolate their specific findings and make sweeping statements about breastfeeding promotion:

Clearly, the researchers conclude, breastfeeding is associated with “multiple health benefits” for both mother and child…”That’s why we need supportive hospital policies, paid maternity leave, and workplace accommodations so that women can meet their breastfeeding goals…” (source: Reuters)

The same double standard popped up a few weeks later, when a study hit the news which found that babies breastfed longer than one year, as well as babies introduced to gluten after 6 months, had an increased risk for celiac disease. Again, hardly any media coverage; the one major outlet (Yahoo News) that covered it used the headline “Parent’s Feeding Choices May Raise Baby’s Risk for Celiac Disease“. Absolutely accurate headline, but no mention of breastfeeding. Granted, there were two findings that came from this study; both of which did involve a feeding “choice”. What I find interesting, though, is that whenever formula is associated with something negative – even if that particular finding is buried in a mess of other data – the headlines make sure to mention it. (Remember the arsenic-in-baby-formula scare of 2012?)

This study had many flaws. (Science of Mom has a great explanation of what these were over on her blog, if you’re interested.) But it didn’t have more flaws than 99% of the formula-is-risky studies which we are subjected to on a weekly basis, none of which are handled with the same degree of intelligence and moderation.

In Bottled Up, I discuss the problem of publication bias, and the professional death knell it is to report or support anything that detracts from the supreme perfection of breastfeeding. This is a bigger problem than one might believe – because if the end goal is to find ways to reduce disease and increase health in populations, we should be striving for information, not propaganda. And this is why I fight so hard to reframe how we discuss and promote breastfeeding – because if we are basing all of our support for the practice on science, then we run the risk of bastardizing – or at least “tweaking” – that science to justify our promotion.

Sometimes, a cigar is just a cigar. But when it comes to infant feeding science, the results are never just the results.

First World Problems: Fill the Gap and #FeedWithLove

Yesterday was one of those days. Overslept. Kid peed the bed. Bad hair day. Traffic. Drama at work. Husband had to work late, again. House a mess. Feeling fat. Zit popped up on my chin. You know. First world problems.

http://www.stickycomics.com/first-world-problems/

http://www.stickycomics.com/first-world-problems/

 

Here’s a dirty little secret: I hate that phrase. Because we live in our own realities. No matter how much of a selfless world-view we attempt to hold, or how fully we own our privilege, we’re human. You can feel depressed about a zit while realizing how insignificant your plight is in the grand scheme. One doesn’t need to cancel out the other. I’d even argue that people who are inherently empathetic typically feel all things deeply – a news report about a displaced deer will affect them more than most, but so will a breakup or a bad day at work. Emotions are emotions – and I don’t think controlling them because of some innate sense of privileged-woman’s-burden is healthy.

 

But here’s the other the reason I hate the phase “first world problems”: there are some majorly screwed up things going on right here in the first world. First world problems are nothing to scoff at. Kim Simon, my #ISupportYou cofounder (along with Jamie Lynn Grumet), has been thinking about one of the most warped aspects of our decidedly first world nation. In the midst of our government shutdown, Kim had started worrying about the people affected by furloughs at WIC programs  – breastfeeding moms who receive extra food to ensure they have the caloric load necessary to produce milk without it taking a toll on their bodies, and formula feeding moms who obtain the powder necessary to nourish their babies from WIC. She realized that aside from emotional support for moms, there’s another kind of practical support we haven’t really discussed. As she writes for Huffington Post and her own blog, Mama by the Bay:

When Suzanne BarstonJamie Lynne Grumet and I joined together to create “I Support You“, we realized that support begins with basic care.  Basic care for many of the mothers in this country means that they need to have access to healthy food for their families.  Breastfeeding mothers don’t always need a lactation consultant or a quiet place to nurse.  Sometimes they need breakfast.  I am nursing a four month old, and I usually eat two dinners.  I am hungry all.the.time.  But I have a full pantry cupboard and a refrigerator that I frequently have to clean out.  Many mothers don’t.  Formula feeding moms don’t always need the newest bottles or the support to feed their babies proudly.  Sometimes they need enough powder left in the can to get them through until their next paycheck, so they don’t have to water each bottle down.

