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.

Ready-to-feed formula may prevent Cronobacter infection in babies

I love when I’m right. I mean, it happens so infrequently (at least according to Fearless Husband).

Even before the Cronobacter scare of 2011, I’d dramatically changed my tune about formula preparation and safety. The research I read surrounding bacterial infection in babies due to formula or bottle use made me see just how piss poor our education on bottle feeding truly is; this is what spurred my interest in starting some sort of pre or post-natal educational workshop/literature for bottle feeders, and also made me suspect that there was an astonishingly simple – albeit prohibitively expensive – solution to the bacteria problem.

Safety, thy name is Ready-To-Feed.

Until now I’ve merely been able to suggest that my personal belief is that ready-to-feed nursettes are the safest bet for newborns, and especially for late pre-term babies or those with any sort of compromised immune system. Now, a study published in Pediatrics gives scientific credit to my completely unscientific gut feeling.

I’d say squeeeand do a little dance of egotistical joy,

but unfortunately I can’t. Because we are talking about infant safety here, and the solution which this study is suggesting is not going to be feasible for many parents due to the cost involved. This is turning my happy ego dance into a sad waltz. Which sucks, because who doesn’t enjoy a good happy ego dance?

The study, Prevention of Invasive Cronobacter Infection in Young Infants Fed Powdered  Infant Formulas, looked at the records of 68 babies infected with invasive cronobacter between 1958-2003, and 30 babies between 2004-2010. A couple of things to note before we get into the nitty-gritty of the study:

1. Invasive Cronobacter infection is extremely rare, and usually affects pre-term babies and very young neonates (all of the infants reflected in these records were under two months old).

2. This study had some significant limitations, considering that it was conducted using records from a variety of international organizations (CDC, USDA, WHO, as well as “personal communications” and “publications”. Definitions might have varied, as well as the quality of the information. This might explain the shocking disparity between the cases reported in the older batch (1958-2003) and the newer batch (2004-2010).

Now that the caveats are out of the way, let’s continue. The study found very different statistics in the two chronological batches. In the older batch, only 24% of the babies were full term; out of the more recent cases, 58% were full term. That’s a radical leap. Plus, while in the 1958-2003 group only 21% became symptomatic at home, that percentage jumped to 52% between 2004-2010. This may have something to do with the fact that there were half the number of cases in the more modern group versus the older one; if bacterial contamination was becoming more rare, then perhaps we’re dealing with a newer or more virulent strain in the new millennium. But I also wonder if part of the disparity between the characteristics of the cases has to do with the lack of formula feeding guidance. The resurgence of breastfeeding since 2000 has led to many fantastic outcomes, but the downside, as we’ve discussed before, is a refusal to address the needs of formula feeding parents. Historically, concerns about bacterial infection were focused on NICUs; the tubing used to deliver food to the tiniest babies could easily become contaminated if the utmost care wasn’t taken, and given the fragile systems of premature or sick infants… well, it wasn’t a great combination of risk factors. But looking at the statistics used in this study, it seems that in the past 12 years, full-term babies in their parent’s care – at home – were equally at risk. I think it merits further reflection, at least, to consider if these cases might have been due to parents being given no guidance or support with formula feeding. We know from our numerous conversations here, and on the FFF Facebook page, that most of us were given ample education on breastfeeding (even if we didn’t get much practical support); very few of us were instructed on how to formula feed safely, sometimes with the excuse from more intolerant healthcare professionals that there was no “safe” way to formula feed.

Regardless, even if we were given better instruction on safe bottle feeding practices, very young infants fed powdered formula are at significantly higher risk of becoming ill from invasive cronobacter. The Pediatrics study found that out of all infected infants studied, 26% had received breastmilk, 23% had received RTF, and 90% had received either powdered infant formula or human milk fortifier (which is another caveat I forgot to mention – powdered human milk also posed a significant risk, not just powdered formula. Apparently Cronobacter loves powder of any sort).

Okay- just so we are crystal clear here – the lowest percentage of infected babies came in the group fed ready-to-feed formula only. It even beat breastmilk (not by much, but I think it should be mentioned, since it would be if it were the opposite). So it’s a no-brainer that the study’s author then recommends the following:

Invasive Cronobacter infection is extremely unusual in infants not fed powdered infant formula/Human Milk Fortifier. RTFs are commercially sterile, require minimal preparation, and are competitively priced. The exclusive use of breastmilk and/or RTF for infants <2 months old should be encouraged.

I’ve been advising that newborns use RTF whenever possible for awhile now, but every time I do I feel like a classist a-hole. Because let’s be honest – the stuff is expensive. Even if you buy the 32-oz containers rather than the more costly (but sterile) nursettes, you’re still talking a major difference in cost for the recommended two months of use. And those first 2 months, there is a lot of wasted formula – babies are erratic, not on a schedule, parents are still figuring out hunger cues… it takes a few months before you know Junior will take exactly 4 oz every 4 hours. Powdered formula is significantly cheaper. And god help you if your baby ends up on a hypoallergenic – buying the RTF version of that stuff will seriously kill your bank account.

The big elephant in the room, of course, is that the formula typically given away in those controversial hospital swag bags is ready to feed – often in the form of sterile nursettes. Not that the amount in the bags would feed a baby for the entire two month window of risk, but the bags I received – generously “supplemented” by the maternity ward nurses since our breastfeeding-friendly hospital didn’t have many formula feeding mothers and there were plenty of leftover bags – gave me enough formula to get us through the first few weeks. Every little bit counts.

Now, I’m not naive enough to believe that the formula companies are giving away RTF out of the kindness of their hearts. But considering that the Ban the Bags movement has grown in popularity, and hospitals are going Baby-Friendly right and left – they are going to need an alternative way to market their products. Why couldn’t we set up a program which would give parents that have chosen to formula feed (or supplement) before leaving the maternity ward to request a “gift” of ready to feed formula? Formula companies could still reap the rewards of brand loyalty, and look somewhat altruistic in the meantime. The parents who receive these samples could be the same ones who already were forced to sign documentation which labeled them as formula feeders, so what would be the harm?

There needs to be a way to provide supplementing and exclusively formula-feeding parents with the safest breastfeeding substitutes possible. In the first two months of life, ready-to-feed formula is the safest commercial alternative. If the formula companies would be wiling to provide at least a few weeks of RTF to take the financial edge off, it might help parents afford RTF for the subsequent 6-7 weeks.

Seems like a no-brainer to me, but then again… you know what Fearless Husband says. I’m hardly ever right.



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