Expressing breast milk in pregnancy: Should all women harvest colostrum?

Some of the long awaited work about expressing in pregnancy for women with diabetes, from Forster et al, and the DAME study has been published.[1] The implications of this work are important for women with diabetes who plan to breastfeed, and hopefully the findings will lay to rest concerns about expressing in pregnancy and risk of preterm labour. The DAME study found no evidence of harm from advising low-risk, pregnant women with diabetes to hand-express breast milk from thirty-six weeks gestation.

There was misreporting of this study in the media with headlines missing out the ‘diabetes’ context, and others using photographs of breast pumps embedded within the stories. To be clear, the study was about hand expressing from thirty-six weeks gestation for low-risk pregnant women with diabetes. What now requires further research is whether other women at risk of low lactation would benefit from hand expressing and colostrum harvesting in pregnancy.

When considering women who may be at risk of low lactation a discussion about lactation ‘insufficiency’, and what is often described as biological or ‘real’, and what is described as ‘perceived’ is needed. Alison Stuebe discusses issues of ‘perceived’ and ‘real’, and suggests that from a health and wellbeing perspective it may not really matter whether biological and perceived are counted together as, “… mothers are suffering, whether they lack glandular tissue and or they lack self-efficacy and support.”[2]

It is unknown exactly how many women are at risk of primary lactation insufficiency although we know that diabetes and other medical conditions are associated with delayed lactogenesis, and some women may have supply challenges due to issues with low glandular tissue amounts, or previous breast surgery. Two percent is often quoted for numbers of women who may have lactation insufficiency, and Neifert suggested in 2001 that up to 5% of women may have primary lactation issues because of breast anatomy or medical conditions.[3] New Zealand Ministry of Health figures from 2014 suggest that out of 61,000 births, 6.6% of these pregnancies were affected by diabetes.[4]

A full breast milk supply requires sufficient breast glandular tissue, intact nerve pathways and ducts, hormone production, and frequent and effective milk removal. If any of these are parts are compromised there is a risk that full lactation may not be reached. Lactation issues with a secondary cause are as difficult to calculate as primary. Secondary refers to women who have a full lactation, or the capacity to develop a full lactation, but some ‘interference’ occurs, which results in low lactation issues. Birth interventions, caesarean births, sleepy babies, latching problems, and lack of support can all lead to secondary issues with milk supply.

Because environmental and social factors also play a significant role in lactation, how we approach discussions about lactation and breastfeeding during pregnancy is also significant, as is what happens to women in labour, birth and the post-birth period. Amy Brown explored the psychosocial and cultural issues around breastfeeding and their impact on the physiology of breastfeeding, why many mothers stop breastfeeding before they planned to, and why low milk supply is commonly cited as the reason. Brown highlights how psychological, social and cultural influences can strongly influence the physiology of breast milk supply.[5] Otsuka et al, in a study of 262 breastfeeding women in Japan found that 73% of the women had a perception of insufficient milk supply,[6] and the Growing up in New Zealand study found that 45% of the women in their cohort cited insufficient milk supply, with 32% also citing their babies were not satisfied with breastfeeds.[7]

In New Zealand there are stories of women with low risk pregnancies, without obvious risk for low milk supply, who have been advised to express colostrum in pregnancy. What is unknown is the outcome of these interventions. Whether milk supply was enhanced, maternal confidence increased or subdued, breastfeeding outcomes were favourable or unfavourable.

Rachel O’Brien, whose Master’s thesis was about women in the US and low milk supply, wrote an interesting blog on milk supply and psychology, where she used response expectant theory (RET) to explain why hearing “over and over” about low milk supply could cause bodies to “respond in the way that we expect them to – by making less milk than we need.”[8] Kirsch describes RET as the anticipation of automatic, subjective, and behavioral responses to particular situational cues,[9] suggesting a non-volitional response can occur due to expectations of one’s own response to a situation. When discussing Kirsch’s RET theories, Stewart-Williams, suggests that the hypothesis has “an intuitive plausibility. For instance, the expectation of anxiety is likely to be anxiety provoking, and the expectation of depression is likely to be depressing.[10]

Amy Brown discusses breastfeeding outcomes, why engagement in pregnancy is important for breastfeeding, and how women who feel prepared, knowledgeable, and confident about breastfeeding have better outcomes after birth.[11] Brown examined behavioural factors contributing to ‘successful’ breastfeeding and found that women with high levels of confidence, and determination about their breastfeeding decisions, managed to navigate their way through the challenges they faced to meet their goals for breastfeeding. This appears to illustrate the positive significance of the development of confidence and self-efficacy.

Funding and resources to undertake breastfeeding research, so practice can be underpinned with evidence wherever possible, is not readily available. Another issue for breastfeeding is the lack of support for breastfeeding women, and this includes limited or no maternity protection, insufficient paid maternity leave, and a lack of government engagement and recognition of breastfeeding and its link to public health. Peer support is recommended by the World Health Organisation for initiation and continuation of breastfeeding. Recent research by Aimee Grant et al, from Cardiff University, found that services for breastfeeding peer support were inadequate.[12] A similar situation exists in New Zealand where there are patchy peer support services available.

