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Wednesday, August 13, 2014

When breastfeeding arguments aren't actually about breastfeeding (Part 2: "No babies" is not anti-breastfeeding discrimination)

A few weeks ago, I talked about the way in which stories about unsafe sleeping practices and child welfare issues sometimes get distorted into "breastfeeding stories" by the media, partly perhaps to create extra controversy and attention. Sometimes, however, it's mothers themselves who create the controversy by using the banner of "breastfeeding discrimination" as a way of getting to do things that they want to do.

Harassment of breastfeeding mothers is common enough that most mothers respond with sympathy when they hear stories about being kicked out of somewhere for nursing. However, as one poster on the Chelsea Flower Show discussion put it, "Not everything involving the words 'Breastfeeding' and 'No You Can't Do That' is discriminating."


Laws against breastfeeding discrimination typically protect the mother's right to breastfeed her child anywhere where she and her child are permitted to be; a closer look at the above instances reveals that the problem was basically the presence of the child, not the way milk was being transferred. Having a baby in your lap amidst risks of dropped scissors and hair splinters is not ideal (there are reasons why hairdressers don’t wear open-toed shoes). It’s not sensible to bring a small child to the almighty crush that is the Chelsea Flower Show—hence the no-under-5s rule. Babies don’t—usually—belong at training days, classes or working conventions. Then there’s the issue of obstruction when someone plonks themselves down to feed in, say, a supermarket aisle, or takes up a changing room when there’s a queue of people waiting. Rule of thumb: if it’d be obnoxious/dangerous to bottle-feed your child in Situation X, it’s probably rude to breastfeed there as well.

Where it gets a bit complex
But of course it’s more complicated than that. You see, there is also the argument that any rules excluding babies from any particular place constitute a kind of indirect discrimination against breastfeeding mothers ("disparate impact") because separation of mother and baby is inherently more complicated—or perhaps impossible—for breastfeeding dyads than for formula feeders. From the Chelsea Flower Show thread: “The discrimination comes [in] because a mother cannot go if she cannot take her child because the child will need to be fed from her and her alone.

 A breastfeeding mother is more affected by this rule than a ff one, the father of the same child or a mother of older children. Therefore it is discriminatory.”

This emphasis on the idea that separating the breastfeeding dyad for any length of time is cruel and unusual seems to be commoner among British and Australian etc. mothers, because the wide availability of maternity leave means that few mums of young babies work outside the home. Mat leave is mostly a good thing; the downside is that bottle refusal is widespread, and a general feeling that Breastfed Babies Cannot Be Left For Any Length Of Time has perhaps grown up in these countries. On Mumsnet, for example, a surprising number of posters seem to feel that leaving a 6mo for just a couple of hours is basically impossible because "the baby is exclusively breastfed."
If a mother wants to do something that’s against the rules (like bringing a baby to a childfree event), perhaps because she lacks childcare or has strong views on attachment parenting, it can be tempting to make the situation into a "breastfeeding issue" because it's a way of getting attention and support from breastfeeding organizations and advocates via social media (by contrast, there is no equivalent of Kellymom or La Leche League for parents who are facing childcare difficulties).

But this comes at a cost. One problem is that “crying wolf” like this will inevitably encourage skepticism about real cases of breastfeeding discrimination. We’re seeing more and more cases where complaints about harassment of breastfeeders are being met with cynical comments about how "I'm sure there is more to this story than meets the eye" and "Well, in my experience, breastfeeding women only meet with negativity when they are going out of their way to cause trouble." Women really are still getting kicked out of places for breastfeeding; the last thing we need is a backlash.

I do understand, sort of, why many breastfeeding advocates tend to be at pains to stress the difficulty of separating a breastfeeding mother and baby; it’s probably partly about advocating for attachment parent-y stuff, but a lot of it is also probably to do with the arguments about breastfeeding in public.

Whenever someone is kicked out of somewhere-or-other for breastfeeding in public and uproar ensues, there’s always one bright spark who decides (with clunkingly heavy sarcasm) to "enlighten" us all: "Hey, newsflash! Did you know that they make these things called BREASTPUMPS nowadays?? Why don't you pump a bottle before you leave the house so you won't have to flop your boob out in public? Or leave your baby at home when you go out? Or feed before you leave the house?" Breastfeeders then point out (reasonably) that pumping is time-consuming and not possible for everyone, that not every baby accepts a bottle, that sometimes babies need a feed at an unexpected time, and that insisting that mothers arse around with pumps simply in order to leave the house is really stupid, and can put off women who might otherwise have given breastfeeding a try.

But you can also set up barriers of a different kind if you go too far in the other direction--i.e. dwelling incessantly on the notion that a breastfed baby basically cannot be left, ever (even for short periods), that introducing artificial teats will doom the breastfeeding relationship, that babies are basically perma-suctioned onto you cluster-feeding round the clock and it's impossible to have any sort of a routine--for a year or so, mind you, not just the first few weeks. I mean, I'm imagining I’m a mother-to-be who lives in an area where formula feeding is normal but is thinking about giving breastfeeding a try, and I'm reading the above description. Honestly, I think I'd be running to the supermarket to buy a crateload of Aptimil. Who on earth would want to feed a baby in a way that sounds like a How-To guide for giving yourself post-partum depression? And it's just not true, dammit. Most breastfed babies will go back and forth from bottle to breast; if they don't, you can do a cup or spoon; if they're at least four months you can spoonfeed a bit of food; and you can absolutely breastfeed on a routine if/when you want to.

I do understand that the minority of women who are unable to pump at all really do have problems leaving their babies for more than, say, three hours or so, but implying that this is the norm is disingenuous. Some women choose to breastfeed 100% on demand for months AND delay solids for a long time AND not introduce a bottle or cup, and this really will make separation tricky; they have every right to feed like this if they choose, but it’s misleading to suggest that this is the standard way to breastfeed or that breastfeeding will somehow not “work” if you don’t do things this way.

Separating mother and baby is always a little more complicated for breastfeeding, while formula feeding is more inconvenient when you are on the run. That doesn’t mean that establishments which fail to provide 70-degree water on tap and cartons of formula from vending machines are discriminating against formula feeding, nor does it mean that situations requiring a short separation of mother and baby are discriminating against breastfeeding. As one of the posters on the Chelsea Flower Show discussion puts it: “Choosing to breastfeed is a parenting choice that you made. It will have some consequences, the same as formula feeding does.”

Friday, June 27, 2014

Why I am (surprisingly) in favor of banning the bags

Increasing numbers of American hospitals seem to be "banning the bags" these days--that is, abolishing their long-established habit of handing out free samples of formula to mothers on maternity wards. The "Ban the Bags" campaign has engendered a lot of debate, with most breastfeeding advocates strongly in favor, and many formula feeding advocates skeptical or somewhat offended. Not surprising, really: "Ban the Bags" very often comes hand-in-hand with measures which have upset many formula feeders, such as harassing or pressuring mothers who choose to bottle-feed. The Baby Friendly Hospital Initiative (BFHI) has been a case in point here. I have "issues" with several bits of the BFHI, as I'll be discussing in a future post. However--perhaps somewhat surprisingly--I'm still inclined to be in support of banning the bags. Here's why.

Paying for the label
The formula samples American families receive in hospitals and doctors' waiting rooms are invariably branded formulas, such as Gerber, Enfamil and Similac. You can buy these at the store, too, but big stores also sell "generics" (store brands) such as Walmart's Parent's Choice. British readers probably won't be familiar with generic formulas, but basically it's like when you're in Superdrug and you could buy either Calpol or Superdrug's own paracetamol suspension. It's just as good a product, but has a less prestigious label (and price tag) on it.

Generic vs brand formula is basically the same deal. All formulas in the States are required to meet strict, identical standards in terms of ingredients, processing requirements and so on. If you have a moment, go to the first link in the "Further reading" section below, and check out the lists of ingredients in generic formulas versus the fancy-pants ones: you'll find that each generic formula is basically identical to its brand equivalent. The various companies are also required to follow identical rules as to the quality and sourcing of each ingredient.

This is not to say, incidentally, that "all formulas are exactly the same"--they're not. There's cow's milk, goat's milk, soy, elemental, there are different levels of iron, there are different whey to casein ratios, there are things like DHA and probiotics which may or may not be added--but the thing is, whatever permutation you are looking for--say, "I want a soy-based formula with added DHA"--you can almost certainly find that option in either a brand or a generic form, and they're both equally good (I think there are fewer organic generic options, but some have appeared in recent years). There is no particular reason to purchase a brand formula unless you actually have found that your child does poorly on the generic option and seems to be better suited to the brand one when you try it out. Otherwise, it's as pure an example of "paying for the label" as you're likely to find. And the price differences are substantial; added up, we're talking anywhere between UD$400 and UD$700 a year. Double that if you have twins. This can be particularly hard on parents who fall into that unsweet spot of being poor yet not quite poor enough to qualify for income support programs or free formula supplies. Worryingly, parents who struggle to pay for formula sometimes try to "stretch" it through over-dilution or feeding leftovers from the last feed.