 

Kim goes on to suggest ways that we can put our money where are mouths are – quite literally – by donating supplies, food, money, and time to mothers in need. Her suggestions are incredibly thoughtful and I urge you to read them, consider them, and put them to use.   But Kim also reminds us that even before the government shutdown, hunger was an issue for many American families – and that it will continue to be after this dumb fight ends and WIC offices are up and running. She’s right: back in 2012, when WIC was fully functional, a study found that 1 in 8 low-income families were watering down formula in order to “stretch” their limited resources – and that “the vast majority of families” in this study were “covered by Medicaid and receive(d) food stamps as well as assistance getting infant formula through… WIC.” (Source: NBC News)

1 in 8 families in this particular study, which was performed in the very first world environment of Cincinnati. 15% of parents already getting aid from government agencies like WIC who are not able to feed their babies adequately.

I can hear the arguments starting already: But that’s why WIC is promoting breastfeeding, FFF! If we could just get these women lactating, they wouldn’t have to put their babies in danger by using diluted formula! And you know what? I agree with you. It would be fabulous if these moms didn’t need to worry about their babies’ next meals, if milk were to flow easily and freely from their breasts. But it would also be fabulous if they weren’t in need. If they had well-paying jobs that allowed them sufficient maternity leave to establish breastfeeding without putting their families at risk. It would be wonderful if they had supportive partners or parents or friends who could stay with them in the early days and take care of their other children while they worked through the breastfeeding learning curve. It would be peachy if we could guarantee that none of them were part of the 5% of women who simply can’t produce milk, or that none of them had ever been victims of sexual assault which made it emotionally complicated for them to nurse, or that none of them had babies who were allergic to milk or soy, because when you’re living with food insecurity, it’s not so simple to go on an intensive elimination diet.

 

We can argue until the cows come home about whether all women in need should or can breastfeed, but once those cows do come home, we need to make sure there’s enough milk. Period. Whether from a can or a breast. We can’t let babies starve or become malnourished while we argue. Because when it comes down to it, arguing over breastfeeding in a theoretical sense  is a first world problem. That is where our privilege will bite us in the overfed ass. No matter what you believe, politically, or about infant formula marketing, or women, or birth, or Santa Claus, we need to address the hunger of our littlest members of first world society. And for now, until issues like maternity leave and adequate prenatal and post-natal care and lactation support and childcare are solved, that means supplying formula – not just whatever brand makes a deal with WIC, but options like hypoallergenic or gentle formula for babies who need it.

 

The breast/bottle mommy war is a “first world problem”. But the solution Kim, Jamie, and I are offering to this war doesn’t have to be. #ISupportYou can support moms in their emotional journeys while also supporting those who don’t have the luxury of worrying about judgment, because they are too busy watching the contents of their Similac can diminish and praying that their babies don’t hit a growth spurt before the next WIC appointment.

 

Privilege isn’t a bad thing. Privilege gives us internet access and time and sometimes (although not always), a little extra cash. I’m asking the FFF community to embrace whatever privilege they have, and begin finding ways to address the issue of hunger in our country. I’ll be reaching out to food banks, shelters, and organizations that serve mothers with young infants to see how we can help, specifically, with formula donations. We have one of the smartest and most educated communities on the internet – I don’t doubt we can come up with ways to fill the gap – nutritionally as well as emotionally – so that all mothers, regardless of feeding method or economic situation, can feed with love.

 

First world problems, here we come.

Want to get involved with #ISupportYou or #FeedWithLove? First, read Kim Simon’s post. Then, post here or there, or email me (formulafeeders@gmail.com), with your ideas, contacts, suggestions, etc. 

Can breastfeeding concerns be overcome with support? Depends on what “support” means

Guess what? Women are having trouble meeting their breastfeeding goals.

Contain your excitement.

Apparently, this is news to the American Academy of Pediatrics, and every major news outlet in North America. The study causing such shock and awe came out this Monday in the journal Pediatrics. Researchers used self-reported data (i.e., interviews) from 532 first-time moms giving birth at a particular medical center (can’t find where, and due to geographical differences in levels of breastfeeding support and acceptance, I think this is vital information that at least one of the articles could have shared with us). The women were asked prenatally about their breastfeeding intentions and concerns, and then re-interviewed at 3, 7, 14, 30 and 60 days postpartum. According to Reuters:

During those interviews, women raised 49 unique breastfeeding concerns, a total of 4,179 times. The most common ones included general difficulty with infant feeding at the breast – such as an infant being fussy or refusing to breastfeed – nipple or breast pain and not producing enough milk.

 

Between 20 and 50 percent of mothers stopped breastfeeding altogether or added formula to the mix sooner than they had planned to do when they were pregnant.

 

Of the 354 women who were planning to exclusively breastfeed for at least two months, for example, 166 started giving their babies formula between one and two months.

 

And of 406 women who had planned to at least partially breastfeed for two months, 86 stopped before then.