There are many interlocking pieces in the puzzle of low lactation including clinical, iatrogenic, psychological, and the care women receive, and until we have more evidence and information to complete the picture, a tailored approach is necessary. This means grounded in up to date practice and care that boosts maternal confidence and promotes self-efficacy, where the individual woman’s situation is the primary concern, and if there are previous experiences of breastfeeding, these are taken into account.

Dahlen discusses “modern maternity care” and whether it has “morphed into a super trawler of risk, scooping up with its well-meaning ‘net’ the bycatch” – well and healthy women. [13] Promoting ante-natal colostrum harvesting to all pregnant women inevitably pulls low risk women into the ‘net’, and may contribute to increased levels of anxiety about milk supply. Some women with risk factors for low lactation are likely to benefit from harvesting colostrum in late pregnancy, and they also need ongoing support for the initiation and establishment of breastfeeding. Women without risk factors for low lactation need support for the development of their breastfeeding self-efficacy and confidence. Lauwers and Swisher discuss the medicalisation of breastfeeding and suggest that:

“It is incumbent on all who work directly with families to be a part of a solution in protecting breastfeeding, not part of the problem”[14]

[1] Forster, D. A., Moorhead, A. M., Jacobs, S. E., Davis, P. G., Walker, S. P., McEgan, K. M., Opie, G, F., Donath, S. M., Gold, L., McNamara, C., Aylward, A., East, C., Ford, R., & Amir, L. H. (2017). Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]: a multicentre, unblended, randomised controlled trial. The Lancet, 389:2204-2213.

[2] Stuebe, A. (2012). How often does breastfeeding just not work? Breastfeeding Medicine/Physicians blogging about breastfeeding. https://bfmed.wordpress.com/2012/10/15/how-often-does-breastfeeding-just-not-work/

[3] Niefert, M. R. (2001). Prevention of breastfeeding tragedies. Pediatric Clinics North America, 48(2):273-297.

[4] Ministry of Health. (2014). Diabetes in Pregnancy. Wellington, MOH.

[5] Brown, A. (2015). Milk supply and breastfeeding decisions: the effects of new mothers’ experiences. NCT Perspective, Issue 29, December.

[6] Otsuka, K., Dennis, C.-L., Tatsuoka, H., & Jimba, M. (2008). The relationship between breastfeeding self-efficacy and perceived insufficient milk among Japanese mothers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 37:546–555.

[7] Morton, S. M. B., Atatoa Carr, P. E., Grant, C.C., et al. (2012). Growing Up in New Zealand: A longitudinal study of New Zealand children and their families. Report 2: Now we are born. Auckland: Growing Up in New Zealand

[8] O’Brien, R. (2016). You get what you expect: low milk supply and psychology. https://rachelobrienibclc.com/blog/you-get-what-you-expect-low-milk-supply-and-psychology/

[9] Kirsch, I. (1997) Response expectancy theory and application: A decennial review. Applied and Preventive Psychology, 6(2):69-79.

[10] Stewart-Williams, S. (2004). The placebo puzzle: Putting together the pieces. Health Psychology, 23(2):198-206.

[11] Brown, A. (2016).What Do Women Really Want? Lessons for Breastfeeding Promotion and Education. Breastfeeding Medicine, 11(3):102-110.

[12] Grant, A., McEwan, K., Tedstone, S et al. (2017). Availability of breastfeeding peer support in the United Kingdom: A cross sectional study. Maternal and Child Nutrition, 13(3):e12476. https://doi.org/10.1111/mcn.12476

[13] Dahlen, H. (2014).Managing Risk or Facilitating Safety? International Journal of Childbirth, 4(2):66-68.

[14] Lauwers J., Swisher, A. (2011). Counseling the Nursing Mother: A Lactation Consultant’s Guide, 5th edition, p. 248. Sudbury, Jones and Bartlett.

 

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Marketing of breast-milk substitutes: National implementation of the International Code – Status report 2016

A recent comprehensive report by the World Health Organisation, UNICEF, and the International Baby Food Action Network (IBFAN), has revealed the status of national laws to protect and promote breastfeeding in 194 countries.[1] The World Health Organisation issued a media release on May 9th and commented that richer countries lag behind poorer ones in their implementation of the International Code. [2]

135 countries, out of the 194 analysed, have in place some form of legal measure related to the International Code of Marketing Breast-Milk Substitutes, [3] and subsequent, relevant World Health Assembly resolutions,[4] [5] and this number has increased by 35 since the last analysis which was carried out in 2011. The International Code had a birthday this year and is now 35 years old, so it is disappointing to note that only 39 countries out of the 194 reviewed have laws that enact all International Code provisions. The International Code, and the essential updates in the form of the World Health Assembly resolutions, are designed to not only protect breastfeeding by stopping inappropriate and misleading marketing of breast-milk substitutes, bottles and teats, but to also protect infants fed on breast-milk substitutes. All parents should have access to unbiased, commercial-free, information about infant feeding, and health professionals also need a source of unbiased, scientific and factual information.

To compile the Status Report 2016, countries were invited to respond to a questionnaire on Code implementation, and additionally IBFAN, the International Code Documentation Centre (ICDC), and UNICEF, reviewed and updated categorisation of information received about country practices and legal measures.