Where your money goes if you buy a brand formula
even though your baby does fine on generic.
 Yes, this is my kitchen. No, it isn't normally as clean as this. 

Can I trust my doctor?
The other casualty here is the credibility of healthcare professionals. Most of us think of doctors as authority figures, so when someone at a hospital or pediatrician's office gives you something, they are--whether this is intended or not--effectively endorsing the product with an unspoken message of "I, as a medical professional, believe that this product is the best thing for you, based on scientific evidence." When that kind of endorsement is being applied to a product whose high price tag is not justified by any superiority of quality, as a result of what is basically a commercial marketing tie-up with a corporation.... well, I find that tacky and also borderline unethical. And yes, I know this is far from the only case of this kind of thing happening--doctors also recommend brand-name drugs over generic versions to patients all the time (and I don't think they should do that either). But doing this stuff to new parents seems like a particularly low trick, given how vulnerable new parents are to marketing that appeals to fear.

Fear is probably the strongest emotion that most of us feel as we take our tiny, precious newborns home with us--that, and a desperate desire to do absolutely anything that might, possibly, help to keep them safe, whatever the cost. (This post comes to you from the woman who gave her baby her first bath at home in bottled water because I was convinced that radiation in the tapwater was going to give her cancer.... or something. Yes, really.) Doubly so for women who really wanted to breastfeed and are now writhing with guilt. Plus, once you have finally succeeded in getting your newborn to feed normally, poo normally and sleep at least fitfully on Brand A formula, you really, really, really don't want to start switching to Brand B. For all these reasons, parents who have been started on Enfamil or what-have-you at the hospital are highly likely to keep on using it.

When people shun vaccines and other conventional medicine recommended by the medical profession, one reason invariably cited for doing this is "You can't trust doctors, because they are shilling for pharmaceutical companies." The idea that the standard vaccine schedule is based on doctors' desire to get free mugs and ballpoint pens from Pfizer and AstraZeneca is bizarre, but when the medical profession falls into the habit of endorsing products based on a commercial rather than scientific rationale, it just doesn't look great. With so many voices out there encouraging parents to mistrust and shun conventional medicine, it's really important that doctors and other healthcare professionals ensure that all their recommendations are ethical and evidence-based.

And it also doesn't help that a high percentage of pediatricians and doctors are also actually recommending branded formulas to families and steering them away from generics--based on precisely zero evidence--which makes me wonder whether the presence of all those attractively packaged samples and freebies is also having a kind of subtle subliminal effect on medical workers' thinking too. Doctors are only human, after all. It's often said (with some truth) that "doctors and pediatricians tend to be clueless about breastfeeding" but looking at articles like this one (check out the comments on generic formula by the vice-chair of Pediatrics who is quoted) makes me feel that some of them could do with a bit more education about bottle-feeding as well.

Formula = Breast pads
Perhaps one's feelings about "Ban the Bags" will depend on where one is coming from (literally). If you are American and have grown up with the idea of formula bag freebies, not having samples is likely to feel like having something taken away and also like an attack on one's choices. For people (like me) from the UK or Australia, where infant formula samples aren't handed out anyway, there is a sort of vague feeling of "Huh? Why would one expect freebies in the first place? This is just being neutral. Nobody's stopping you from buying your own formula if you want it." Nobody should ever be harassed for feeding choices, but I don't think "not giving a freebie" amounts to harassing women for formula feeding any more than my hospital's failure to provide me with free breast pads, nipple cream and nursing aprons could be considered disrespecting my choice to breastfeed. 

How about just handling formula in hospitals in the same kind of way we handle other maternity-related supplies, like breast pads? What that would mean in practice will depend, ultimately, on how your hospital/healthcare system/insurance coverage works. If a hospital is in the habit of providing products like breast pads, diapers and sanitary protection for free, there's no reason it can't provide formula as well--but it should be providing generic formulas that meet the requirements of food regulation authorities, not overpriced brand versions, and not as part of marketing or commercial tie-ups. If, on the other hand, a hospital expects mothers to provide their own sanitary protection, breast pads and so on (as did my hospital), it's perfectly reasonable to expect them to bring their own formula to the hospital as well, if they choose to formula feed. If a woman runs out of formula or if a breastfeeding mother needs formula or changes her mind, the hospital can provide her with generics, and add the cost to her hospital bill at the end--just like if you ran out of nipple creams or diapers. And yes, hospitals should be supplying low-priced generic breast pads and diapers too, as long as these do the job as well as the fancy brands.

By the way, there is definitely nothing wrong with formula companies posting free samples of Similac or whatever to families who email them with a request, but this should be based on an informed decision. It would be good if prenatal infant feeding education gave clear, science-based information on formula, including discussing the fact that generic formulas are not inferior to the brand versions. 

In summary, while there are reasons to be concerned about certain aspects of the BFHI, there is also a sound rationale for getting rid of the practice of having medical institutions pushing marked-up brand formulas at parents without any scientific basis for the inflated cost. Instead of handling formula like either an illicit substance or a money-spinner for companies, let's handle it like what it is--a babycare product--and in a manner that's neutral and science-based. Doing so will not only result in better support for both breastfeeding and formula feeding families, but can also help ensure that the medical profession maintains the respect and trust of parents.

Further reading
Supplement to Consultant for Pediatricians (February 2014): A Comprehensive Overview of Store Brand Infant Formula/Guiding Parents in Formula Selection: How Do Store Brands Compare to National Brands?  This easy-to-read supplement is worth a look. It also has a big, colorful table where you can look at the ingredient comparison for yourself.

Thursday, June 19, 2014

When breastfeeding arguments aren't actually about breastfeeding (Part 1: Alcohol and breastfeeding)

What do the following headlines all have in common?

Drunk Mom's Baby Dies During Breastfeeding

Breastfeeding Mom Kills Baby While Drunk

Mom Suffocates Baby While Breastfeeding, But It Could Have Been Prevented

"They all describe incidents that are about alcohol and breastfeeding," might seem like a reasonable response. Actually, the funny thing is that they all describe incidents that are indeed about alcohol but not really about breastfeeding at all. Here's why.

From the first story:
...for a mom from Maryland, breastfeeding her baby turned to tragedy over the weekend. Cops say Yadina Indira Morales was both breastfeeding and "highly intoxicated." Together the two proved to be dangerous for her 2-month-old daughter, who was found unresponsive and later pronounced dead at a nearby hospital. Most respectable pediatricians will tell a breastfeeding mom to pump and dump if she's going to drink. Baby should either get formula or some breast milk expressed before the alcohol was consumed. However, it doesn't seem like the alcohol in mom's milk was the worst part here; it was mom's drunken state. Cops indicate Morales passed out while breastfeeding and that the baby was found underneath her, unresponsive.
In fact, the "alcohol in mom's milk" was not even an issue here. The tragic death of this little baby was due to suffocation when her intoxicated mother collapsed on top of her.

Second story:
Imagine a mom's worst nightmare. She settles in to breastfeed her baby girl for the last time for the night, baby snuggled at the breast, happy and content. Then she falls asleep. When she wakes up, the baby's dead. Would you judge her? Now what if she had an entire bottle of wine in her system? ...A glass of wine, one mug of beer, when you're breastfeeding, and most of us will look the other way.  But I've yet to meet a doc who'd suggest the best way to build up your milk supply is to chug that wine... Just like pregnancy, breastfeeding requires a mom to keep baby in mind as she eats and imbibes throughout the day. 
Well I'd agree that you shouldn't drink a bottle of wine and get into bed with your baby... but that's something you shouldn't do regardless of whether you are feeding your baby from breast or bottle. Like the first baby, this poor little girl died because she was suffocated, not because of alcohol-laced breastmilk.

Story No. 3:
It's a mother's nightmare come true. A 1-month-old baby boy recently died via suffocation while his mother was breastfeeding him. The 32-year-old new mom had reportedly gone out for a night of drinking, and when she returned to nurse her baby, she fell asleep while doing so. The next morning when she woke up... she realized her brand new baby had passed away. I will say, probably not the best idea to go out imbibing all night -- if this is true -- when you're breastfeeding. ...You have to give up things. And "nights of drinking" are among those things. If you really, really can't do that -- honestly? Switch to formula... And, please, don't co-sleep if you're wasted.
The writer is right on the money with that last comment. It is not, however, clear how feeding a baby with formula (or expressed breastmilk in a bottle, or Cheetos, for that matter) would have prevented the baby from suffocating as he lay in bed with his mother.

