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Thursday, May 7, 2015

What to expect when you wean your child at the age of 4.2 years


When I had my baby, I didn't quite expect that I'd be breastfeeding her for longer than 12 months. If you'd suggested to me that the duration of our nursing "relationship" might be reckoned in years rather than months, I'd have laughed and told you to stop talking nonsense.

And yet it wasn't until a few months ago that I nursed my child for the last time. She was just past her 4th birthday--actually, not so far from the famous "4.2 years" which is sometimes bandied about as the global average for the duration of breastfeeding (not true, as I pointed out in another post). Well, it may not be the global average, but it was the average for my children--or child, rather, since I have just the one child and there probably won't be any more of them.

I carried on nursing for this long mostly because I was simply taking the path of least resistance--I didn't mind nursing her and had no particular reason to stop. I stopped nursing her for pretty much the  same reason. She had been losing interest for the last year or so, and I have other ways to relate to my child. She's old enough to do fun things with, now--we can chuck a ball around, we draw together and sound out simple words, she is developing a keen interest in baking and crafts, especially trying to "make" dresses for her dolls out of tissues and play-dough. I can see she will be into knitting and needlework in a few years' time.

After I had realized that she had basically stopped nursing, I was happy enough but felt slightly bothered, somehow, that I couldn't remember when the "last time" was. So when (a couple of weeks later, shortly after her 4th birthday) she asked to nurse again, I agreed and let her, simply because I wanted that sense of closure. I said to her "This is the last time, though, because you're a big girl now." She said "Yes, Mummy," very calmly and demurely. And we nursed that one last time. And that was it.

That was now several weeks ago. No weird hormonal changes or breast oddities so far. In fact, not-nursing-a-preschooler is pretty much exactly the same as nursing-a-preschooler (it had been so sporadic for that last year, after all). I haven't even stopped producing milk. I can still squeeze a drop or two out, even now--a couple of months later. Sometimes I wonder if that will ever go away.

And I'm still interested in infant feeding politics, and I can't see that changing any time in the future either. That interest has to compete with other sources of interest these days, of course--education-related stuff is the new obsession, and my interest in politics has picked up a lot as well in the past year. But I'll still be keeping the blog going, and in fact I'm aiming to get my act together and start posting a bit more regularly. Some time in the next couple of weeks or so, I will be putting a post together on "the real advantage of nursing a child past 12 months." Watch this space.




Thursday, February 5, 2015

Pumping cultures, nursing cultures: Japan, Britain and the United States



I am a British blogger, who lives in Japan... and I follow a lot of motherhood-related stuff in the States, because a lot of my favorite blogs and parenting groups/forums are US-based. There are lots of differences in breastfeeding culture between the three countries that one could potentially talk about--differences in attitudes to supplementation, newborn procedures, cultural oddities like beliefs about alcohol and diet while nursing--but one aspect where one sees big differences is attitudes towards pumping and bottlefeeding expressed milk.

Breastfeeding advocacy has always had an ambiguous, push-me-push-me attitude towards expressing--is it a "good" thing that replaces formula in bottles, or is it a "bad" thing that competes with the act of nursing directly at the breast? You might imagine that cultures which make it easy to nurse your baby directly will also be places that make it easy to pump and bottlefeed your breastmilk. In fact, that's often not the case, as we shall see. A quick disclaimer--the following discussion is mostly based on my personal experiences of these breastfeeding cultures both online and in real life, so this time I don't have a lot of data to back me up. If anyone does have any data that disproves anything here, speak up!

United States
My "main" mums' board when Baby Seal was tiny was predominantly American, and one thing that stood out was the amount of time spent talking about pumping. The United States is almost unique among developed countries in that maternity leave is still not considered standard; unless you are exiting the workforce for a bit, you will probably be back at work about six to eight weeks after giving birth. For US breastfeeders, therefore, pumping is a continual source of conversation, commiseration, competition and anxiety, and US-centric breastfeeding blogs and pages tend to spend a lot of time talking about women's pumping rights at work.

To a certain extent, the normalization of pumping and bottle-feeding EBM has bled over into the experiences of stay-at-home mothers in the US, who often sock away quite substantial amounts of milk in the freezer "just in case," or with the hope of donating it at some point. The custom of carrying bottles of expressed milk around in public for feeding the baby with also seems to be commoner in the US than elsewhere, probably because public breastfeeders are more likely to get hassled (although, like everything else American, this is very regional). Exclusive pumping seems to be commoner in America too--on British fora like Mumsnet, women who want to feed their babies this way are often advised to look on American fora and Facebook pages for advice. Perhaps widespread car ownership also tends to make exclusive pumping a bit more doable in the US than elsewhere, because you can pump in the car and because a car makes it easier to tote bottles, ice packs and heavy-duty breast pumps around with you. A few women even opt for exclusive pumping due to personal choice.

