Guest Post: I Am Not a Cow

I’m thrilled to share this post with you, from my friend Andrea Nord. Andrea is the chairperson for the non-profit organization “Bottle Feeding in Sweden” and is an admin for a Swedish Facebook group like the FFF private group, which can’t be an easy job, considering the infant feeding attitudes of that country. She’s one of the most astute, brave, and seriously awesome women I’ve had the pleasure of getting to know in this crazy sort of advocacy I’m in, and I’m glad I get to share her brilliance with you via this post (which she graciously translated into English for us). The post originally appeared on Petra Jankov Picha’s bottle feeding blog “Att Flaskmata”.

About twenty km east of Lund, in the southernmost part of Sweden, is a large natural area called Revingehed. The Swedish military uses this area for short periods for their exercises and sometimes you can hear the sounds of gunfire in the village of Veberöd where I live. But for the most part, the area is a quiet and peaceful place where hundreds of cows graze freely to keep the grass short and the grounds open. Sometimes we take a drive there for a near-cow-experience, as my kids call it. If you are lucky you may see cows on the road just when you are driving by. It’s a really lovely experience that I heartily recommend, especially now when the calves are small.

When you think of cows you might think of beautiful black and white Holsteins wandering back to the barn after a long day of grazing in the meadows. All the cows are the same, it’s just the patterns on their coats that are different. Otherwise, they all have the same needs, they all want the same things and they all do the same things all day long. There are no cows with any special needs or aspirations, except of course the famous fictional cow Mamma Moo from the Swedish children’s books with the same name, the cow who was not satisfied with just grazing and chewing. She wanted to do everything that people did, she wanted to swing and go down a slide, despite her good friend the crow’s desperate attempts to point out to her that she is in fact just a cow, and cows do not behave like humans. Period.

Source: http://9teen87spostcards.blogspot.com/2011/07/mamma-moo-cow-riding-bicycle.html

Source: http://9teen87spostcards.blogspot.com/2011/07/mamma-moo-cow-riding-bicycle.html

 

Part of what makes Mamma Moo so funny is her inability to comply with expected and “natural” cow behaviour. Mamma Moo is a.. feminist! Imagine that! And then the idea hit me – why does the WHO and our Swedish National Board of Health and Welfare assume that all women in the world are the same, that we all do the same things and want the same things? Why do people think that women don’t have different needs, wants or conditions? Why this astonishment whenever we want to do something different from the expected and “natural”?

Does the world see us women as.. cows? Because if you do not see women as unique individuals but as cows, then it is close at hand to recommend that we should all do things exactly the same way. What is “best” is then best for everyone. The word recommend is perhaps the wrong word, require is probably closer to reality. And there are many “truths” that we women are expected abide by and now we come to The Mommy Wars, which I see as the social pressure to get all women to comply to a perceived truth. You see, all of us women are supposed to do things exactly the same way!

If there was tolerance for women doing things in different ways, then there would be no reason to get all upset about it. But women do in fact want different things – some want to work, others want to be at home. Some breastfeed, others bottle feed. The nerve of them!

It’s interesting that I find it hard to find similar examples where one would try to get all men to do the exact same things or get upset if they didn’t. The mere idea is completely ridiculous, for men are seen as individuals, they are all different and they are allowed to do what they think is best. The only example I can think of, when trying to get all men to do the same thing, is when you recruit them into the army and send them out to war. Then and only then are men oppressed to all do the same thing. But in peacetime, they are all free to do whatever they want and however they wish to do it. Now I would like to end this rant with an appeal to the WHO, the National Board of Health and Welfare and all the health authorities: stop seeing us women as cows! See us instead as unique individuals capable of thinking and making decisions about what is best for ourselves and our families!

Let us be free to decide how we want to feed our babies and stop trying to round us up and herd us all into a corral. We are women, not cows.

A slightly curmudgeonly rant about the drama over Save the Children’s “Superfood for Babies” campaign

The problem with writing a post which criticizes an organization which strives to help starving kids is that it makes you feel like the Grinch. Or Gargamel. I feel like I should be stroking an acrimonious cat and arching a pair of overgrown eyebrows inward.