Alcohol and breastmilk
There is a paucity of really good data on breastfeeding and alcohol, but Linda Geddes' book Bumpology (which is well worth a read, by the way) does a good job of rounding up and analyzing what evidence there is. As far as we can tell, about the worst thing that can be said about breastfeeding while imbibing is that babies whose mothers have drunk heavily (we're talking several drinks, mind you, not a glass of beer with a meal) show subtle changes in their sleep/wake patterns: namely, they sleep more frequently but in smaller doses, and spend less time in active sleep. That, for me, is a reason to refrain from feeding for the next four hours or thereabouts (and use expressed milk or formula in the meantime if the baby needs feeding) if one has had more than a couple of drinks and is actually buzzed.

But even if you neglect to take this precautionary stance, your baby is not going to die or even get sick, and it really is deceitful for writers and editors to imply that this could happen. There are rare reports of long-term health issues (obesity, elevated cortisol levels etc.) in babies who are being breastfed all day every day by mothers who are chronic heavy drinkers, but I've been unable to find a single case of acute alcohol poisoning resulting from breastfeeding while drunk.

 (Note: "Pump and dump" has been largely discredited. There are certain medications which if taken will stay trapped in breastmilk, requiring the milk to be pumped away; alcohol in breastmilk, however, is gradually wafted back into the bloodstream over the next few hours in a process known as "retrograde diffusion," leaving the milk clean. The only reason to P&D is if delaying the next feed causes you to become uncomfortably engorged.)


Because they stop short of actually saying "alcohol in breastmilk killed these babies," the articles and their headlines are not actually telling fibs. However, when you juxtapose these two ideas against the background of a social context in which most people are actually quite confused about whether drinking while breastfeeding is acceptable (partly because excessive anxiety about drinking during pregnancy has bled over into breastfeeding), you ensure that most people will come away from the article under the impression that drinking while breastfeeding is dangerous and poisons infants. Certainly the writer of the first two Cafemom articles seems to have got this idea, judging by her dippy comment about how "If you really, really can't [give up nights of drinking]--honestly? Switch to formula." As though a bottle of Similac would have somehow miraculously stopped the baby from, you know, suffocating to death.

I can see why sites like Cafemom choose to turn things into "breastfeeding arguments" when they're actually not: you get to stir up the mummy wars in the comment section, bring the sanctimummies out in force AND include the word "!!!Breast!!!" in your headline, all of which tend to generate more clicks and page views than titles like "Baby Dies Due To Failure to Follow Safe Bedsharing Guidelines" which would have been a lot more accurate. (I suppose I'm a bit of a hypocrite in this regard since my blog also brandishes the word "breast" around... but in my defense, I get about 600 page views a day whereas CafeMom probably gets several million.) Trouble is, before you know it you've then got this rumor buzzing around that There Was Once This Mum Who Poisoned Her Baby With Her Alcoholic Breastmilk, which in turn leads to breastfeeding mothers having a drink with a meal being judged and tutted at... or, in one case, having the cops called on them. (And check the poster in the Comments section who defends the police-calling waitress's actions on the grounds that "Considering that a mom just killed her baby (from alcohol poisoning) consuming large amounts of alcohol while breastfeeding is dangerous.")

The other problem with turning these kinds of tragedies into "breastfeeding topics" is that it distracts attention away from the real issues at stake here, like safe sleeping arrangements and social welfare problems. When you make out that a case of baby suffocation is actually a breastfeeding issue, you are sending out the message that as long as you are bottle-feeding it is completely fine to be drunk to the point that you are at risk of passing out while holding your baby. I personally feel that the safest sleeping place for a baby is a cot (crib) in the parent's room, but if parents must bedshare (and I do "get" that for some parents, it may literally be the only way anyone gets any kip), it's very important to follow safe bedsharing guidelines, including getting rid of blankets and pillows, and not being drunk or on drugs. And the Morales case (from the first story) is full of red flags indicating child welfare problems, including charges of child abuse inflicted on her other child by a former boyfriend. I doubt formula would have saved her child, but perhaps better support and education might have done so.

Further reading

Mulled wine? But you're breastfeeding...  Linda Geddes (Bumpology) on alcohol and breastfeeding

You should not be drunk while caring for your baby (from PhD in Parenting)

Alcohol and lactation: a systematic review  Quite interesting reading. One (plausible) argument often made against overly strict anti-alcohol guidelines for breastfeeding mothers is that they can form a barrier to breastfeeding by making it sound like you have to be a saint if you want to nurse; this review makes the case that giving mothers no guidelines at all could also become a barrier, on the grounds that drinking significant amounts of alcohol can subtly change babies' wake/sleep patterns and make them harder to care for, leading to maternal exhaustion. It's food for thought, that's for sure.

Wednesday, May 7, 2014

Why don't Gypsy and Traveller women breastfeed?

I came very late to the Channel 4 documentary series "My Big Fat Gypsy Wedding," having spent the last couple of months catching up on the two 2011-2012 series. The series itself was largely fluff--in the most literal sense, since it focused on traveler weddings and the enormous, puffy net-crinoline dresses that tend to be worn at these events--and much of the information on the program was wildly inaccurate, but it was still enough to get me interested in Britain's Travelers... and of course, to take a look at these groups through the lens of infant feeding politics.

(By the way, given the controversial nature of both Travelers and breastfeeding in popular culture, I'm wryly amused that I have somehow wound up discussing both issues together in the same article. Good job this post doesn't include discussion about pit bull terriers as well, otherwise it might just explode in an incendiary fireball of its own making....)

Britain's Travelers
The biggest nomadic groups in Britain today are Romani Gypsies and Irish Travelers. Romani gypsies (otherwise known as Romany, Rom or just plain "gypsies") trace their origins back to a group of nomads who left Northern India centuries ago and traveled through Europe, reaching Britain by about 1500. Irish travelers are the result of several waves of emigration from Ireland. Things get complex because the term "gypsy" is often used as a catch-all term covering both groups, while other people use "traveler" to mean Irish Traveler, as opposed to Romani Gypsy. In recent years, a new wave of "Roma" gypsies from Romania and Bulgaria--who come ultimately from the same roots as the English Romani--has arrived in Britain as well. Many people classified as Travelers, by the way, live in houses or other permanent accommodation and do not travel; others live on caravan sites but may travel for part of the year depending on work. Traveler men typically work in areas such as tarmacing, building, and scrap metal dealing. Women generally live within a carefully defined female sphere, marrying young (around 16-20), having quite large families and usually not working outside the home.

Travellers and breastfeeding
The word "gypsy" has a romantically Bohemian image, and indeed, a quick search for "gypsy breastfeeding" threw up a ton of results for whimsically-patterned baby carriers and cloth diapers. You could almost imagine yourself wandering around the hedgerows in a gypsy skirt and a gypsy baby-wearing wrap, breastfeeding your cloth-diapered gypsy baby and generally being at one with nature. All this is of course rather removed from the real lives of modern Romany Gypsies and Irish Travelers, who tend to go in for modern petrol-powered caravans, the swankiest prams they can afford, and cleaning everything with lots of bleach. They also almost always formula feed: in fact, Travelers have the lowest breastfeeding rates of any ethnic group in the UK. In a 2011 survey of Traveler women, breastfeeding rates were "2.7% at birth and 0% at six to eight weeks" (Pinkney, 2011 (*1)) while in "My Big Fat Gypsy Christening" (a babycare special that was broadcast in 2013), a midwife who had worked with Travelers for 30 years said that in that time she had only known a handful of women who nursed their babies. Low breastfeeding rates have been just one of several aspects of Traveller childrearing practices that have come in for criticism, the others including unhealthy diets, unsafe driving practices and the fact that many Traveler groups still remove children from schooling at around puberty. The MBFGW series and christening special certainly sparked off a lot of (mostly negative) online discussion (see here and here), though given the tendency for TV programs to sensationalize it is difficult to know how seriously to take the version of the Traveler lifestyle that the series portrayed.