In the report New Zealand is one of the countries with no legal measures (Annex 1, p. 50) and although it is recorded that the Ministry of Health has formal mechanisms for monitoring the Code in place, which is noted to be transparent, independent, budgeted, empowered to take action, sustainable and monitored monthly to annually, the report states that it is not free of commercial influence (Annex 3, p. 62). Additionally the NZ monitoring mandate does not include retail shops or pharmacies and the report notes that although violations were recorded no sanctions were imposed (Annex 3, p. 63). As stated in the WHO media release, monitoring is essential to detect violations but it is important that these measures are fully operational and results should be published. Meaningful sanctions are also essential to reduce violations.

It seems timely to refer back to the recent Lancet Series on breastfeeding which contained the economic argument for breastfeeding, and the need for protection of breastfeeding and infant feeding, via the International Code of Marketing of Breast-Milk Substitutes. McFadden et al, called for a coordinated global action to combat inappropriate and misleading marketing. [6] WHO/UNICEF and IBFAN urge countries who have not yet adopted legal measures to do so. With the aggressive and misleading marketing of breast-milk substitutes continuing largely unabated, and a global sales revenue of US$44.8 billion, which is expected to rise to US$70.6 billion by 2019, this Status Report highlights the need for urgent action by governments now.

[1] World Health Organisation/UNICEF/International Baby Food Action Network. (2016). Marketing of breast-milk substitutes: National implementation of the International Code – Status report 2016. Geneva, WHO. http://www.unicef.org/lac/20160509_WHO_UNICEF_IBFAN_2016_Code_Status_Report_EN.pdf

[2] World Health Organisation. (2016). Laws to protect breastfeeding inadequate in most countries. Geneva. WHO Media Centre. http://who.int/mediacentre/news/releases/2016/breastfeeding/en/

[3] World Health Organisation. (1981.) International Code of Marketing of Breast-Milk Substitutes. Geneva, WHO. http://www.who.int/nutrition/publications/code_english.pdf

[4] World Health Organisation. World Health Assembly resolutions and documents: Infant and young child nutrition. http://www.who.int/nutrition/topics/wha_nutrition_iycn/en/

[5] International Baby Food Action Network. The Full Code. WHA Resolutions. http://ibfan.org/the-full-code

[6] McFadden, A., Mason, F., Baker, J., Begin, F., Dykes, F., Grummer-Strawn, L., Kenney-Muir, N., Whitford, H., Zehner, E., & Renfrew, M. (2016). Spotlight on infant formula: Coordinated global action needed. The Lancet, 387:433-435.

Cows & their milk do not live in a parallel universe, so support women to breastfeed, and at the same time let’s clean up the world #Regulation #Accountability #Breastfeeding

A recent article by Du, Gridneva, and Gay et al in the journal ‘Chemosphere’, ‘Pesticides in human milk of Western Australian women and their influence on infant growth outcomes: A cross-sectional study’, is about the levels of persistent organic pollutants in human milk.[1]

Highlights were reported as being;

  • Cross-sectional study of 88 POPs in human milk over first year of lactation.
  • p,p′-DDE was detected in 87.5% of the human milk samples.
  • No significant associations between p,p′-DDE and infant growth outcomes.
  • Estimated daily intake overestimates human milk POP concentration.
  • Human milk infant intake of DDTs is below the recommended daily intake guidelines.

And the abstract concluded with this;

“Furthermore, for the first time no significant association was found between p,p′-DDE concentrations in HM and infant growth outcomes such as weight, length, head circumference and percentage fat mass. The calculated daily intake was significantly different to the estimated daily intake of total DDTs and was well below the guideline proposed by WHO. The DDTs levels in WA have also significantly decreased by 42 – fold since the 1970s and are currently the lowest in Australia.”

So, good news – pollution of the environment, and human exposure to it, is reducing through the restriction of usage of some chemicals. Whether it’s fast enough and widespread enough is another question.

Why I’m writing this really is in response to the Alternet article, ‘Pesticide Levels in Breast Milk Have Dropped Significantly, but Health Concerns Remain.’[2] The article itself is quite good, given that it mentions not only human milk but also blood and urine, which is a good thing, as sometimes articles miss this point and readers can mistakenly construe that breast milk is the only fluid with an issue. But the article forgot to mention that babies are exposed to chemicals in utero and breastfeeding is really important as it mediates this exposure. So here are a few important points gathered together –

  1. Levels of pesticides in breast milk have dropped significantly over the past 40 years.
  2. Alternet doesn’t mention it, but breastfeeding actually mediates the exposure that has already occurred in utero, and breastfeeding/breastmilk supports the development of the infant immune system.
  3. This means that breastfeeding is still recommended and is optimal for infant feeding and infant growth, wellness and development.
  4. It Illustrates the positive impact banning pesticides can have on the health of individuals, especially vulnerable infants.
  5. And that’s the issue – the need to keep up the pressure to clean up our pesticide-riddled world as babies and small children, and their mothers, are exposed to hazardous chemicals through contact with products such as carpets, clothing, furniture, household and cleaning products, as well as those in food, the air and the soil.
  6. So, the chemical industries responsible, and the governments who fail to regulate them, need to be held to account.
  7. And, just to remind everyone – cows & their milk do not live in a parallel universe either, so feeding formula to infants is not the answer.