Save the Children does a lot of wonderful things for children in dire straits, and I don’t want to come down on them too hard. And in many respects, I applaud their recently announced “Superfood for Babies” initiative. I do believe that breastfeeding is a hugely important part of improving childhood mortality in resource-poor nations, and the report supporting the program offers some excellent perspective on the challenges of raising exclusive breastfeeding rates in these areas.

In public health circles, there’s a lot of discussion on messaging – how to make PSAs culturally appropriate, sensitive, and effective. The thing is, this doesn’t only hold true for at-risk groups – it also applies to the middle-class factions of western nations. It’s just as ineffective (and inappropriate) to try and graft a message addressed to people living in tribal societies with problematic water sources onto a secretary in suburban Iowa as it would be to do the opposite. Yet, this is what happens – repeatedly – in our international discussions of breastfeeding. (Incidentally, this is at the root of my beef with Unicef and WHO, and why I feel it’s necessary to amend the Baby Friendly Hospital Initiative set forth by those organizations to be more culturally appropriate to developed, Western societies.)

This brings us to my scroogey analysis of the “Superfood for Babies” campaign.  I would encourage everyone to read the literature – it offers some truly excellent insight into the specific issues at play in a variety of developing nations, and makes it clear (whether or not it intends to) that formula is not the only barrier to encouraging exclusive breastfeeding. In some cultures, there are beliefs that breastfeeding for the first few days of a babies life is detrimental; in others, women feel pressured to produce as many babies as possible, thus making the fertility-restricting nature of breastfeeding a downside; and in others, it’s not formula which is used as a supplement but raw animal milks or concoctions of grains.

Save the Children (STC) did a lot right with this report. They addressed the need for social change; advised that governments subsidize breastfeeding women so that those in unstructured agricultural jobs (which don’t exactly come with a 401k or paid maternity leave) don’t need to return to work immediately, and have to choose between making a living and feeding their babies; and they press for better education and involvement from medical workers and midwives. I think their motives were great, and they did their homework.

Unfortunately, in their excitement, they lost perspective in three key areas…

1. They were (intentionally or unintentionally) vague about the research

Look, I would never argue that breastfeeding isn’t the best choice – by far – for babies in places where food is scarce, infection and disease runs rampant, medical care and antibiotics are severely limited, and the water source is questionable. Formula feeding is dangerous in these settings. But since breastfeeding advocates and orgs like WHO have made breastfeeding a global issue, we have a responsibility to be honest about what our body of research actually says. There are numerous instances in the STC report where claims are simply not held up by their citations. For example, this quote, on page vii of the report’s introduction:

It is not only through the ‘power of the first hour’ that breastfeeding is beneficial. If an infant is fed only breast milk for the first six months they are protected against major childhood diseases. A child who is not breastfed is 15 times more likely to die from pneumonia and 11 times more likely to die from diarrhoea[2]. Around one in eight of the young lives lost each year could be prevented through breastfeeding,[3] making it the most effective of all ways to prevent the diseases and malnutrition that can cause child deaths[4].

Let’s take a closer look at the citations. The first one, #2, is from a UNICEF report on diarrhea and pneumonia- not a study, but a report. So it took a bit of digging to see exactly where they were getting their data from. I *think* this figure comes from a table attributed to a Lancet piece, which “estimated”  that “Suboptimum breastfeeding was… responsible for 1·4 million child deaths and 44 million disability-adjusted life years”. I couldn’t get the full study on this one, but again – it was an estimate, most likely based on other studies – not hard data.

Citation #4 is the one that’s bothersome, however (#3 is just a footnote with the definition of “exclusive breastfeeding”). The sentence “making it the most effective of all ways to prevent the diseases and malnutrition that can cause child deaths” is most likely read as “breastfeeding is the most effective way to prevent child death”. That’s quite emotive. The citation leads you to a Lancet paper on child survival, which does have some dramatic data and charts regarding the interventions which would most reduce infant mortality in the developing world. Breastfeeding is shown to offer the most dramatic reduction in risk- but there’s one important point to consider: while this report focuses on death in children ages 0-5, the majority of these deaths occur in the first few months of life. Exclusive breastfeeding, as opposed to mixed feeding or exclusive feeding of substitutes including goat or buffalo milk, paps, or formula (important to note that in many of the countries STC is concerned about, traditions include feeding neonates animal milks or solids within hours of birth – so I think it’s arguable that the issue here is the risk of giving a baby anything but breastmilk via the breast, rather than breastfeeding being the “magic bullet” the report dubs it to be. Otherwise, we probably wouldn’t see consistently poor outcomes in mixed-fed kids, as a “magical” substance would compensate) is going to reduce the risk of infections that cause death in very young babies. In other words – if the most deaths are in newborns, and breastfeeding saves newborns more than any other interventions like vaccines, clean water, etc – then there will be a disproportionate representation of “babies saved by breastmilk” in the results. This is not to say that breastfeeding isn’t an incredibly worthwhile and effective solution to reduce infant mortality, but it’s a bit of a stretch to suggest that breastfeeding alone will be the most effective intervention for ALL childhood deaths, which is exactly what the STC report does.