Cultural taboos
Ethnological studies of Romani Gypsy and Irish Traveller women universally indicate quite negative attitudes towards breastfeeding among both men and women.
"It is viewed with contempt by these women and also by their partners. One traveler woman described it as ‘weird just weird, what would I do that for?’ Another woman claimed that even if she had wanted to, there was no way her husband would have permitted her doing so. Breasts for these women were associated more with ones sexuality rather that performance of breastfeeding. All of the women claim that they were made aware of the benefits of breastfeeding, however none of them expressed any desire to do so, nor to encourage other family members to do so. One woman claims that if she were to have a family member do so –‘she would be an embarrassment and a lot of people wouldn't want her around their families if she was doing that sort of thing’." (*2)
 "The aversion to 'personal' matters may play a part in the very poor breastfeeding rates among Gypsy and Traveller women. Okely [10]  found social taboos to be the main reason women did not breastfeed: "We wouldn't let a man see. That's filthy'"(p208). None of the women interviewed breastfed any of their children and the taboo, perpetuated by oral tradition, impacts greatly on their health at all ages." (*3)
“I don’t like the thought of [breastfeeding] and I was not gonna get my bits [sic] out." (*4)
Why has breastfeeding become so taboo among British Traveler women? Travelers (Romani and Irish) have for centuries observed strict rules about bodily decency--including taboos on premarital sex, elaborate codes of cleanliness in which pets and toilets are kept separately from living quarters, and beliefs about the polluting nature of childbirth and menstruation. Modern British Traveler culture seems to have put breastfeeding into the same sort of category--a shaming and disgraceful display of the breasts.  And yet this can hardly be a truly traditional attitude--if one goes back a couple of generations or more breastfeeding surely must have been the norm among Gypsies and Irish Travelers, because until quite recently rearing a child "by hand" was something close to a death sentence (even without the vagaries of a traveling lifestyle). Indeed, among many Romani-related ethnic groups outside the UK (*5-*8) such as the Eastern European Roma, breastfeeding has remained the norm; in fact, Roma women from these countries are well-known for breastfeeding openly in public, even with toddlers.

I don't know when breastfeeding stopped being the norm among British Gypsies and Irish Travelers. I'm guessing that what happened is at some point in the 20th century, after bottle-feeding had become normalized among white working-class British women (who continue to this day to bottle-feed almost universally), the custom probably spread to Traveler women, and has since come to seen as a social norm and as an ethnic marker--hence the remarks in the ethnological literature about how "we Travelers don't breastfeed." Travelers have their own peer group norms and see themselves as being culturally distinct from settled people--a fact hinted at by the fact that most Irish Travelers retain their Irish accents generations after leaving Ireland.

I just want to emphasize this, because a lot of public conversation about breastfeeding--especially in the United States--tends to focus strongly on the idea of "everyone wants to breastfeed, but economic barriers get in their way, such as inability to afford time off work, lack of maternity leave and pumping rights, and lack of access to healthcare professionals." But Traveler women still generally choose formula even though they do not usually face work/mat. leave-related barriers and the majority (90%) of the women surveyed by Pinkney cheerfully agreed that breastfeeding was cheaper than formula feeding. Poor women and women from disadvantaged ethnic groups (just like relatively privileged women) aren't solely motivated by monetary considerations, nor are socio-economic barriers the only reason why they may not do certain things; cultural identity, desire for status, personal preferences and what their friends do may also be important factors. As the saying goes, "Culture matters."

(By the way, I'm strongly in favor of things like universal access to maternity leave, pumping rights and all the other things, for various reasons--but if US lactivists are under the impression that bringing these things in will result in breastfeeding becoming the norm across America, they are probably in for a big disappointment. Just saying.)

Which is easier--breast or bottle?
Given that most Traveler women don't work outside the home and may sometimes lack access to running water and electricity required for making up bottles, it's somewhat surprising to see that 65% of the women surveyed by Pinkney (strongly) agreed with the statement "Bottle feeding is easier than breastfeeding," while 60% (strongly) disagreed that "Breastfeeding is easier than bottle feeding."

It's still common in many Traveler communities for kids to be removed from schooling at around age 12 or so (having often attended only sporadically before that); girls are expected to take on much of the housework and babysitting work from an early age. Traveler sites where this is still the custom consequently tend to resemble the kind of villages you get everywhere in the world where mass schooling hasn't been developed yet--where kids keep an eye on their siblings and cousins, and every girl seems to have a baby/toddler on her hip. The thing about breastfeeding is, it's only more convenient if you are at home alone with your baby and you are responsible for most of the childcare yourself. If you always have a lot of childcare in the form of older kids, bottle-feeding does tend to be the easier option; you can easily leave the baby with anyone.
We have loads of people come round and the baby would have starved cos I wouldn’t have fed it with people there or husband. That’s wrong.
I just couldn’t try it. I know it's good for the baby but we don’t do things like that and we have so many family coming round... the men would have had to stay out of the house.
Virtually all women who breastfeed are adamant that the first few weeks of breastfeeding, well, suck. You sit there hour after hour, your breasts hurt, and many women find books and web surfing are a lifesaver for getting through this difficult period (I maintain that the arrival of the World Wide Web has been a huge factor behind the increases in breastfeeding rates in most developed countries in the last couple of decades). Conversely, low levels of reading ability among many Traveler women make it harder to use the Net as a place to get advice and encouragement or simply to have someone to talk to when you've been by yourself for hours on end. Combine this with cultural taboos that make women embarrassed to nurse around other people, and it's no wonder the few women in the Pinkney survey who did initiate breastfeeding dropped it after a few weeks.
Health Promotion England (2000) acknowledges that many families initially find breastfeeding difficult however it tends to improve and becomes easier with time, patience and perseverance. It is therefore possible that Gypsy and Traveller women which have historically initiated breastfeeding may have stopped due to early difficulties and then verbalised their problems associated with early breastfeeding to other Gypsy and Traveller women. Research by Dion (2008) highlights that in the Gypsy and Travelling community there is a “strong oral tradition” (p33) and information is readily passed verbally from one generation to the next. This process if negative would therefore reinforce the belief amongst the Gypsy and Traveller community that breastfeeding is difficult. (*1)
It's one of the curious paradoxes of infant feeding culture that breastfeeding (generally seen as "natural") has seen a revival in modern times at least partly as a result of the technological revolution of the internet, while bottle-feeding has most likely remained strongly entrenched among Travelers at least in part because Travelers remain one of the few modern peoples who maintain a strongly oral culture.

A way forward
Pinkney's survey concludes that "In general the attitude scores provided evidence that the community [i.e. Travelers] would benefit from receiving more information on the health benefits of breastfeeding" and suggests that providing more information on this might result in more Traveler women initiating and persisting with breastfeeding. I confess to being a little skeptical about this. For one thing, other discussions about infant feeding among Travelers (see the Bromley paper linked below) suggest Traveler women are already getting plenty of information on this score, with many receiving considerable pressure to breastfeed from National Health Service (NHS) nurses.
"They kept on at you about that. They tried to push you into it. I didn't want to. They kept on about it." (*4)
"I would rather they let you have the choice but they make as if you have to. They made me feel bad and they wouldn't even tell me where the formula was kept." (*4)
Meanwhile, in Pinkney's survey a full 45% of women agreed with the statement that "Breastfed babies are healthier than bottle fed babies," while 50% agreed that "Breast milk is more easily digested than bottle milk."

Thing is, though, there's a big jump between "knowing that XYZ is, all things being equal, a little better," and "being determined to actually do XYZ no matter what it takes." I know perfectly well that (for example) having babies in one's twenties is better than doing so in one's thirties, yet I delayed childbearing till 32 and would do the same again if I had the chance to do things over. I wouldn't have wanted to become a mother in my twenties (I had too much traveling to get out of my system, for a start) and quite honestly, no amount of well-meaning "education" from healthcare workers would have changed my mind about something I felt this strongly about. Culture matters. Of course, the interesting thing is in terms of the age at which they first get pregnant, Traveler women (who typically start their families at around 19 or 20) are actually far closer to the medical ideal and biological norm that the average British woman, who probably doesn't get started till 30 or so. Let's face it though--popular culture and the healthcare profession tend to be a lot more forgiving about "slightly-less-than-100%-optimal" mothering decisions that are popular among educated women (such as delaying motherhood until later in life) while tongue-lashing mothering decisions that are attended with a similar level of risk which happen to be common among young working-class mothers or (shall we say) less-than-popular ethnic groups.

That said, I don't want to be completely gung-ho about Traveler women's preference for bottle-feeding. For one thing, while the benefits of breastfeeding are probably modest in developed country environments, some Traveler women effectively live in the twilight zone between developed and developing world due to intermittent access to running water and electricity (*9). Indeed, it's surprising that things like gastroenteritis are not more of a problem (though Travelers' famously high standards of cleaning are probably helpful in warding off the worst problems). Infant mortality rates among Traveler infants certainly are strikingly high (*10), though it appears that much of this is due to congenital problems caused by high rates of consanguinity. But there is also substantial evidence of sub-optimal bottle-feeding practices in Traveler families, such as feeding young babies cow's milk, or allowing toddlers to walk around sip-feeding off bottles all day long, sometimes filled with sweet drinks and other inappropriate substances, which can cause serious dental and nutritional issues (*11).