[1] http://www.sciencedirect.com/science/article/pii/S0045653516313777

[2] http://www.alternet.org/environment/pesticide-levels-breast-milk-have-dropped-significantly-health-concerns-remain

‘Why the politics of breastfeeding matter’ – Author Gabrielle Palmer -Book review

This is another excellent book from the ‘why it matters’ series from publishers Pinter and Martin. Gabrielle Palmer is well known for her ground-breaking book, The Politics of Breastfeeding, which was first written in 1988. Palmer is a nutritionist with a myriad of experience in the world of infant feeding, including working in Mozambique and China, supporting the establishment of the UK International Baby Food Action Network (IBFAN) group Baby Milk Action, and health and development agency work, including UNICEF. This new book is a condensation of the central concepts from the Politics of Breastfeeding, and it delves efficiently into the systems set up to sabotage the intentions of breastfeeding women, milk economics and the creation of a market that aggressively pushes breast-milk substitutes. It describes the differences between advertising and information provision, and also describes the International Code of Marketing of Breast-milk Substitutes.  This new book provides an accessible introduction into the corporate forces and vested interests that affect infant feeding decisions, with explanation of the historical underpinnings, as well as provision of an up to date, contemporary focus. The World Breastfeeding Week theme for 2016 was shaped around breastfeeding and sustainable development, and Palmer addresses climate change, dairy and environmental damage as part of her analysis of the costs of not breastfeeding. This revealing book is essential reading for all those who work with mothers and infants. It challenges us to rethink what we think we know about women’s infant feeding decisions, from the frame of simple, independent choices to a frame that recognises that the dice have been very loaded against breastfeeding women for a significant length of time.  Some mothers have been unknowingly situated at a distinct disadvantage, with great costs to their own health, their children’s health, society and the planet.

The International Code of Marketing Breast-milk Substitutes, dairy science fiction, and how health workers can make a positive impact in the world of infant and young child health.

The International Code of Marketing Breast-Milk Substitutes and subsequent, relevant World Health Assembly resolutions are a starting point for the consideration of ethics in the world of infant feeding. There is a surfeit of misleading marketing of breast-milk substitutes to parents who are often information hungry, unclear about the differences between breastfeeding and infant formula feeding, hoping to find the ‘best’ product for their babies, or thinking that they need to purchase the most expensive products. At the same time we read simplistic under-researched media stories that perpetuate the fantasy that breast-milk can be replicated and breastfeeding replaced. This dominant milieu influences the general public who may have limited awareness of marketing tricks. Because prime marketing strategy involves forming health alliances it is essential that health workers have a clear understanding of the issues of conflict of interest, endorsement by association and the importance of breastfeeding. It is also essential that they become sources of unbiased commercial-free information for parents on all aspects of infant feeding.

Key words: International Code, Breastfeeding, Breast-Milk Substitutes, Infant feeding, Infant formula, Marketing, Conflict of interest, Health workers, Price placebo, Puffery

We regularly see media releases heralding the scientific discovery of yet more amazing components in breast milk but most of the scientists quoted, if media reports are to be believed, appear to see their latest discoveries as a way to develop ingredients to add to cow’s milk formulas to make them closer to breast milk (Medical Xpress 2013). Regardless of this science fiction fantasy, because it is indeed a fairy story, the media perpetuate the news stories, usually without a balanced perspective, and industry continue to make misleading claims about their products already on the market. As all infant formula products are required to meet legislated criteria regarding ingredients, the nutritional composition of the majority of products is exactly the same. Kevin Frick notes that companies use substantial resources to differentiate themselves from each other for the purpose of competition. This monopolistic competitive quest for parental attention, which is inappropriate due to the vulnerability of infants and the critical importance of what they are fed, results in a market not operating efficiently to provide goods at minimum cost, with the benefits to infants of this broad range of products being unclear (Frick 2009). The International Code of Marketing Breast-Milk Substitutes (World Health Organisation 1981), and subsequent, relevant World Health Assembly resolutions provide the framework necessary to control misleading health and nutrition claims but the majority of countries do not have regulations or legislation in place to enforce the Code. Instead many allow industry to write, monitor and enforce their own voluntary codes of practice.

The International Code of Marketing Breast-Milk Substitutes is a set of recommendations from the collective membership of an international body in the field of health, the World Health Assembly. It does not ban the sale or use of breast-milk substitutes, or any particular company’s products, but instead it is directed at unethical marketing practices, and false and misleading advertising. The Code is also clear that there are legitimate reasons for using breast-milk substitutes, and it is concerned that parents who use breast-milk substitutes have access to accurate, safe and unbiased information. The International Code always needs to be considered alongside the subsequent, relevant World Health Assembly (WHA) Resolutions as they keep the Code, which was written in 1981, up to date. In 2010 a WHA resolution item,11.6, called for an end to the inappropriate promotion of food for infants and young children and highlighted the need to ensure that nutrition and health claims shall not be permitted for foods for infants and young children (Baby Milk Action 2010; World Health Assembly 2010).

The vulnerability of infants in the early months of life and the risks involved in inappropriate feeding practices underpins the International Code and this is described in the preamble to the Code. It is this infant vulnerability which makes the usual marketing practices we are exposed to relentlessly in our everyday 21st century lives, unsuitable for breast-milk substitutes.