2. They didn’t consider the societal implications of their recommendations, beyond the scope of infant health

I was taking notes as I read the STC report, and my heading for the section which included this quote was “OMGOMGOMG”:

Many women are not free to make their own decisions about whether they will breastfeed, or for how long. In Pakistan, a Save the Children survey revealed that only 44% of mothers considered themselves the prime decision-maker over how their children were fed. Instead it is often husbands or mothers-in-law who decide….

 

….To overcome harmful practices and tackle breastfeeding taboos, developing country governments must fund projects that focus on changing the power and gender dynamics in the community to empower young women to make their own decisions.

Changing the power and gender dynamics sounds like a fantastic idea, and I would support any program that attempted to do this. But STC has to realize that “empower(ing) young women (in developing countries) to make their own decisions is a complex and uphill battle that extends far beyond infant feeding. I fear that by placing an emphasis on UNICEF-lauded solutions like warning labels on formula cans/making formula prescription-only, and on educating fathers/elders on the importance of breastfeeding using the current overzealous and often misleading messages, in these countries – places where, all too often, females are already considered “property” and subjected to any manner of injustices – it will create an atmosphere where women who are physically unable to breastfeed will be ostracized, shamed, or penalized. I agree that we need to empower women, but I think that we also need to be verrrry careful about presenting “suboptimal breastfeeding” as a risky behavior in certain cultures.

In another section, the authors report that breastfeeding rates have gone up in Malawai despite poor legislation on maternity leave, breastfeeding rights, etc. – that these improvements are based solely on strict implementation of WHO Code. I’d like to be reassured that as women are being given no option other than breastfeeding without any of the protections which would make EBF feasible while working, this isn’t having a deleterious effect on their lives. It’s wonderful that breastfeeding rates are up, but what about correlating rates of employment, poverty, and maternal health?

3. They failed to differentiate between resource poor and resource rich countries

I’ve seen a wide range of opinions on the STC program online in the past few days. Most of the drama is over British media reports which mention putting large warning labels on all formula tins – not just the ones going to resource-poor countries. Some feel that these labels will cause unnecessary upset in the West; others argue that when it comes to saving starving/sick third-world babies, privileged mommy pundits should STFU. And others keep insisting that the STC report was misrepresented, and that the labeling stuff was a minor part of the larger plan and shouldn’t be harped on.

All of these arguments are valid, and yet all are missing the nuance necessary to have a productive conversation. We need to realize that not breastfeeding has quite different implications in certain parts of the world. We also need to acknowledge that a woman’s rights are important no matter how much money she has or where she lives, and that we all have a right to stand up for what we believe – it’s rather useless to play the “eat your dinner because children are starving in Africa” game, and rather un-PC as well.

But STC also needs to take responsibility, here. The fact is that the report does not really differentiate between resource-poor and resource-rich countries when it is discussing WHO Code and formula marketing.  For example, this passage on p. 45 describes laws which STC wants implemented worldwide:

Breast-milk substitute companies should adopt and implement a business code of conduct regarding their engagement with governments in relation to breast-milk substitutes legislation. Companies should include a public register on their website that outlines their membership of national or regional industry bodies or associations, any meetings where the WHO Code or breastfeeding is discussed, and details of any public affairs or public relations companies they have hired, alongside the nature of this work… Any associations (such as nutrition associations or working mothers’ associations) that receive funding from infant formula companies should be required to declare it publicly. In addition to this information being made publicly available on the websites of individual companies, the International Association of Infant Food Manufacturers should publish a consolidated record of this information, updated on a quarterly basis.