Japan
Complete contrast here. Although you won't actually see many women nursing publicly in Japan, Japanese culture seems to be far more accepting of the "nursing relationship" than the States. But while Japanese culture is fairly nursing-friendly, this does not extend to pumping. You can get breastpumps in Japan, of course, and increasing numbers of women use them. But relatively few women work outside the home when their babies are small, due to maternity leave and the fact that so many women leave the workforce for many years or permanently once they have children. Using babysitters also seems to be relatively uncommon.

As a result, the culture of pumping and bottle-feeding EBM has not become rooted in Japanese culture in the way it has in the States. Quite a lot of women do give the odd bottle, but more often than not there will be formula in the bottle--a fact facilitated by the fact that Japanese mothers seem less likely to place a strong premium on breastfeeding exclusively. It's the same story with the pumping side. If you are one of the minority of women who goes back to work early, don't expect much provision or understanding for your pumping needs if you want to pump. I mostly work from home, but was asked to take on an on-site once-a-week position when my daughter was six months old. When I nervously broached the subject of pumping, they were nice enough but said that there was nowhere in the company where I could express milk. Given that the company in question consisted of a 37-storey megablock, I found that hard to believe--but it was clear that my prospective employers were having difficulty envisaging what I was asking for, because they had never received such a request. In the end, I turned down that particular job for unrelated reasons, but it was an awkward moment.

And then there's the question of getting milk into the baby. Like many things in Japan, the process of sending EBM to daycare is based on lots of silly rules and the most unbelievable inefficiency. In theory, public daycares are supposed to accept EBM; in practice, many of them outright refuse, or put enormous pressure on parents to send formula. If they do accept EBM, the majority insist on the milk being frozen first. Some daycares further stipulate that the milk has to be frozen BUT also pumped within the last week (which means that you basically have to pump, freeze the milk, and then almost immediately dig it out of the freezer to thaw it in the fridge). Apparently, even NICUs often insist on using frozen EBM rather than fresh. I have no idea why the Japanese are so obsessed with freezing EBM--are they under the impression that the freezing process "kills germs" or something? It doesn't, of course (and thawed frozen breastmilk is actually more prone to spoilage than milk that's never been frozen, because the freezing process zaps some of the natural microbicidal compounds). Given the critical shortage of daycare spots in big cities in Japan, it's unlikely that we'll see women demanding that daycares change these ridiculous rules any time soon--most women who have got a spot are too busy feeling relieved and grateful to raise many complaints, and content themselves with writing fake dates on their bags of frozen milk.

Britain
In Britain, as in America, it would be pretty much unthinkable for a daycare to refuse to handle expressed breastmilk. On the other hand, British women, like their Japanese counterparts, tend not to work full time when their babies are young because most take maternity leave. So pumping has never made quite the inroads into British culture that it has in the States (which is perhaps why the slightly awkward word "express" seems to be the commoner verb to use), although the majority of breastfeeders do own a pump and use it now and again. On British (and Australian) discussion fora, quite a lot of breastfeeding advocates encourage women not to make any use of pumping and bottlefeeding at all, on the grounds that conveying milk this way is unnecessary, might mess up the mother's supply and/or create a preference for artificial teats in the baby, and is less healthy/optimal than direct breastfeeding. I think it would be a rare American lactivist who was so negative about pumping and bottlefeeding; so many American breastfeeders work full-time that she would risk alienating a large percentage of her target audience, and if you overemphasize the difficulties of maintaining breastfeeding through pumping and bottlefeeding to mothers who are going to WOH anyway, they might just give up and decide to use formula instead.

Pumping breastmilk to avoid breastfeeding in public is also far less common in the UK than in the US, because although breastfeeding rates in the UK are low, breastfeeding in public seems to be more acceptable than in the States. In any case, the reality is that when you are with your baby and breastfeeding him or her round the clock, it is really difficult to fit "pumping a bottle and feeding it to the baby" into the routine, and if a baby does not get a bottle regularly--several times a week, at minimum--there is a high chance that he or she will eventually reject bottles altogether (as I discovered to my cost). Consequently, it seems that a large percentage of breastfed babies in the UK will not drink from bottles, and this seems to have contributed towards a general feeling on British parenting boards that breastfed babies "can't be left" for any length of time.