There are a range of marketing messages tailored to appeal to parents with claims about immune system development support, beneficial gut flora support, brain development and abilities to solve infant feeding problems. However, robust independent scientific evidence for the efficacy of added novel functional ingredients is limited and unclear (Ackerberg 2012; Schulzke et al 2011; Simmer et al 2011; Starling 2010; Vy 2002; Yau 2003). A parent, Roberta, who is a Momsrising member, posted about what she termed “New Parent Infant Formula Selection Paralysis” (Farber 2010).

“The few times I had to buy formula for my son, I was paralyzed by the wall of options in the grocery store. Each brand made a different claim about what their formula would do for my son’s health, and the more claims there were, the more expensive the can. Even my son’s paediatrician couldn’t recommend a choice”.

In marketing there is a phenomenon called price placebo which is based on consumers believing that if they pay more for a product then it means it must be a better product. So at the same time parents using breast-milk substitutes are trying to decide which product to buy for their babies they are not only influenced by health and nutrition claims but by price, and they are likely to buy the high-price-high-claim products. Some parents who find it hard to afford the breast-milk substitutes for their infants, have been found to practice what is referred to as ‘formula-stretching’ which involves reducing feed amounts/times and/or watering down feeds. Formula stretching practices are associated with serious short and long-term consequences such as failure to thrive and developmental deficits (Burkhardt et al 2012). Burkhardt et al also found that 58% of the urban parents in their study would not use the cheaper generic formulas, and 50% believed that generic formulas and brand name formulas were not equivalent. The reason for this is simple – marketing.

The aim of commercial marketing is to eliminate choice or to establish a strong bias towards only one choice, rather than to increase the choices for consumers (Heinig 2006). The ultimate aim being to increase profits for your shareholders by giving consumers the impression that they need your product, and in the case of breast-milk substitutes, that parent consumers need to continue to use product for longer than recommended by global infant feeding guidelines.

Berry et al in Australia, found that toddler milks function as indirect advertising for other breast-milk substitute products such as those marketed for infants below six months –stage one – and those marketed for above six months to one year – follow-on products (Berry et al 2010). Neither the follow-on, nor the toddler products are necessary, as infants can continue up to one year on the ‘from birth’ products and after one year infant formulas are not needed as cow’s milk is considered appropriate for the majority of toddlers.

The reach of marketing has expanded significantly with the explosion of social media and sites such as Facebook and YouTube. Abrahams found that out of the eleven brands she examined, eight had Facebook pages and five a YouTube presence (Abrahams 2012). This is significant because of the reach of social media but also because of the difficulties in both monitoring and regulating this relentless marketing.

Parents buying breast-milk substitute products making health and nutrition claims are being exposed to what could be termed a form of puffery. Puffery on consumer products is recognized and accepted by industry, regulators and consumers and is described as being about the legitimate and harmless exaggeration of advertising claims to overcome natural consumer scepticism and to make a product look better than those of the competing brands. Because the claims in ‘puffery’ are described as being vague and subjective, they are not believed to be misleading to most consumers. The assumption is that consumers expect advertisers to claim that their products are the best but that they will not believe this to be true (Adams & Maine 1998).

Winstanley & Cressey reported that parents taking part in a survey about the preparation of powdered infant formula in New Zealand were ‘information hungry’ and that the information on the infant formula tin seen was seen as ‘available, authoritative and trusted’. Although the report was primarily concerned with how parents were interpreting instructions and preparing feeds it did find that some parents avidly read about ingredients and the differences between brands. One parent considered the information on the tin as a ‘legal document written by experts’ and another stated that the ‘tins did not lie’ (Winstanley & Cressy 2008). As previously described, the Code preamble clearly states that the marketing of breast-milk substitutes requires special treatment, which makes the usual marketing practices unsuitable for these products, and the assumed ‘harmless exaggeration’ is unlikely to be harmless and is therefore totally inappropriate.

Health professionals need to know about the International Code and resolutions, but they also need to consider issues such as sponsorship, conflict of interest and endorsement by association. Conflict of interest is defined as a situation in which financial or other personal, employment or professional considerations have the potential to compromise or bias professional judgment and objectivity. The International Baby Food Action Network, in their position statement concerning sponsorship and conflict of interest, ‘call upon all health care workers, including health professionals and their associations, to avoid accepting any donations or funds, offers of assistance in cash or kind from companies with a commercial interest in infant and young child health and development, particularly in the feeding of babies’ (IBFAN).

Health professionals who work with parents, infants and young children need to know about all aspects of infant and young child feeding, understand the responsibility to protect breastfeeding, and also provide non-judgmental information about the use of breast-milk substitutes to parents who require this information. There is no dispute about the value of research which could lead to an improved breast-milk substitute. However, perpetuating mythology and making claims suggesting that breast milk, containing around 150 long chain polyunsaturated fatty acids, 130 oligosaccharides, lymphocytes, secretory IgA, lactoferrin, lysozyme, nucleotides, hormones, growth factors and the recently reported over 700 beneficial bacteria, just to name a few of the components of human, living, synergistic breast milk, can ever be replicated is pure science fiction. Unfortunately as explained by Lewandowsky et al, repeated exposure to a story or statement is known to increase its acceptance as ‘true’ (Lewandowsky et al 2012), so continued work is necessary to counter misleading media reports. Davies also highlights another ever increasing concern, ‘churnalism’. This is when journalists no longer gather news but instead passively process whatever material comes their way (Davies 2009). Hence we see inaccurate, unbalanced, under-researched stories echoed all around social media sites and the internet.