Personally, I think the money spent on a “governing association” in order to police this policy would be better spent on funding literacy programs to help parents read the labels we’re arguing about. Some of these countries have literacy rates of like 30% – which makes me wonder exactly who the labels are geared to, if not the Westerners for whom formula feeding is far, far less of a risky endeavor.

Don’t mistake me – the evidence given in this report about the shady practices of formula co’s is alarming. There needs to be something done about unethical marketing practices in parts of the world where information is limited, education is a true privilege, and options are a joke. Yet, in the STC report, there is ample (and quite good) evidence that the unethical efforts of formula companies are only one slice of a thick-crust, Chicago-style pizza. There’s a lot of gooey, barely distinguishable elements which all combine to make a rather heavy problem, and focusing so much on one of them will leave you with the policy equivalent of Domino’s.

Further, the situation with breastfeeding in the developing world is markedly different from what’s going on in Great Britain, the US, Canada, and so forth. The online arguments are proof of this. I’ve seen the same people who argue that breastfeeding is a global issue turn around and tell concerned Americans and Brits that they have no idea what’s appropriate in Peru or Ghana. This may be true, but so is the reverse. International groups like STC have to remember that when they release papers making global recommendations about infant feeding, that they are inviting commentary from a global audience. That’s why we can’t make blanket statements about infant feeding and child health, or try and implement the same rules in order to get the same results. We wouldn’t go into a rural village where families share a 300-square foot hut and start lecturing them about the dangers of co-sleeping, and yet we assume that the same one-size-fits-all public health messaging is fair game when it comes to infant feeding. Breastfeeding might indeed be a global issue, but the type of issue it is varies greatly depending on what part of the globe you’re on.

 

Formula feeding education, or lack thereof

Reading through my Google alerts, I almost squealed with excitement when I saw a link entitled “Health Tip: Preparing Baby Formula” from none other than U.S. News and World Report. A major news outlet! Formula feeding education! Squee!

Well, turns out the article was less “squee” and more “eh”.

According to the esteemed publication, the formula-related health tip that was so vital that it necessitated being “called out” (publishing world lingo for highlighting a fact or quote) was the following:

Wash Your Hands.

The rest of the tips have to do with general hygiene- cleaning surfaces, sterilizing bottles, etc. I’m probably being unnecessarily snarky, because this is important information; it is important to keep things as clean and sterile as possible when making up an infant’s bottle. They also throw in one useful tip about keeping boiled water covered while cooling (great advice). But most of this is certainly not new information, and in many ways, I think it’s a waste of newsprint.

Why? First, I expect most parents know they are supposed to wash their hands and clean their bottles. What they may not know is why. There is no mention of the risk of bacterial infection here, so it just comes of sounding like vague, somewhat stodgy advice, like something your mother-in-law tells you in that tone. (You know the one.) The kind of advice that gets filed in the “I know I should do it, but come on, what’s the harm” portion of your conscience, alongside “floss twice a day” and “never jaywalk” (unless you are in Los Angeles. Then you probably take the jaywalking thing seriously, as the LAPD will ticket your ass for crossing where you shouldn’t). I think an acknowledgement that these precautions will help you avoid potentially deadly bacterial infections would make the advice seem a tad more topical.

But also, this is standard food prep protocol. There are other intricacies to formula feeding that may not be as intuitive- safety precautions like mixing the proper amounts of water to formula; not diluting the formula; using the right type of water; discarding formula after specific amounts of time; opting for ready-to-feed for newborns. Or what about other tips which might help avoid other formula-related health problems? Like a run down of the different types of formulas so that parents can choose the right type for their babies. Advice for understanding hunger cues. A bit of education on growth spurts; what’s normal when it comes to formula-fed babies and spit-up and elimination (both pee and poop); a quick description of how to feed a baby holding the bottle at a good angle?

I get that this was merely a half-column filler, not an 800-word feature. I understand that U.S. News & World Report isn’t in the business of imparting feeding advice to parents (and in fact, the article in question was syndicated, from Health Day) . And I seriously do appreciate the effort to give a bit of valuable info to formula feeding parents. Yet, I can’t help but wish that this half-column was put to better use. A short paragraph on when (and just as importantly, why) formula should be discarded would have been infinitely more interesting and useful.