Conclusion
Living in Japan, it's certainly easy for me to be irritated by aspects of the culture which are interconnected with the difficulties of expressing and bottling breastmilk. Japanese culture tends to emphasize the importance of the mother-child bond; this can be liberating in some ways (very few people here will look down on you for breastfeeding a toddler or even letting them share your bed), but it's also connected with the fact that Japan has been very slow to get women into the workplace--something which is now a big problem for Japan given its shrinking workforce and its resistance to accepting large-scale immigration. The cultural squeamishness towards breastmilk that's been separated from the mother's body and the lack of legal protection for pumping at work means that many women are not able to pump their milk or feed it to their babies if they want, which deprives them of choice; others (as outlined above) are forced to go through unnecessary and time-consuming procedures which add to their burden. While maternity leave provision is a good thing, I think we should also recognize the fact that some women want to return to work while their babies are small--and they have every right to do so and leave pumped milk if they wish. I don't think that the cultural resistance towards using babysitters does Japanese marriages any good, and I'm not a fan of seeing cranky babies being toted around to smoky restaurants late at night, as is frequently seen here in Tokyo.

On the other hand, normalization of pumping can also become a trap in its own way. There is a danger that each technological innovation can become something that merely shifts the goalposts of what mothers are expected to be able to achieve. Since breastpumps have been invented, women have increasingly been expected to combine breastfeeding and working outside the home (whereas their mother's generation, if they worked outside the home when their babies were small, just shrugged their shoulders and used formula); more efficient breastpumps have raised the bar higher, with working women increasingly expected not only to "breastfeed" but to "breastfeed exclusively without formula supplementation"; with bigger freezers, better designed storage containers and more affordable double-electric pumps, even women who are not working outside the home may increasingly feel that it is expected and normal to pump "just-in-case" stashes or donate milk. And writers like Olivia Campbell may have a point when they suggest that this technological fix (ever higher-performing breastpumps) has enabled American society to avoid confronting the issue of maternity leave, opting instead to place a double burden (working and pumping) on the shoulders of fragile postpartum mothers. Similarly, because most people in the US are aware that pumping and bottle-feeding EBM is a "thing," this can lead to more pressure on mothers to carry bottles of pumped milk around with them, and can become an excuse for negativity towards women who are trying to nurse their babies in public ("Come on, lady--they invented breastpumps for a reason!! Why don't you just pump a bottle before you leave the house??").

Considering each of the above countries in turn, I think my own country--the UK--probably represents the best overall balance for respecting women's right both to feed at the breast and to pump when they need or want to--although I do wish that there was a bit more awareness in the UK of the fact that bottles are not the only way to get breastmilk into a bottle-refusing baby. I hope that each of these countries can work towards achieving a cultural consensus that will allow women and babies to take advantage of the best aspects of both direct nursing and pumping/bottlefeeding--without either becoming something that places unnecessary burdens on women or restricts their freedom.

Further reading

Baby Food: If breast is best, why are women bottling their milk? (Jill Lepore, New Yorker)
Why I pump and why you shouldn't feel bad for me (Healthy Tipping Point)
The Unseen Consequences of Pumping Breast Milk (Olivia Campbell)

Wednesday, December 3, 2014

No-BS breastfeeding resources updated

Finally got round to sorting out the HTML issues on that page, not to mention updating some of the content, getting rid of/fixing broken links and reorganizing the categories somewhat. Will go through and put hyperlinks in at some point. Cheers.

Sunday, November 2, 2014

Bullshitometer: Women with HIV should not breastfeed their babies


Should HIV-positive mothers breastfeed their babies? Canvas a few different sources--the La Leche League (LLL), the American Association of Pediatrics (AAP) and your local mums' group--and you are apt to get several different replies. Who is right? Read on....

Full circle
The commonly-held feeling that "HIV-positive = Don't breastfeed" dates back to 1985, when the first case came to light of a baby infected with HIV from its mother's milk. In the years following, international agencies and non-governmental organizations (NGOs) around the world rolled out programs for preventing mother-to-child transmission which including advising HIV-positive women not to breastfeed while providing them with free formula milk. Given the extreme panic over what was virtually a death sentence, it seemed like mere common sense at the time.