Learning more about the International Code and resolutions helps to keep the policy issues on infant and young child feeding alive internationally, and at national and local levels, and provides the understanding needed for health workers to become advocates and watchdogs in regards to breastfeeding protection, safe infant feeding and formula usage and appropriate marketing. It would be valuable for health workers involved with infant feeding to support breastfeeding protection and safe infant feeding advocacy work by reporting Code violations to the appropriate monitoring bodies, keeping up to date with what is happening in the world of breast-milk substitutes and countering inaccurate stories doing the rounds in the media. Each contribution is important for infant and young child health. As Martin Luther King Jr said, You don’t have to see the whole staircase. Just take the first step”.

References

Abrahams SW (2012). Milk and social media: Online communities and the international Code of Marketing of Breast-milk Substitutes. Journal of Human Lactation, 28:400-406.

Ackerberg TS Labuschagne IL & Lombard MJ (2012).The use of prebiotics and probiotics in infant formula. S Afr Fam Pract, 54(4):321-323.

Adams D & Maine EL (1998). Business Ethics for the 21st Century. Chapter 7, Advertising and Marketing. Mountain View California, Mayfield Pub.

Baby Milk Action (2010). http://info.babymilkaction.org/pressrelease/pressrelease22may10

Baby Milk Action http://www.babymilkaction.org/ (For reporting Code violations)

Berry N Jones S C & Iverson D (2010). “It’s all formula to me”: Women’s understandings of Toddler Milk ads. Breastfeeding Review, 17(3), 21-30.

Burkhardt MC Beck AF Kahn RS et al (2012). Are our babies hungry? Food insecurity among infants in urban clinics. Clinical Pediatrics, 51, (3):238-243.

Davies N (2009). Flat Earth News: An Award-winning Reporter Exposes Falsehood, Distortion and Propaganda in the Global Media. London, Vintage.

Farber K (2010). Formula companies can discourage breastfeeding: Take action with Momsrising. http://www.non-toxickids.net/2010/07/formula-companies-expensive-claims-can.html

Frick, KD (2009) ‘Use of economics to analyse policies to promote breastfeeding’, in F Dykes & V. H Moran, Infant and Young Child Feeding: Challenges to implementing a global strategy, Oxford: Wiley-Blackwell Publishing Ltd.

Heinig MJ (2006). The International Code of Marketing of Breastmilk Substitutes: The challenge is choice. Journal of Human Lactation, 22,(3):265-266

International Baby Food Action Network (IBFAN). Position statement on sponsorship and conflicts of interest. Accessed via www.ibfan.org/art/91-1.pdf

Lewandowsky S Ecker UK H & Seifert CM et al (2012). Misinformation and its correction: Continued influence and successful debiasing. Psychological Science in the Public Interest, 13,(3): 106-131.

Medical Xpress (2013). http://medicalxpress.com/news/2013-01-breast-bacteria-microbes-infant.html

Schulzke SM Patole SK & Simmer K (2011). Long-chain polyunsaturated fatty acid supplementation in preterm infants. Cochrane Database Systematic Review. http://www.ncbi.nlm.nih.gov/pubmed/21328248

Simmer K Patole, SK & Rao SC (2011). Longchain polyunsaturated fatty acid supplementation in infants born at term (Review). Cochrane Database Systematic Review. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000376.pub3/abstract;jsessionid=3D81A03678062194BD7E7E8926B4869F.d03t04

Starling S (2010). EFSA rejects Daone’s infant immunity prebiotic claim. http://www.nutraingredients.com/Regulation/EFSA-rejects-Danone-s-infant-immunity-prebiotic-claims

Winstanley A & Cressey P (2008). Information sources and practices – preparation of powdered infant formula in NZ. Report prepared as part of a New Zealand Food Safety Authority contract for Scientific Services by Institute of Environmental Science & Research Limited.

World Health Assembly (2010). 63rd WHA May. Infant and young child nutrition

World Health Organisation. (1981). The International Code of Marketing Breast-Milk Substitutes. Geneva, WHO.

Yau K Huang C Chen W et al (2003). Effect of nucleotides on diarrhea and immune responses in healthy term infants in Taiwan. J Pediatr Gastro Nutr, 36:37–43.

Vy Y (2002). Scientific rationale and benefits of nucleotide supplementation of infant formula. J Paediatrics Child Health, 38(6):543-549.

Infant feeding bottles, infant feeding & consumer protection

Infant feeding bottles, infant feeding & consumer protection

A few thoughts about the infant feeding bottles with inaccurate markings issue – yes, it’s an ‘old’ story in New Zealand but one that’s bugged me for a while.[1]  [2] Let’s unpack this and look at some other associated issues at the same time.