Given these results, the study authors come to the conclusion:

Breastfeeding concerns are highly prevalent and associated with stopping breastfeeding. Priority should be given to developing strategies for lowering the overall occurrence of breastfeeding concerns and resolving, in particular, infant feeding and milk quantity concerns occurring within the first 14 days postpartum. (Source: Pediatrics)

 

The headlines, as usual, were both amusing and infuriating. “Nursing Troubles May Prompt New Moms to Give Up Sooner”. “Early breastfeeding challenges make women quit.” “Some moms discontinue breastfeeding within two months die to nursing difficulties”. And my personal favorite, “95% of breastfeeding problems are reversible.”

One might easily blame the media for their usual skewering of the science to make for a juicier headline, but one can hardly blame them when the experts giving interviews about this study say things like, “It’s a shame that those early problems can be the difference between a baby only getting breast milk for a few days and going on to have a positive breastfeeding relationship for a year or longer… If we are able to provide mothers with adequate support, 95 percent of all breastfeeding problems are reversible.”

So, what’s my issue? I think the study is fine. Sort of a no-brainer, considering they could’ve came to the same conclusion years ago had they just listened to moms instead of insisting we just needed more convincing of the benefits of breastfeeding, and we’d all magically lactate to the satisfaction of the World Health Organization. But the quote above (from Laurie Nommsen-Rivers, one of the study authors) makes me wonder if the results of the study are being taken in the wrong context.

The focus is on moms not getting enough support –  something that I 100% agree needs to be focused on. Like, yesterday. But where the experts quoted in these articles and I part ways is on what type of support is needed. This passage from NPR illustrates my point:

The researchers didn’t do physical exams of the moms and babies, so they don’t know what was happening for sure. But they speculate that some of the first-time mothers may have misread the babies’ cues, mistaking fussiness for hunger, for instance, or thinking the babies weren’t getting enough milk when they’re doing just fine…

 

Once again, the assumption is that women are wrong about their bodies, and about their babies. The study authors surmise that access to lactation consultants in the first week postpartum, after hospital discharge, will be the solution to many of these problems. Again, I absolutely agree that this is a great start. And yet – reading through the scores of FFF Friday stories, I have to wonder… is this really going to make a difference, given the current state of our breastfeeding culture? How many LCs have we all seen, cumulatively? How many were bullied or shamed by medical professionals? How many of us have been told our babies were fine, only to end up in the ER with a dehydrated infant? How many of us were told – by professional lactation consultants and pediatricians – that every woman can breastfeed, and that we should just keep on nursing and it will all work out?

Looking at this study, this is what I see: a ton of women are claiming to have pain, trouble latching, and concerns that their babies aren’t getting enough milk. NPR also reports that the group with the least amount of reported problems was comprised mostly of women under 30, and women of Hispanic origin. That begs for further research, doesn’t it? Could age and legitimate lactation failure be associated? What about race/ethnicity? Are there conditions more prevalent in older, non-Hispanic populations that are also associated with breastfeeding problems?

And this is what I also see: We have an opportunity – no, a responsibility- to look at the type of support these women are getting. Is it truly evidence-based? Or is it based on dogma; on the belief that “95% of breastfeeding problems are reversible”? (By the way, I am super curious about the research backing up that claim.) Are the individuals giving the support truly listening to the mothers, examining them, considering the delicate balance of hormones necessary for lactation, or the effect of emotional or physical trauma around birth on a woman’s ability to withstand latching pain or her infant’s cries? Is there nuance? Are these mothers being seen, or are they being treated as uniform breasts, needing to be “handled” so that they can fulfill their duty of providing exclusive breastmilk for 6 months?

I’m not knocking a study that advocates for more support for moms. I simply want us to open up the discussion, rather than going in circles, with the same researchers and the same experts telling us the same things – if mothers only knew better. If they could only be taught to recognize their babies’ cues. If they would only listen to us. 

I think it’s time they listened to us, instead. Which brings me to what I’d really like to see from this study: a follow-up where they ask the women who “failed” to meet breastfeeding recommendations what they think would have helped them reach their goals. Because without that piece, I really don’t think we can get very far.

 

The ads on the bus go bad, bad, bad – a response to the Calgary Breastfeeding Matters Group campaign

“Children of parents who have diabetes have higher risk of diabetes themselves. Reproduce responsibly. Learn more.”

“Hispanic and Black children have higher risk of diabetes. Race matters. Learn more.”

“Children who are poor have higher risk of diabetes. Money matters. Learn more.”