There are a few reasons why formula feeding education is as hard to come by as a good house under half a million in the greater Los Angeles area (I’m bitter about real estate at the moment). Many people think it’s unnecessary; formula feeding is seen as the “easy way out”, and assumed to be as simple as scoop and shake. Some breastfeeding advocates believe that prenatal formula education/preparation is counterproductive to breastfeeding promotion – the theory being that if you discuss it, it will be taken as an endorsement, when formula should only be used in an all-else-has-failed scenario. (The World Health Organization’s “WHO Code” basically forbids health workers from even uttering the words “infant formula” until it becomes clear that there is no other option.)

What is puzzling to me about this situation is that breastfeeding, while definitely a lost art in our bottle-heavy society, does have an intuitive aspect to it. Or at least it is portrayed that way – something so natural, so instinctual, shouldn’t require training. Assistance, yes. Support, most definitely. Protection, you bet your bottom dollar. But instruction/education? That seems rather – well, quite literally, counterintuitive.

Formula feeding, on the other hand, is something which has always been a man-made, lab created, medically-approved (at least up until recent events) form of infant feeding. It does require instruction; you don’t see our primate cousins giving birth and popping open a can of Similac (although I am quite sure they could be trained to do so, considering how smart they are. I’ve seen Rise of the Planet of the Apes. Scared the bejesus out of me). Yet parents leave their prenatal classes and hospital stays with plenty of info on birthing and baby care and breastfeeding, but little to no instruction on how to make a damn bottle.

The vast majority of babies will have some formula in their first year. Heck, by the time they are 6 months old, it’s a safe bet to assume most of them are partially, if not exclusively, formula fed. We can’t sell infant feeding as the number one predictor of infant health and development and simultaneously ignore the primary way our nation’s babies are being fed.  It’s bogus, and irresponsible.

This is not to imply that parents are putting their babies in dire jeopardy because they leave a bottle out too long, or forget to scrub their hands like Lady MacBeth before mixing formula. Heck, I committed almost every formula feeding sin and my kids are pretty normal. (Except for Fearlette’s suspicious fear of police helicopters, but I blame that on her past life.) But until we ensure that parents are properly educated on formula feeding – something that could be done with one quality, AAP-endorsed pamphlet, or a few minutes of discussion in a hospital baby care class – we can’t possibly get a clear idea of the real risks of formula feeding (I bet we’d see an even smaller difference in breastfed versus formula fed if all formula feeding parents were doing it correctly), or feel confident that all of our babies are getting the best version of whatever feeding method their parents have chosen.

For now, I’d suggest checking out Bottle Babies – a great non-profit organization run by some friends of mine. They’ve put together some excellent, research-based information on a myriad of bottle-related issues. Or feel free to click on the link to the FFF Quick-and-Dirty Guide. And I hate to say it, but for the moment, the formula companies are probably the best resource for formula feeding parents. At least they give a crap about their customer base, even if this is rooted in a desire for customer loyalty and a fear of litigation.

And, ya know, remember to wash your hands.

Why the Gerber Good Start ad irks me

I’d finally finished my work for the night, and had just settled into bed to watch my DVR’d episode of Once Upon a Time (best show on television right now, by the way). Breasts and bottles were the last thing on my mind, until I was zipping through the commercials and glimpsed a formula can. Of course I had to stop fast-forwarding and watch, and here is what I saw:

Cute baby, but that’s beside the point.

This ad got me very riled up, and – dare I say it – took me out of the (in my case, very willing) suspension of disbelief required to enjoy a show about fairy tale characters come to life.

I am not against formula advertising, any more than I’m against cell phone advertising, or baby food advertising, or car advertising. In fact, considering I still do some commercial acting on the side, I’m fully in favor of advertising as an industry. (Except pharmaceutical ads, because they make me a total hypochondriac.) But this ad rubbed me the wrong way, for one major reason: why is an ad about formula focusing so much on breastfeeding?