As the years went on, however, concerns began to be heard about the effects of these policies, especially from NGOs and community leaders on the ground who were beginning to see what the rough end of formula feeding in the developing world actually looked like in practice. Reports began to come in of high mortality and morbidity rates among babies who were being bottle-fed in areas lacking clean water, refrigerators or facilities for sanitizing bottles and teats, and where erratic supplies of formula were resulting in mothers filling in the gaps with cow's milk or by over-diluting bottles.

This is what formula feeding in resource-poor environments looks like. 

Breastfeeding, as it happens, doesn't seem to be a very efficient vector of HIV--not least because it contains certain substances which reduce the risk of transmission; indeed, HIV-positive women produce certain immunoglobulins not found in the milk of HIV-negative women such as anti-HIV-IgG, -IgA and -IgM. As the data began to come in, it became clear that even in the worst-case scenarios (mothers who were taking no medications and who were mixing breastfeeding with formula and other foods), the majority of babies were still free of HIV by the time they weaned. In fact, the rate of babies who both survived and were free from HIV long-term tended to be higher for breastfed babies, because so many formula fed babies were dying of other things (1).

What's more, it was also becoming excitingly apparent that the rate of transmission could be beaten down still further by putting mothers on medications to control their viral loads (2); moreover, sticking exclusively to breastfeeding (rather than adding in formula/solids) for the full six months lowered the risk further still (3). It's not clear why mixed feeding increases risk: perhaps the other substances compromise the integrity of the intestinal mucosa, or perhaps the problem is that in developing countries, food is often premasticated (4) (resulting in tiny amounts of blood from gums mixing with the saliva and chewed food). This could also explain why a small percentage of exclusively formula fed infants also tend to wind up with HIV.

So, to bring the discussion full circle: what are the recommendations for HIV-positive women? Roughly speaking: Women in the developing world are now recommended to breastfeed exclusively for six months, and alongside solid foods until around 12 months old if possible. However, HIV-positive women in developed countries are still advised to choose formula--by the AAP (5), by BHIVA (6) and just about every medical body. Why the difference? Because in rich countries, formula feeding is basically safe/fine, and the risk of infection (while against the odds) is therefore more worrying in comparative terms. Oh, and another point which is often forgotten is that HAART medications themselves tend to get into your breastmilk; studies have indicated fairly low toxicity but also to an increased rate of anemia in infants breastfed by mothers on HAART (5). I wouldn't want my baby drinking HAART-laced milk; these are not very nice drugs at all.

Breastfeeding advocates deserve much applause for their tenaciousness in helping to bring to light the serious drawbacks of bottle-feeding in developing countries, a move that will probably save hundreds of thousands of lives. You would think that that would be enough; however, judging from the HIV-and-breastfeeding information displayed by sources such as Kellymom, LLL and Best For Babes, it appears that some lactivists cannot be content with showing the breastfeeding is the best option for HIV-positive mums in developing countries; rather, they insist on trying to make out that it is the best option for HIV-positive mums in developed countries as well. That, roughly speaking, is where the science ends and the woo starts.

Hard cases
In the UK, a large and growing proportion of HIV-positive mums consists of immigrants/asylum seekers from countries such as Zimbabwe and Somalia. They are often highly resistant to the suggestion to formula feed, because of the stigma of bottle-feeding in communities where breastfeeding is normalized, and because of concern that this could "out" their HIV-positive status. The danger is that if these women are threatened with child protection services for breastfeeding, they most likely will continue to breastfeed in secret anyway, and that secrecy will make it impossible to counsel them on risk reduction measures like avoiding combo-feeding, dealing with cracked nipples promptly and so on. They may also be more likely to avoid medical services altogether which will make it harder to vaccinate the kids and so on. For this reason, medics in many countries are now advising pragmatism--counsel mothers to bottle-feed, but if they absolutely refuse, then you support them to reduce risk as much as possible rather than threatening to call in the social workers. It is essentially a "harm reduction" measure, like needle exchange programs for drug addicts; peds are not endorsing HIV-positive breastfeeding any more than needle exchanges are endorsing the use of illegal drugs.

An even harder case is represented by asylum seekers, because if an HIV-positive woman is encouraged to formula feed only to have her asylum application fail, she'll be left up shit creek; she will be forcibly repatriated to her own country where formula feeding is not safe, while her milk will have dried up. Thankfully, this loophole has now been closed (in the UK, at least), with breastfeeding now encouraged for such women until it is clear that they have the right to stay in their new host country. These common-sense and compassionate exceptions will help to safeguard some very vulnerable mothers and babies, so it's a real shame to see that some lactivists have chosen to take advantage of these to try and create deliberate confusion, implying that doctors have now given the green light to HIV-positive breastfeeding for all women in developed countries. In fact, doctors have done nothing of the sort.