Starting with the history – after health workers expressing concern that measurements on some infant feeding bottles were inaccurate, this issue became ‘live’ in New Zealand in 2013, with informational, warning notifications to health workers about the issue, accompanied by media releases. This information outlined the dangers of too dilute or too concentrated feeds and suggested that parents take their bottles to a pharmacy for a measurement check, with the added note that pharmacists could charge for this service.

Now firstly, issues are NOT just confined to the measurements on the bottles and the powder scoops to water ratios, even though this is important. Consumer Affairs point out that some bottles overestimate the fluid volume by up to 40 percent and that may have serious health consequences for infants.[3]  Even though media messages at the time suggested ‘all’ ‘we’ needed to do was make sure the measurements were correct and all risk would be reduced, this is quite clearly not the case. Although the formula industry would like the world to believe that a parent making up a feed correctly is the only issue, the research evidence about infant & young child health would quite significantly beg to differ.

Secondly – health workers such as midwives and nurses in maternity facilities are there to support ALL parents with ALL aspects of infant feeding – the protection, promotion and support of breastfeeding AND ensuring parents using infant formula/bottle-feeding have access to non-judgemental support and information about how to prepare bottle feeds/reconstitute powdered infant formula as safely as possible. Lead maternity carer midwives and Tamariki Ora Well Child Nurses continue the support for parents in their own homes. Are we really suggesting that the pharmacy is the only place where parents can get support with feeding bottles?

I’m pretty sure that midwives and well child health nurses would see checking the feeding bottle, if necessary, as being part of the essential information and support that they could give to families using infant formula/baby bottles. All it takes is a plastic syringe and some water. Do parents really need to go to pharmacies to get their bottles checked where they may also be charged a fee and potentially steered towards expensive bottle purchases? I don’t think so.

Another related issue – mothers who are expressing breast milk for their babies who are concerned about the accurate measurements of amounts being expressed, or being given to their babies. If you are a mother with a baby in a Neonatal Intensive Care Unit – you can be pretty certain that the amounts given to your premature or unwell baby will be measured accurately in the NICU so no need to add another worry into your life about bottles. Many NICUs use sterile, liquid ready to feed products as well. If women are expressing breast milk for a well baby at home the slightly inaccurate measurements on any bottles being used for expressed breast milk really don’t matter.

However, a serious issue related to scoops and water amounts, is the one of formula stretching. Nothing to do with bottle-markings but a lot to do with poverty – but wait, bottle markings do have something to do with poverty. Parents who are struggling with a low income do not tend to purchase the expensive feeding bottles which are more likely to be standardised with accurate measure markings, but the very cheap ones instead with inaccurate markings. These parents are also unlikely to pop into a pharmacy where there may be a charge for a bottle check.

But, back to formula-stretching; a study of families in the US in 2012 found that both food insecurity and formula stretching were common. [4]  Formula stretching happens when parents try to make formula powder last longer and they hold back feeds or dilute them to the detriment of nutrition and infant development. One of the issues mentioned in this US study was that parents bought expensive branded formula products and saw the cheaper generic products as not being equivalent.  Formula literacy can be elusive in the face of misleading industry marketing, but parents using formula should know that they do not need to purchase the expensive products, nor do they need to use any formula milk after their babies reach one year of age. Most unlikely they will get this information from industry of course – just more misleading health claims tempting parents towards the more expensive products and enticements to use formula products for longer than necessary (if formula feeding the formula is only necessary until the infant is one year old and a stage one product is suitable for that year).

Industry should not be providing feeding information of any kind to parents as they have an obvious commercial interest. Health workers need to get up to speed here, but they need support and access to good information themselves. In the UK it’s easy as the excellent First Steps Nutrition Trust provides all the information needed about the infant milks on the market. [5]

But wait – there’s more – one of the FAQs about inaccurate measurements on bottles does ask a pretty reasonable question about why do we (NZ) allow these faulty products that could harm babies into the country at all? This is a very good question. The Ministry of Business, Innovation and Employment says that this issue falls outside of the scope of current consumer law; “The provisions of the Fair Trading Act 1986 allow mandatory standards relating to products which may cause injury. Baby bottles which do not meet the EN14350 standard are not in themselves unsafe, rather they may have the potential in some cases to lead to adverse health effects.” [6] At this point I need a cup of tea and a lie down due to serious head banging activities. We can’t protect our babies from companies making faulty products? The smallest and most vulnerable of consumers?

I spotted a media report a few days ago from Canada about a self-feeding baby bottle. Health Canada announced a recall of an ILLEGAL hands-free baby bottle system. [7] Yes, illegal. “Products that position infant feeding bottles and enable infants to feed themselves without supervision are prohibited by law, Health Canada said, adding that babies could choke or inhale the liquid in the bottles. Unattended infant feeding practices are discouraged by Health Canada and Canadian professional medical associations the alert said.” [8] I may be out of order here, but I have searched for a similar regulation in New Zealand without success. Feel free to inform me if I am wrong – that snippet of news would be very welcome.