It might be more practical for NHS healthcare workers to put their focus on giving young Traveler mothers clearer information about sound bottle-feeding practices (not giving babies cow's milk at too young an age, making up formula correct as per the manufacturer's directions, not filling bottles with sweet drinks or putting children down to sleep with bottles, and bottle-weaning at appropriate ages). Although breastfeeding might in many ways be a more logical choice for women who do not work outside the home and sometimes lack access to the things that make bottle-feeding safe and feasible, the reality is that cultural practices are hard to change, especially when they have become an ethnic marker for a particular group. Putting strong pressure on Traveler women to breastfeed effectively presents them with a choice between maternal guilt and social isolation, increasing the vulnerability of a group of women who already struggle with low social and economic status. Resentment inspired by such pressure could also make Traveler mothers less receptive to taking on advice about more urgent matters such as vaccines, well-baby checks, hearing tests and optimal bottle-feeding practices themselves. Given the sometimes fraught relations that have long existed between Britain's Travelers and the settled community, a pragmatic approach is surely best for safeguarding Traveler children's welfare.

Further reading

*2: Irish Traveller women (Ellen D'Arcy)
*3: Gypsies and travellers: cultural influences on health
*4: The Experience of Maternal Health services by the Bromley Gypsy Traveller Community
*5: Taboo and shame (Ladž) in traditional Roma communities
*6: Social exclusion at the crossroads of gender, ethnicity and class. A view through Roma women's reproductive health
*7: Risk factors for childhood malnutrition in Roma settlements in Serbia
*8: Purity and impurity in the traditional Romani family
Gypsies and Travellers: Their lifestyle, history and culture
*9: The big fat truth about Gypsy life (Guardian)
*10: Traveller infant mortality is persistently higher than the general population in the All Ireland Traveller Birth Cohort study
*11: Child Poverty Relating to Gypsy and Traveller Children and Young People in Sussex 

It didn't seem to fit anywhere into this discussion, but I was interested to stumble across the somewhat random fact that the condition known as galactosemia (where the baby cannot digest lactose and must be fed with a soy formula) is particularly common among Traveler infants, probably as a result of consanguinity. See here:

Saturday, March 29, 2014

Bottles for toddlers, nursing for toddlers

Well, it's been a while since I blogged: choosing nursery school programs (my baby is now three! How did that even happen?) while working full time and studying tends to do that to a girl. In fact, for a while I kind of lost my obsession with infant feeding politics, and even found myself contemplating the idea of starting a blog about education instead. Still, now that the school thing is settled and things are starting to quieten down, I'm looking forward to posting a bit more frequently than I have done these past few months.

So: bottles for toddlers vs. nursing for toddlers. Many parents can't help noticing that there seems to be a bit of a double standard in the world of toddler-feeding advice: nursing beyond the age of 12 months is officially condoned and even encouraged by the Powers That Be (the World Health Organisation (WHO), American Association of Pediatrics (AAP) and the National Health Service in the UK), while bottle-feeding parents are advised in no uncertain terms to stop the bottle at 12 months, if not before. This chafes at some bottle feeders; the attachment that babies form to their bottles not only makes bottle weaning quite tricky, but also makes many parents reluctant to take away something that seems to give their child so much comfort. Is this double standard justified or not?

Bottle problems
Pediatricians and health visitors tend to be down on bottles because they come across so many examples where prolonged, frequent use of bottles causes lots of problems; this is why in child welfare departments, there is a lot of talk about "delayed bottle weaning" as a social problem, and many public health authorities actually carry out "bottle-to-cup" campaigns in an attempt to get babies off the bottle. The "prolonged bottle use" thing and the problems that it is associated with tend to be seen most often in young, poor parents with low levels of education and a lack of family support; they are also commoner in certain ethnic groups. You see a lot of kids dragging bottles and dummies around in the South Yorkshire city I where grew up (which has quite a lot of poverty and social problems).

Feeding toddlers meals is a PITA; you have wrestle your screaming gremlin into a chair, nag/beg/persuade the food into them, and then clear up all the mess. By contrast, toddlers love their bottles, and all you have to do is fill it up and hand it to them. It keeps them quiet in the house, in the stroller, in the car seat. It can be awfully tempting to just keep handing out the bottles rather than make serious efforts to get the kid eating proper meals at proper times. But this results in a child having a constant drip-feed of calories into their mouth, greatly increasing the risk of serious dental decay. Before long, parents often start putting regular fridge milk in the bottle rather than formula, with the result that the toddler fills up on way too much cow's milk, causing serious nutritional imbalances. Worse still, sweet drinks and juice sometimes get put in. Toddlers drop bottles constantly, pick them up covered in grot, and then put them straight into their mouths again. Having a bottle teat (or pacifier) in the mouth too much may also increase the risk of dental malocclusion such as an overbite. The worst problems are seen in toddlers who are "put down to sleep with a bottle"; this can lead to rampant tooth decay, sometimes requiring the removal of multiple teeth. (Oh, if you do a search for "baby bottle mouth" or "bottle rot," by the way, for God's sake make sure "image search" is switched off first; there are some truly disturbing pictures of rotten teeth out there on the Web).

Does doing-bottles-past-12-months have to look like the above scenario? By no means. My own nieces, for example, continued to have a single bottle of formula with their bedtime story (before tooth brushing) for many years, and suffered from none of the above problems; they ate meals and drank properly from a cup during the daytime. A bottle of formula around bedtime was just a comforting bedtime ritual for them, not to mention being a much-appreciated nutritional backup for times when picky eating was playing havoc with their diets. Clearly, then, the whole bottles-for-toddlers thing is very much a question of degree. I think a distinction needs to be drawn between parents letting their toddlers wander around with bottles (or lie down with them at night) versus those who allow bottles for toddlers but only in a careful and restricted way.

What about breastfeeding?
Honestly, I think breastfeeding a toddler is a little different to bottles for a couple of reasons.

The expression on this mummy sheep's face somehow
 makes me feel that nursing has been "extended"
a bit longer than she's comfortable with...
For one thing, bottles can potentially be filled up with all sorts of stuff like sugary drinks, whereas nothing comes out of a breast except breastmilk. Breasts, unlike bottles, can't be dropped on the ground and put back in the mouth covered in germs. It's not quite clear whether daytime breastfeeding is connected with tooth decay; if it is, the relationship seems to be a lot less strong than with extensive bottle-feeding. And breastfeeding for longer does not seem to be linked with dental malocclusion, unlike prolonged and extensive use of pacifiers and bottle teats. This is probably because although sucking milk out of a breast may look superficially similar to sucking out of a bottle, what's actually going on inside is surprisingly different. For a start, when a breast goes into a child's mouth, the action of the palate s-t-r-e-t-c-h-e-s the nipple it to make it conform to the inside of the mouth, whereas a bottle teat undergoes little stretching while the child's mouth adjusts to conform to the shape of the teat. (This interesting article gives a rather graphic blow-by-blow account of the different oral dynamics of bottle- vs breastfeeding; I particularly enjoyed the description of the baby removing milk from the bottle with a "piston-like stripping action"--where do these health professionals get their metaphors from?)

But I think the big difference between breastfeeding and bottle usage during the toddler years is that breastfeeding is by its nature self-limiting. Nursing means mum has to sit/lie down while kiddo has to interrupt whatever play or activity they are engaged in--which of course toddlers resent doing. So the vast majority of toddler/mother pairs quickly cut down on nursing as the child becomes more mobile. Bottles, on the other hand, are not attached to a person, so if you are stressed, overstretched, uneducated or just a bit lazy, it can be tempting to let the kid wander around with one or have in their mouth constantly in the stroller or car seat. I remember thinking about this suddenly last summer when I was at South Yorkshire Wildlife Park for the day; you saw a lot of toddlers and preschoolers walking around with a bottle or dummy on and off throughout the day, but you couldn't possibly do extended nursing like that. Like, what would you do--get one tit out and shuffle along backwards on your knees for hours on end? All in all, I can see why public health authorities generally don't bother much about extended nursing as a possible health concern in the way they worry about prolonged use of bottles; most of the issues which are associated with excessive use of bottles don't really apply to breastfeeding.

I do think, however, that a partial exception should be made for nighttime nursing; if mothers bedshare, night-nursing is the one type of nursing which really can potentially go on for hour after hour, and there does appear to be the potential for breastmilk to "pool" in the mouth. The jury seems to be out on whether night nursing causes tooth decay; personally, however, I feel that if there is any question that it could…. really, why on earth would one choose to take the risk, given that early childhood caries is irreversible, painful, traumatic and often very expensive to deal with? Toddlers don't need to eat all night long.

I talked about this a bit in a previous post, but something we have to bear in mind that public health advice tends to be written with the lowest common denominator in mind. I am guessing that The Powers That Be feel more comfortable imposing a crude blanket rule of No Bottles After After Twelve Months, because the parents who are most likely to make genuinely dodgy parenting decisions are the least likely to able to understand and apply advice that is complicated or nuanced in any way. And imagine being the doctor who's had the horrible experience of dealing with a child who has to have a mouth full of rotten teeth yanked due to never-ending sip-feeding out of a bottle. I can understand why health care workers who have to deal with the results of genuinely dodgy bottle use would start to have an almost viscerally negative attitude towards the sight of a toddler drinking from a bottle.