Obviously, I know why. Anyone who frequents this blog knows why. In the US, this is about as close as we get to following WHO Code. The formula companies can do pretty much whatever they please, so long as they tack a “breast is best!!” message onto it. I’ve talked about this before, in regards to shady practices like running “breastfeeding support lines” or sponsoring “feeding guides” that talk far more about breastfeeding than bottle feeding. I think it is hypocritical, and demeaning to the intelligence of parents. If you were to ask me (a lifelong vegetarian, sometimes vegan) for a recommendation on the best steakhouse in town, I’d worry about your sanity. Likewise, relying on a formula company for breastfeeding advice is probably not the wisest move.

Nestle, who makes Good Start, has a reverse halo effect that is going to take about 1000 years to dissipate. Anyone who is involved in breastfeeding advocacy thinks the company is the devil, and for very good reason. Saying the words “Gerber knows that breastfeeding is best” comes off as totally disingenuous. It’s not going to make up for the thousands of deaths the company caused by marketing formula irresponsibly. Unfortunately, Gerber probably feels it has to make the requisite breast-is-better
statements because the company is making claims (which are indeed backed by research) that this particular formula has been associated with a lower risk of allergies.  (They even go one step further than most formula ads, subtly suggesting that their customers will most certainly be breastfeeding up until a point with the phrasing “if you do decide to introduce formula…”) Anyway… all this is to say, I get it. I get why they constructed the verbiage of the ad this way.

But this is what hit me last night, when I should have been enjoying some mindless entertainment: the fact that formula company advertising involves so much discussion about breastfeeding being superior, might actually be hurting breastfeeding advocacy. 

By talking about breastfeeding being the best way to feed your child, the advertisers are immediately creating an unconscious comparison between the two feeding methods. Comparisons necessitate qualifications like good, better, best. Parents might decide (quite justifiably, in my opinion, but that is neither here nor there) that better is pretty darn close to best, so why go to the trouble of breastfeeding?Within this model, breastmilk is also seen as a competitor to formula, which inspires subliminal pro/con lists in our heads.

What if Gerber hadn’t mentioned breastfeeding in this ad? The downside, I suppose, would be the implication that this formula could protect against allergies better than breastmilk. But that could be accomplished by making accurate claims, a rule that all advertisements are expected to follow, even if they don’t always do so. (I would suggest simply giving some statistical information, i.e, “Studies have found that breastfeeding exclusively for the first four months is associated with x amount of reduced risk of allergies. Gerber Good Start has been found to decrease the incidence by x,” but that is probably why I don’t write ad copy…)

 If formula could just be advertised as formula, instead of a poor man’s substitute for breastmilk, we wouldn’t lead consumers into a nebulous cloud of comparison. Because honestly, why compare the two? They are two different ways to get a child fed. The benefits and risks of breastmilk are fodder for a conversation between a care provider and patient, not the territory of a money-grubbing corporate conglomerate or over-zealous activists. What if we simply held formula companies to the same standards as, say, pharmaceutical corporations? No false claims; caveats of “talk to your doctor” if there are any statistics or medical studies cited.

Extolling the virtues of what is essentially a competing product (which is why I passionately believe we need to stop commoditizing breastmilk, but that would entail a much longer conversation than I want to have right now, as I have the rest of that episode waiting for me and it’s getting quite late) is something unique to formula advertising, and I wish it didn’t have to be that way. I wish that breastfeeding advocates could see that making formula companies pay homage to the Almighty Breast is serving no one. It just makes for a confusing and annoying ad, and we don’t need more of those cluttering up our DVRs and ruining a perfectly good evening of escapist television.

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

To: Whom it May Concern

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

From: The collective voices of FearlessFormulaFeeder.com

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

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

Who we are

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

The paper

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

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

Lack of impartiality

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

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

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

Lack of due diligence

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

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

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

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

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

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

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

WATER

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

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

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

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

BOTTLES

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

COST: $48.65 for 42 bottles

A storage container $11.00 (crazy clarks)

50 Large Zip lock bags – $5 (Coles)

Paper towels – 400 $4.70 (Coles)

Detergent – 1L $1.06 (Coles)

Antiseptic Wipes – 80 pack – $10.68 (Coles)

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

TOTAL COST: $132.13

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

Lack of adequate information

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

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

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

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

Sincerely,

The Readers and Author of FearlessFormulaFeeder.com

Sources

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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