So, in the end there’s more to be concerned about alongside baby bottle-markings. Recently in New Zealand we’ve had another scare about contaminated formula powder (to add to the real melamine tragedy, the terrifying botulism concern, the nitrates worry, and the fertiliser aid dicyandiamide (DCD) in milk powder). This latest concern is related to an individual, or individuals, [who must be seriously deranged], threatening to add the poison 1080 to infant formula powder. No 1080 has been found yet in any products but this threat has been terrifying for parents using formula products. Suddenly the tins on the supermarket shelves have their own rather bored bodyguards (young employees who have to stand next to the shelves watching the formula tins), there are big signs telling parents how very safe formula products are and reassurances about all the checks the ultra-processed baby food goes through from the cow to the shelf. Worried parents have found suspicious looking defects in the foil lids but no contamination of 1080 in any of these tins has been found, thank goodness. I thought it interesting to note there were quite a few processing issues blamed for these faulty looking products– but nobody pursued that manufacturing concern.

Another thing never mentioned is that the powder in the tins is not actually sterile. I noted a recent media report from the UK where a baby was admitted to hospital with a serious campylobacter infection and parents said the baby’s diet was just one brand of formula.[9] In a media statement the company involved said that “the milk was pasteurised and heat treated to very high temperatures.” That would reassure parents and make them think it was a sterile product wouldn’t it? But the company is talking about the MILK, not the end result powder. Formula powder cannot be sterilised as the temperature would destroy some ingredients. That means that contamination with bacteria such as chronobacter sakazakii, campylobacter and salmonella is possible during the many processing stages. If the feeds are made up and used correctly then any bacterial contamination will be dealt to, but in many countries parents are not given the correct information and it’s certainly not on the tins I’ve looked at in New Zealand. Here’s a link to the real story from the World Health Organisation where it explains clearly why the temperature of the water used to reconstitute the non-sterile powder needs to be at 70 degrees centigrade.[10] Some countries, including the UK, are following these optimal recommendations. [11] [12]

In 2013 I had a look at the products on the shelves in some NZ supermarkets (I wouldn’t want to be doing this now). In total I examined the labels on nine different companies’ tins. Instructions ranged from stating fresh or safe drinking water should be boiled and allowed to cool, to instructions stating that water temperatures should to be from 40 to 60 degrees C, but despite the diverse range of instructions not one was optimal. There is also no such thing as a standard scoop across all brands, so scoop-water ratio varies from brand to brand.

It’s time for a re-examination of the recommendations for making up a powdered formula feed in New Zealand, and time to look at consumer protection laws and regulations with infant advocacy and protection in mind.

Oh, BTW, avoid Googling ‘scoops of formula.’ It’s not very helpful, you get ‘extra scoops’, ‘3 scoops’, ‘5 scoops’, and ‘per ounce.’ Talk to a midwife or well child nurse about infant feeding concerns, scoops and bottle measurements. Check out First Steps Nutrition Trust as well for some great information. [13]

References

[1] Ministry of Health. (2013). Inaccurate volume markings on baby feeding bottles. http://www.health.govt.nz/our-work/preventative-health-wellness/nutrition/inaccurate-volume-markings-baby-feeding-bottles

[2] Inaccurate baby bottle markings. (2013). Media release. http://www.health.govt.nz/news-media/media-releases/inaccurate-baby-bottle-markings

[3] Consumer Affairs. Inaccurate baby bottle markings. http://www.consumeraffairs.govt.nz/news/product-safety-alerts/innacurate-baby-bottle-markings/?searchterm=baby%20feeding%20bottles*

[4] Burkhardt, M. C., Beck, A, F., Khan, R. S., & Klein, M. D. (2012). Are our babies hungry? Food insecurity among infants in urban clinics. Clinical Pediatrics, 51(3):238-243.

[5] First Steps Nutrition Trust. (2015). Infant milks in the UK: A practical guide for health professionals. http://www.firststepsnutrition.org/newpages/Infants/infant_feeding_infant_milks_UK.html

[6] Ministry of Health NZ. Questions and answers on inaccurate markings on baby bottles. http://www.health.govt.nz/our-work/preventative-health-wellness/nutrition/inaccurate-volume-markings-baby-feeding-bottles/questions-and-answers-inaccurate-markings-baby-bottles#mandatory

[7] Health Canada. (2015). Bed Bath & Beyond Canada L.P. recalls Podee® Hands Free Baby Bottle System.

http://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2015/52717r-eng.php

[8] Bed Bath & Beyond recalls illegal self-feeding baby bottle

http://cnews.canoe.ca/CNEWS/Canada/2015/03/30/22317326.html?cid=rssnewscanada

[9] Aptamil infant formula linked to UK Campylobacter case given all clear at plant. http://www.dairyreporter.com/Regulation-Safety/Aptamil-infant-formula-linked-to-UK-Campylobacter-case-given-all-clear-at-plant

[10] World Health Organisation. Safe preparation, storage and handling of powdered infant formula: Guidelines. http://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf

[11] NHS Choices. Making up infant formula. http://www.nhs.uk/conditions/pregnancy-and-baby/pages/making-up-infant-formula.aspx#close

[12] NHS Guide to bottle feeding: How to prepare infant formula and sterilise feeding equipment to minimise the risks to your baby. NHS, UNICEF UK, The Baby Friendly Initiative, Start for Life. http://www.unicef.org.uk/Documents/Baby_Friendly/Leaflets/guide_to_bottle_feeding.pdf

[13] First Steps Nutrition Trust Homepage http://www.firststepsnutrition.org/