So… I do understand that well-educated formula feeding mothers (who wouldn't dream of letting their toddler wander around with a grubby bottle for hours on end) may find such blanket rules a bit frustrating, but I think the key thing here is to understand that these rules are written primarily with the intention of protecting the children of the less-well-informed from iron deficiency anemia and "bottle rot," not to further alienate and condemn formula feeding mothers, and do not really apply to sensible and restricted bottle usage.

Monday, November 18, 2013

Bullshitometer: Rice cereal edition

Rice cereal is widely used in many countries as a first food for infants, either stirred into a bottle or mixed with breastmilk/formula and fed with a spoon. Hang around any discussion group with mothers of babies and you're sure to hear someone talking about how they plan to "skip the rice cereal" or "start giving baby rice." Debates on the subject can get very heated--astonishingly heated, really, when you consider that this is basically an innocuous-looking white powder that most babies probably only eat in very small amounts anyway.

Some people have been assured by their doctors that it is hazardous to give babies anything other than rice cereal as a first food. Other people believe that rice cereal is harmful, and that the only reason we are told to start with it at all is due to the machinations of the good old formulaandbabyfoodmilitaryindustrialcomplex. Still others hint that giving cereal is okay... as long as it's organic, or homemade, or brown/wholegrain, or is something other than rice. So, who's telling the truth? As there are so many claims that are made about rice cereal, I'll break them down into "In favor" and "Against." As you'll see, sometimes the bullshitometer verdict is of the "It Depends" variety.

Claims made in favor of rice cereal

Rice cereal will make your baby sleep longer at night
Bullshitometer verdit: Basically false
It appears that this particular myth is still doing the rounds. However, the sole randomized control study that I have been referred to found that cereal at bedtime makes no difference to babies' sleeping patterns. (If your baby has gastrointestinal reflux, however, it's a different story: see below.)

Only rice cereal should be given at first, because it's hypoallergenic
Bullshitometer verdit: False
Rice is one of the foods least likely to provoke an allergic reaction, so some parents find it a "reassuring" first food. However, it's a bit of a stretch to imply that this means parents should give rice first, or give nothing but rice for the first few months.

About 10 years ago, there was a spate of advice from medical bodies which basically told mothers and mothers-to-be to avoid foods associated with allergies--no peanuts during pregnancy, no eggs for baby until 12 months, etc. As far as I can tell, this advice was never based on any actual data, but rather on a vague sense of panic that Allergies Are Increasing And We Must Do Something About It. Since then, most of the "avoid allergens!" advice has been dropped, and the American Association of Pediatricians and Britain's National Health Service now state that other than a few exceptions like honey, there is no particular reason to delay any food beyond six months. For every (small, unsatisfactory) study which seems to indicate that delaying the introduction of wheat or egg reduces the risk of allergy, there's another (equally inconclusive) study which hints tantalizingly that early-ish introduction of the allergen in question might be better--see here and here, for example. When the EATS study results come out in 2015, we'll have a better idea. Till then, there seems to be no reason to stick exclusively to rice cereal in the early weaning stage.

Rice cereal is rich in iron
Bullshitometer verdit: True
Fortified rice cereal is a good source of iron; indeed, that's a large part of the reason why it's recommended by doctors. I discussed the importance of iron here. It's the fortification that gives baby rice its iron, by the way, so if you make your own "rice cereal" at home it won't provide the same benefit. Nor do many organic cereals, because generally if any food is fortified artificially it can't be called "organic."(NB: I am told that this is actually not the case in the US, so this may be one of those #regional things.)

Rice cereal helps with reflux
Bullshitometer verdit: Somewhat true
Thickening formula or expressed breastmilk with rice cereal is popular advice for helping babies suffering from acid reflux. A 2008 meta-analysis found that thickening feeds was helpful for reflux--although only moderately so.

Claims made against rice cereal

Rice cereal can cause constipation
Bullshitometer verdit: True
Rice cereal can indeed constipate some babies. This is sometimes attributed to its being white and refined, but the real culprit appears to be the iron with which it is fortified. It's the reason why "traditional" weaning regimes like that of Gina Ford include a lot of loosening fruits like prunes and pears.

Rice cereal is bland and taste of nothing (or even "Rice cereal tastes and smells disgusting")
Bullshitometer verdit: Sort of true, but...
I don't think anyone is ever going to claim that baby rice is as flavorful as, say, a plate of hummus or a Thai curry. That said, the rhetoric one sees about "How can people give their babies slop that tastes of wallpaper paste!?!" seems a bit unfair on poor old rice cereal.

For a start, there's surely room for both intensely and subtly flavored foods in our diets, and I doubt many parents give their babies nothing but rice. Plus... at the risk of pointing out the bleedin' obvious, rice cereal mixed with breastmilk tastes primarily of--surprise, surprise--breastmilk. Given that lactivists are so big on the idea that breastmilk takes on all these interesting flavors from the mother's diet and so on, it seems a bit odd to simultaneously insist that cereal mixed with breastmilk tastes of absolutely nothing. To make matters even more confusing, crunchy forums are full of mothers who say that rice cereal shouldn't be given because it's tasteless, yet consider rice cakes (for self-feeding) to be A-OK. I'm not sure what the reasoning is here--that rice magically acquires lots of exciting flavor when you puff it up and press it into a styrofoam disc? Given that rice itself doesn't really taste of anything, I feel confident saying that if a serving of breastmilk-mixed-with-cereal smells or tastes disgusting, it's probably something to do with the breastmilk. Unfortunately, some mothers' milk acquires fishy/metallic flavors when stored for any length of time.

One Dr. Greene, by the way, has made claims that rice cereal is not only bland but will give your child a lifelong preference for bland, starchy foods, based on the curious idea that the babies will "imprint" on the cereal, like a duckling fixating on the first moving object it sees. I think it makes sense to expose babies to lots of interesting flavors, but there is not a shred of evidence to support his idea that giving a baby any cereal whatsoever is going to do terrible things to their palate. Anyway, if you find cereal a little bland, there's nothing to stop you mixing it with other things.

Rice cereal is indigestible because babies can't digest grains until they are a year old/two years old/until their molars come through etc.
Bullshitometer verdit: False
The idea that we should avoid giving babies grains has become increasingly popular in the last few years in parallel with the rise of so-called "paleo" diets which limit the consumption of starchy cereals. A much-shared article from Food Renegade "Why Ditch The Infant Cereals?" is typical of this genre:
In order to digest grains, your body needs to make use of an enzyme called amylase. Amylase is the enzyme responsible for splitting starches. And, guess what? Babies don’t make amylase in large enough quantities to digest grains until after they are a year old at the earliest. Sometimes it can take up to two years. You see, newborns don’t produce amylase at all. Salivary amylase makes a small appearance at about 6 months old, but pancreatic amylase (what you need to actually digest grains) is not produced until molar teeth are fully developed! First molars usually don’t show up until 13-19 months old, on average. 
I do not have the time to go through every single scientific and historical error in the entire Food Renegade article, so, briefly: contrary to what Food Renegade claims, pancreatic amylase starts to be produced by infants from about one month of age, and is present in substantial amounts by a few months later. What's more, salivary amylase (which is present in your saliva) starts being produced from around birth and is at around two-thirds of adult levels by three months of age. Finally, expressed breastmilk itself is full of amylase. There's also evidence that breastmilk amylase continues to be active even when it's in your baby's stomach. Food Renegade claims that pancreatic amylase is the only one that will digest grains, but this is false; salivary, pancreatic and breastmilk amylase are all alpha-amylases and all will break down the starch in cereals.

If you're lactating and are feeling bored today, you can actually try this out for yourself: pump, and mix your freshly expressed milk in a bowl with enough rice cereal or flour to make a thick goo. Wait five minutes, and look at it again. It will have gone runny or sloppy, because the amylase in your milk is actually predigesting the starch in the cereal. Very young babies may have difficulty digesting cereal, but if your baby is four months or older you shouldn't need to worry.

Rice cereal is nutritionally void
Bullshitometer verdit: False
The iron with which infant rice cereal is fortified is useful to babies--especially since it's one of the few things they won't get from breastmilk. Rice cereal won't provide much else other than iron, true--but then, it doesn't really need to: breastmilk/formula meets all other nutritional needs except perhaps zinc.

Rice cereal in a bottle can cause choking
No TinyTears™ dolls were harmed in the
 making of this photograph
Bullshitometer verdit: Perhaps somewhat true
Cereal-thickened milk in a bottle is often said to be a "choking risk" for infants. Now... I am nitpicking a little, but the concern about thickened liquids is not choking but aspiration (choking = something completely blocking your windpipe; aspiration = something getting into your windpipe that shouldn't be there). OK, now I've got that off my chest (pardon the pun), what's the risk of aspiration from cereal in a bottle?