 

If any of the above statements were posted on the walls of a bus, there would be an intense backlash, and rightfully so. Not only do these messages contribute to the shaming of people with diabetes – a condition that, according the American Diabetes Association, is primarily due to genetic predisposition – they are also offensive, misleading, and would fit quite well into a sci-fi thriller about eugenics. True, these factors are associated with higher rates of diabetes, but the story is far more complex than these slogans suggest, and to imply otherwise is nothing short of irresponsible.

Yet, a similar advertisement will be posted on public buses in Canada, suggesting that mothers of children who develop diabetes may be to blame for their children’s condition, due to their infant feeding choices (or lack thereof).

Ad from the Calgary Breastfeeding Matters Group (CBMG.ca)

Ad from the Calgary Breastfeeding Matters Group (CBMG.ca)

The slogan Babies who aren’t breastfed have higher risk of diabetes, is problematic. The omission of the word “may” (“Babies who aren’t breastfed may have higher risk…) implies that ALL babies whose mothers do not (or cannot) provide mother’s milk are doomed to a higher risk of diabetes.

Yet, the recent meta synthesis study by the World Health Organization (1) which examined 314 studies from 43 countries, reported that while breastfeeding may have protective effect for type -2 diabetes among adolescents, “Generalization from these findings is restricted by the small number of studies and the presence of significant heterogeneity among them” (p. 12). Moreover, there is no evidence to support that breastfeeding is protective against Type 1 diabetes, which is more common in the pediatric population (2).

To understand how this ad is misleading, it’s important to understand that diabetes is not one disease, but actually a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Saying blanket statements about diabetes is like saying “Brittany S sucks”. Who? Brittany Spears? Brittany Snow? Brittany S. Pears from Glee? Brittany spaniels? Same name, but very different entities. The causes of the various types of diabetes also vary. Although there are 3 main types of diabetes (Type 1, Type 2, and Gestational), people can get diabetes as a result of other conditions, like cystic fibrosis, organ transplantation, or having HIV/AIDS.

Type 2 diabetes, formerly known as non-insulin dependent diabetes or adult onset diabetes, is the most common form of diabetes across the general population. It is most often associated with older age, obesity, family history of diabetes, previous history of gestational diabetes, physical inactivity, and certain ethnicities, and can typically be managed via weight control, dietary changes, and exercise. It has come to be viewed in society as a disease of “fault”; another spoke in the wheel of the obesogenic machine that is currently speeding through our society like a shiny, red Corvette, crushing all nuance and holistic scope in its path.

Type 1 diabetes is an autoimmune disease, unrelated to weight or lifestyle factors. This is important to distinguish because children with Type 1 and their parents often get unjustly blamed for the condition (imagine how it must feel, on top of worrying about your chid’s blood sugar levels getting deathly high or low, to contend with people asking if you fed him or her nothing but junk food?) While there is some data suggesting the existence of environmental, viral, or physiological “triggers” for Type 1 diabetes, current research has not shown that it can be prevented (3) by any means, including maternal feeding.

Furthermore, to date, no studies have shown direct correlation between maternal feeding and the development of either form of diabetes, as this campaign would suggest. There is some evidence that children who were breastfed have a lower incidence of developing Type 1 diabetes [4] but the data are merely associative, as there are multiple confounding factors known to develop conditions for the disease. For example, the data coming from the burgeoning field of epigenetics have demonstrated a fairly robust association between allostatic load, or stress, in pregnancy, and higher risk for diabetes, coronary and ischemic disease. [5]

The Babies who aren’t breastfed have higher risk of diabetes advert, sponsored by the Calgary Breastfeeding Matters Group (CBMG), is the fifth in a series of pro-breastfeeding posters. The first four successfully inform and empower public awareness regarding breastfeeding; promoting the message that breastfeeding in public is normal with witty slogans and amusing imagery. This makes the current diabetes-themed poster all the more troubling–with its image of a bottle marked with the word “insulin” next to a foreboding hypodermic needle. To promote the scientifically inaccurate message with hyperbolic imagery misleads the general public, and burdens the parents and children affected by both Type 1 and Type 2 diabetes with unnecessary doubt and concern.

The CBMG may have expected backlash as its website offers a “Resource Sheet” to accompany the advertisement. They link to three different sources of data to back up their claim, with the introductory proclamation that “Recent 2013 research states that breastfeeding as a preventative measure against Type I and Type II diabetes is Level III Evidence”. The first link, to a Nordic systematic literature review, does confirm that the evidence supporting longer-term breastfeeding as a preventative measure (as opposed to “any” breastfeeding) is “Level III evidence”, indeed. What the CBMG fails to mention is that “Level III evidence” is defined as “limited-suggestive”. [6] (To be fair, the study does qualify the evidence for “any” breastfeeding being potentially protective as Level 2 – “probable” – based on studies of varying quality and methodologies.)The other two citations – another review and a seminar about epigenetics [7] [8] – both contain numerous caveats about their findings; neither offers anything close to conclusive evidence that breastfeeding is protective against diabetes – evidence that is hardly worth screaming from the rooftops. Or posting on the wall of a bus.