Well, not much, judging from a trawl through Google Scholar, which produced only discussions of cereal-thickened milk being used to prevent aspiration of milk. However, occasionally medical professionals have expressed a preference for alternative thickeners to cereal for this reason. The concern is that because the cereal forms irregular lumps in the milk, carers may be tempted to make the hole in the bottle teat excessively large to allow the milk to pass through, which in turn may cause excessive flow from the bottle, increasing the risk of aspiration. This may be a particular concern with breastmilk because the action of amylase makes the thickening action unstable and unpredictable. So some medical professionals now prefer thickening gels/carob bean gum, which are not broken down by amylase (see here). Hopefully these alternative thickeners will become more widely available; in the meantime, it seems wise for parents to feed thickened breastmilk with care, resist the temptation to make the teat hole too large, and never prop bottles.

Mmm…. red meat. Yum yum.
There are better sources of iron than rice cereal
Bullshitometer verdit: True, but...
You will sometimes hear people say that "The iron in rice cereal is poorly absorbed." This is sort of true, but needs to be understood in context. Only about 4% of the iron in rice cereal is absorbed, but that's because all non-haem iron is absorbed poorly, not because there's something uniquely crap about rice-cereal iron. Iron from beans, quinoa, peanut butter  etc. is also absorbed at around 4%. But because the infant cereal is fortified with so much iron, the absolute amount that the baby ends up getting is far higher than for these natural foods. The WHO guidelines specifically recommend iron-fortified foods on the grounds that without them, it may be difficult for babies to get enough iron in practice (see p.25).

Haem iron--the sort found in meat and eggs--is absorbed at a much higher rate, and there's loads of it, plus zinc which babies may also need. If parents have the time to prepare meat purees they should by all means do that, and pediatric authorities increasingly recommend meat as superior to cereal. Honestly, though, I can kind of see why doctors push the rice cereal. Rice cereal is inexpensive, easy and innocuous to feed, whereas not everyone has the time/inclination to make their own meat purees, and as for jarred meat-based babyfoods.... well, I think many parents understandably feel a bit reluctant to feed their infant shelf-stable liquidized meat products of indeterminate origin that smell rather like dog food. So if pediatricians just completely ditched the rice-cereal recommendations, I think what would actually happen is that a lot of babies wouldn't get either cereal or meat, and anemia would probably increase substantially as a result.

Rice cereal contains arsenic
Bullshitometer verdit: Contains a kernal of truth, but...
There has been a bit of concern in parenting circles about arsenic in rice cereal, ever since a Consumer Reports article on this subject back in 2012. I'll confess straight-up that I live in a country with a rice-based diet and the world's highest life expectancy, which probably biases my own views somewhat. So I'd like to hand this over to KevinMD and his excellent blog.

The Consumer Reports has some sensible advice and information about arsenic in general. But then the report goes all alarming, with a great big table showing the amounts of arsenic in some common rice products, the excessively high ones being shown in scary red font.

Here's the thing, though: in this table, "excessive" arsenic is defined as anything exceeding 5ppb, this being the Environmental Protection Agency's maximum permitted level for water (not rice or any foodstuff). As KevinMD points out, the reason why the levels for any-sort-of-contamination in water are set so incredibly low is because people drink many large cupfuls of fluid a day; any given foodstuff is consumed in far smaller amounts, so it doesn't make any sense to subject foods to the same standards. Of course, ideally nobody wants any arsenic in their food, but as the report itself points out, vegetables and fruits contribute more arsenic to our diets than rice; what's more, all foods contain tiny amounts of poisons/carcinogens--manmade and natural--and trying to completely eliminate them is futile.

For example: two of the rice-y foodstuffs that the Consumer Reports article comes down the hardest on are rice milk and brown rice syrup (a form of sugar). Here's the funny thing: I can remember when people were choosing rice milk as a healthy drink--because they were afraid of soya milk because of the phytoestrogens, and afraid of cow's milk because it was, well, cow's milk. And brown rice syrup was being lauded a few years ago as a healthy alternative to the dreaded high fructose corn syrup. Rice itself became more popular a few years back due to worries about gluten. If we now have to start avoiding rice because it's "bad," we'll have to eat more of something else instead...quinoa, perhaps, or sweet potatoes. Before long, there'll be a media scare story about each of those foods as well and we'll have to replace them with yet another food. And so on. We can either choose to live our lives constantly bouncing around from food to food in an effort to avoid the latest killer de jour, or we can take the approach that there is not a food on the planet that does not contain something that might kill you if you somehow contrived to eat several kilos of said food at a single sitting, and that the solution is to eat a varied diet with a little of everything. Same goes for babies. Same goes for rice cereal.

(For what it's worth, even the Consumer Reports article doesn't actually advocate that people stop eating rice or feeding it to babies altogether--that's just what some worried mums on the internet have been telling each other to do.)

Overall bullshitometer verdict
Overall, there doesn't seem to be any super-strong case in favor of or against rice cereal. It can be used for reflux (but other thickening agents may be slightly better); it can provide iron (but meat-based baby foods may be slightly better). There seems to be little evidence to support any of the other claims, either positive or negative.

Given this somewhat underwhelming reality, why do people talk about rice cereal as much as they do on the parenting boards? I'm guessing that it's because rice cereal has become one of those "materno-political" issues: when mothers say things like "We don't do rice cereal in our family" or "We're giving two servings of rice cereal every day just as the pediatrician tells us" they aren't really talking about the white powdery stuff itself, but are making a statement about what "type" of mother they are. If we took the time to look at the data and see how pallid the evidence is on either side, I reckon we'd all argue about these things less and parenting boards would be more peaceful places.

Further reading:
The Case for Rice Cereal: What it says.

Almost immediately after hitting "publish" I noticed, with mortification, that one of my favorite bloggers, Science of Mom, published her own blog post on starch/amylase in infancy about two weeks ago! I can only assure anyone who has spotted this that there was no copycat intention here--I have had a draft version of this post hanging around for months and kept meaning to finalize the damn thing and publish it, and having been busy with school choices the last couple of weeks I have not been able to keep up with my favorite bloggers at all. Anyway, I thoroughly recommend her fascinating post which looks at amylase in more detail than I am able to. Cheers. BFWOBS.

Monday, October 28, 2013

"Las Dos" and breastfeeding diversity

"Las Dos" 
"Las dos" (meaning "both") is a phrase used among many Hispanic women to describe the common practice of using formula supplementation alongside breastfeeding--not necessarily out of dire need but more as a matter of preference or culture. Many Hispanic women feel that "las dos" offers them and their babies the best of both worlds--they feel that their milk may not be enough, that formula will offer extra vitamins or that breastfeeding is just more convenient this way.

"Las dos" was recently discussed by the breastfeeding advocacy site Best for Babes, picking up from a 2010 poster campaign run by the Massachusetts Breastfeeding Coalition (scroll down to see). The posters urged Hispanic women to breastfeed exclusively, with the legends "Both Breast and Bottle? No!" and "If you give me formula, you won't produce enough milk for me/Your milk is full of important vitamins" in Spanish or English, accompanied by either a worried-looking baby or a picture of smiling breasts versus a bottle with a frowny face. Not a lot of room for ambiguity there, then.

The Best for Babes write-up covers the familiar territory: "But the problem with doing 'las dos' is that it deprives the baby of the benefits of exclusive breastfeeding, and it creates problems with the mother’s milk supply." ("It creates problems," mind you; not "It's possible it could create problems" or "It can create problems for certain women" or "Excessive supplementation creates problems.") We all know roughly what the argument is here: because breastfeeding is supply and demand, giving any formula at all is apt to lead the mother down the "slippery slope" of ever-increasing formula usage. Best for Babes suggested that women who practice "las dos" do so because they don't know better--a suggestion echoed by the study linked to on the same page, "Las Dos Cosas: An Analysis of Attitudes of Latina Women on Non-Exclusive Breastfeeding." (But don't worry; the study noted that "Women consistently demonstrated a willingness to learn from health professionals" about the need to avoid supplementation. So that's alright then.)

How true are the claims?
Now, the whole debate about the benefits of exclusive breastfeeding and how much greater these are compared to supplementing is a complicated one and I won't go into it in full here. I'll just say this: Exclusive breastfeeding to six months matters a lot in developing countries where a single serving of porridge/formula etc. made with contaminated water can kill a vulnerable baby. In developed countries, the benefits are likely to be "modest" and much harder to quantify.

I want to focus on the claim that adding-in formula causes supply issues (the "slippery slope" argument). The  trouble is, the evidence that combo-feeding causes supply problems in Hispanic women is actually kind of weak. For one thing, there's the awkward fact that in spite of frequently preferring to add in some formula, Hispanic women consistently show the highest rates of breastfeeding of any racial group in the United States, as long as the criteria used is "any breastfeeding" rather than exclusive breastfeeding.