Without going into a lengthy discussion on the limitations of using two reviews and a lecture as the basis of an emotive advertising campaign, It should suffice to say that infant feeding has not been adopted as a significant reductive factor worthy of promoting to the general public by the American Diabetes Association, nor the Canadian Diabetes Association, expert authorities on this condition (although both of these sources do discuss the research into the breastfeeding-diabetes connection on their websites). In fact, diabetes expert Dr. David Lau  has already spoken against about the campaign, telling the Calgary Herald that the studies used to support the campaign “were essentially surveys…(and) he called any ad based on current, formal research to be an ‘extrapolation’.”

The CBMG “Resource Sheet” also contains a “Q and A”:

So, I breastfed my baby but she still got diabetes!  Is that my fault?

  • There are many risk factors which influence chronic diseases, not breastfeeding is only one of these risk factors.
  • When you have not realized your breastfeeding goals, you may inappropriately blame yourself, when it is the lack of information and support which is the real culprit
  • Let go of guilt. Use that energy to enjoy and celebrate your child and the accomplishments you have made.

This ad is cruel! It makes women who did not breastfeed feel guilty.

 

  • This argument by the public and health professionals takes the responsibility away from those supporting mothers who have not provided the information and support to help her reach her breastfeeding goals. 

  • Information about the health risks of formula do not come from formula companies, but it is very important for moms-to-be to realize there are risks. This needs to be delivered along with breastfeeding support resources.

(Source: CBMG.ca)

In other words, if your baby was breastfed and still got diabetes, there’s a potential that other factors may be at play- but more likely, you didn’t meet your breastfeeding goals. Don’t feel guilty, though – you were probably booby trapped! It’s not your fault you gave your baby diabetes. Although it kind of is.

This ad, well intention as it may be, will quite possibly inflict unnecessary shame and guilt on the parents of children with diabetes; perpetuate the confusion between Type 1 and Type 2 diabetes; and stigmatize women into breastfeeding rather than encouraging them to do so in a positive, constructive way. It would serve CBMG to remove this ad from their otherwise positive breastfeeding promotion campaign. Otherwise, they risk ruining an empowering, powerful campaign with the usual polarizing, negative, and historically ineffective tactics that have perpetuated the “bottle/breast” wars and kept parents from the important work of keeping themselves, and their babies, happy and healthy.

This post was a collaborative effort between Suzanne Barston (the FFF) and Walker Karraa, MFA, MA, with assistance from Polly Palumbo, PhD,  Sarah Lawrence, PharmD, MA,  Teri Noto, and Kristin Cornish, and several others who wish to remain anonymous for professional reasons. 

Citations

[1] Word Health Organization. 2013. Long-term effects of breastfeeding: A systematic review.

[2] University of Rochester Health Encyclopedia, date unknown. Type 1 Diabetes in Children.

[3] American Academy of Pediatrics, 2013.  Healthy Children.org – Diabetes Mellitus.

[4] American Diabetes Association, date unknown. Genetics of Diabetes.

[5] Barker DJ, Winter PD, Osmond C, Margetts B, Simmonds SJ (1989) Weight in infancy and death from ischaemic heart disease. Lancet 2:577-580.

Barker DJP, Bull AR, Osmond C, Simmonds SJ (1990) Fetal and placental size and risk of hypertension in adult life. BMJ 301:259-262

Barker DJP (1995) Fetal origins of coronary heart disease. BMJ 311:171-174.

Barker DJP, Osmond C, Forsén T, Kajantie E, Eriksson JG (2005) Trajectories of growth among children who later have coronary events. N Engl J Med 353:1802-1809.

[6] Hörnell A,et al. Breastfeeding, introduction of other foods and effects on health: a systematic literature review for the 5th Nordic Nutrition Recommendations. Food Nutr Res. 2013; 57: 10.3402

[7] Nolan CJ, Damm P, Prenkiki M.Type 2 diabetes across generations:from pathophysiology to prevention and management. Lancet. 2011 Jul 9;378(9786):169-81.

[8] Patelarou E, et al. Current evidence on the associations of breastfeeding, infant formula, and cow’s milk introduction with type 1 diabetes mellitus: a systematic review. Nutr Rev. 2012 Sep;70(9):509-19]


 

 

 

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