What about if you compare Hispanic women who do supplement with those who don't? Linda Geddes looked at this area in her excellent book Bumpology. There's a dearth of evidence on the subject, but there is a 2005 analysis of 6,788 mother/child pairs of various races which found that "65% of the infants who were exclusively breastfed were still receiving any breastfeeding at 4 months compared with only 40% of the children who were fed a combination of breast milk and infant formula during the first week of life" but that "CBFF [combination breast milk and formula-feeding] is associated with shorter overall breast-feeding duration in white but not Hispanic or black mother-baby dyads." So for the babies overall, supplementing with formula early on significantly increases the chance that the mother stops nursing altogether--but for the non-white babies, this seems not to be the case, with those who get formula supplements being just as likely to go on breastfeeding as those that do not.

It tends to be the same story across many ethnic minorities in majority-white countries (African-American women being an important exception (Note 1)). In the United Kingdom, white women have the lowest breastfeeding rates of all racial groups (Note 2), while any-breastfeeding rates and predominant-breastfeeding rates are highest of all for African immigrant women (Zimbabwean, Somali etc.) followed by a tie between Asian (Note 3) and Afro-Caribbean women. But the exclusive-breastfeeding-to-six-months rate is low for all these groups because so many women do things like give formula till their milk comes in, add-in some formula even after that, or start solids before six months. Among Somali women in particular, comparing breastfeeding cessation rates for combo vs exclusive feeders would be tricky because supplementing is so normal that it's hard to find a control group. And exceptionally high numbers of Somali women breastfeed--around 90-95%. In Japan too we have high rates of predominant breastfeeding yet low rates of exclusive breastfeeding--most women add in some formula.

I once talked to a maternity ward nurse who worked in a London hospital where there were a lot of Somali mums, and I asked her if there was any conflict between the NHS's focus on exclusive breastfeeding versus the Somali mums' preference for supplementation. She laughed and said "The new nurses try and talk the mums out of supplementing at first. And then after a while they shut up, because they start to realize that the mums are a) taking no notice, and b) doing a good job of breastfeeding anyway, even though they're technically breaking all the 'rules.'"

Why might white women have more difficulties combo-feeding?
If combo-feeding is indeed more difficult  for white women than for other races, why would that be? There could be some kind of biological mechanism going on, but there could also be cultural explanations.

One possibility is that among white women, adding-in formula is not a cause of breastfeeding issues, but rather is a "marker" for women who tend to have breastfeeding/supply issues anyway. The theory goes something like this: "White" breastfeeding culture (which tends to be dominated by books, lactation consultants and the LLL) places a strong emphasis on exclusive breastfeeding and this is presented to white women as the ideal. So women avoid adding-in formula unless things are going wrong, like supply issues, a baby who isn't latching well or the presence of formula-feeding families/friends who pressure the mother to add some bottles to "fill him up." So when you look at the two groups, the "exclusive breastfeeding" group contains mostly women who find breastfeeding easy anyway, and the "combo-feeding group" has lots of ladies who have supply issues and other problems or are surrounded by unsupportive formula feeders... and maybe it's these issues that are causing them to give up, not the "slippery slope" of the formula itself. Among Hispanic, Zimbabwean etc. women (so the theory goes), combo-feeding is not seen as second-best and so the decision to combo-feed tends not to be strongly correlated with the existence of breastfeeding "problems."

Another possibility is that it's to do with confidence and normalization. If a Hispanic, Somali etc. woman thinks of breastfeeding as normal, when faced with issues she may take the pragmatic attitude of "Let's see if I can mix things up a little." A white Anglo woman may be surrounded by stronger external pressures to formula-feed--if she experiences difficulties she may be more likely to see breastfeeding itself as the cause of her worries, and feel that the best thing to do for her sanity is to cease nursing altogether. She may not have successful combo-feeders among her peers; if she is getting her breastfeeding knowledge and support primarily from online fora and lactation consultants, attempts to discuss combo-feeding may just result in lectures rather than practical advice. Perhaps white breastfeeding culture's emphasis on the "slippery slope"makes a struggling breastfeeder feel that attempts at combo-feeding are doomed to fail anyway and will just add to her stress.

A final possibility is that certain childrearing practices make combo-feeding easier, or are so supportive of breastfeeding that they "make up for" any issues that combo-feeding might create. In my thoughts on breastfeeding in Japan, I mused that the widespread practice of bedsharing (and frequent night-nursing) might be why widespread formula supplementation, low nursing-in-public levels and rigid, old-fashioned hospital routines don't seem to send Japanese women's breastfeeding into a tailspin. Bedsharing is commoner among Hispanic America, African immigrant, British Asian and Afro-Caribbean women than among white women, so perhaps this is worth looking into. Other practices like extended periods of post-partum rest following childbirth, common in several cultures, also merit investigation.

So much to talk about
We have a situation where the highest breastfeeding rates in both the UK and the US are found among non-white ethnic minorities, and in the UK in particular white women are less likely than any other racial group to breastfeed...and yet mainstream breastfeeding advocacy remains very white. In general, breastfeeding advocates' response to the non-white minorities where breastfeeding rates are high has been either to a) Ignore them; or b) Complain that the minorities in question aren't breastfeeding "properly" (because they give solid foods too early or add in formula), and then advise the minorities in question on how to breastfeed in the "approved" way. The Best for Babes article does have some really interesting discussion on how American hospitals and ways in which hospitals have tried to cater to Cambodian-, Chinese- and Mexican-American women's needs, and mentions that Hispanic women initiate breastfeeding more often than white women, yet skirts over the fact that they are also much more likely to still be breastfeeding at six or 12 months. Black Breastfeeding Week in the United States a few months ago provoked some great discussion about the barriers faced by African-American women hoping to breastfeed, but there was surprisingly little discussion of the fact that other groups of black women in America already have very high breastfeeding rates and are highly confident in their breastfeeding abilities.

Wouldn't it be good if these women's voices were reflected more in conversations about infant feeding? I'm curious to know how women from Laos or Nigeria or Somalia feel about the breastfeeding advice they are getting in English-speaking countries. Is it helpful? Is it annoying? Does it allow for individual and cultural preferences? If breastfeeding rates are high among certain groups, wouldn't it be great to start analyzing why they are high? And combo-feeding can be a Godsend to women working outside the home; if we want to develop good guidelines on how to combo-feed, perhaps breastfeeding advocacy needs to be getting more input from groups of women who are already combo-feeding successfully...?

What diversity really means
So many ways to breastfeed---including, apparently, 
with breasts made out of multicolored fun-fur
Although the question of "how much better is exclusive breastfeeding than combo feeding" is complex, in developed countries the differences are unlikely to be large enough to justify the Massachusetts Breastfeeding Coalition's approach of basically ordering everyone to exclusively breastfeed, without pausing to consider cultural
differences and individual preferences, as though the feelings of mothers counted for absolutely nothing. And while the question of whether combo-feeding increases the risk of giving up breastfeeding is not 100% clear, there is enough uncertainty surrounding the issue that the blanket statements of the Massachusetts' advocacy materials--"Breast and Bottle? No!""If you give me formula, you won't produce enough milk for me"--sound pretty bossy and over-the-top.

What we really need is more research on what's going on with combo-feeding and breastfeeding styles among women of various ethnic backgrounds. In the meantime, if some Hispanic women prefer to supplement, I suggest that the Powers That Be in hospitals and elsewhere respect their choice and give them the best advice we have at the moment--like making sure women have the basic facts straight (if a woman is combo-feeding purely because she thinks her baby won't get enough vitamins from breastmilk alone, it's surely reasonable to inform her that that's unlikely to be the case), teaching women how to keep an eye on their supply so that formula use does not keep creeping up and up, and making sure that women understand how to prep and feed bottles in an optimal manner--an area the National Association of Hispanic Nurses is now focusing on. True diversity is not about putting a few token non-white faces on display in breastfeeding books and blogs; it's about opening one's mind to the possibility that there could be many ways to breastfeed successfully.

(Note 1) I use "African-American" to refer to black people in the United States who trace their origins to African slaves in that country, while "Afro-Caribbean" refers to black people in the US and UK whose immediate origins are in the Caribbean rather Africa--i.e. they or their parents etc. migrated from there. I use "African immigrant" to refer to black people who migrated from Africa or whose parents or grandparents did so. I'm not thrilled with the term as I don't think someone who has lived in the UK/US all their life can be described to as an "immigrant," but I don't know of any other term that can be used to include all the people in this group.

(Note 2) Except for Romani Gypsies and Irish Travellers

(Note 3) In the UK, most Asian people are of South Asian origin--i.e. their ethnic origins lie in places like Pakistan, India and Bangladesh--rather than East Asian as tends to be commoner in the US.