Take the World Alliance for Breastfeeding Action (WABA) paper for example (7). Under "Current infant feeding recommendations for resource-rich settings," the WABA paper says:
"Their [BHIVA and CHIVA's] current published Position Paper 48 recognises in paragraph 3 that an HIV-positive woman already receiving triple ART, with a repeated undetectable viral load at delivery may, after careful consideration, choose to exclusively breastfeed for the first six months of her baby’s life. In such a scenario, the current guidance recommends: Continuing maternal triple ART treatment and short-term infant prophylaxis. Exclusive breastfeeding for six months, Frequent follow-up, Careful monitoring of maternal adherence until week after weaning. Monthly checks on maternal viral load and infant HIV status."
This is what BHIVA actually says:
"...avoidance of breastfeeding is still the best and safest option in the UK to prevent mother-to-child transmission of HIV. BHIVA/CHIVA recognise that occasionally a woman who is on effective HAART and has a repeated undetectable HIV viral load by the time of delivery may choose, having carefully considered the aforementioned advice, to exclusively breastfeed...While not recommending this approach, BHIVA/CHIVA accept that the mother should be supported to exclusively breastfeed as safely, and for as short a period, as possible. Thus, 3. In the very rare instances where a mother in the UK who is on effective HAART with a repeatedly undetectable viral load chooses to breast feed, BHIVA/CHIVA concur with the advice from EAGA and do not regard this as grounds for automatic referral to child protection teams...Breastfeeding, except during the weaning period, should be exclusive and all breastfeeding, including the weaning period, should have been completed by the end of 6 months. The 6-month period should not be interpreted as the normal or expected duration of breastfeeding in this setting but as the absolute maximum, since exclusive breastfeeding is not recommended beyond this period under any circumstances. The factors leading to the maternal decision to exclusively breastfeed should be regularly reviewed and switching to replacement feeding is advocated as early as possible, whether this be after one day, one week or 5 months."
Bit of a difference in tone and emphasis, huh? The BHIVA and CHIVA people are very clear that breastfeeding is a less safe option, but that one might consider allowing an exception for an absolute bare minimum of time if Mum really, really wants to breastfeed. The WABA spin makes it sound as though the docs have changed their minds and are all gung-ho for HIV-positive mums to get the boobies out. For what it's worth, the WABA paper is mostly a decent document with a good run-through of why breastfeeding makes sense for HIV-positive mums in poor countries. The problem is that, like a lot of lactivist literature, it can't resist trying to take things a stage further by twisting the evidence to make it look like breastfeeding is now the recommended approach for rich-country mums too. It isn't.

Smoke and mirrors
"IBCLCs can now feel more confident than ever before in supporting HIV-positive clients who express a desire to breastfeed. With certain safe-guards, including maternal adherence to antiretroviral (ARV) regimens which are mandatory in developed countries, the risk of transmission of HIV through breastfeeding can be reduced to virtually zero" states international board certified lactation consultant (IBCLC) Pamela Morrison in New HIV and Breastfeeding Resource from the World Alliance for Breastfeeding Action (WABA) in early 2013, which discusses the WABA paper mentioned above.

Now, that WABA paper is a little coy about the exact HIV/breastfeeding transmission figures--it kind of hides them away in the middle of one of the files--but when I found the relevant figures and crunched the numbers, it works out as follows: if you do everything "right" (proper ARV regime, exclusive breastfeeding with no formula or solids), your chance of transmitting HIV by age six months is about 0.74%, or approximately 1 in every 135 babies. That is not "virtually zero." It's a decent level of risk for a mother in a Cambodian stilt village; for a mother in a developed country who can formula feed safely it is absolutely unjustifiable, considering that we're talking about an incurable viral infection which requires a lifetime on a pretty unpleasant drug regime.

Shockingly, when two HIV-positive mothers themselves ask for advice in the Comments section on Morrison's article, Morrison continues to recommend breastfeeding to them without enquiring as to whether they are living in an area where formula-feeding is feasible, and even (in one case) after the mother has herself stated that she lives in the United States. We even see her advising a mother on nursing to 12 months--not six--which significantly increases the risk of infection above that 1-in-135 figure. Morrison's spin about reducing the HIV infection risk to "virtually zero" was picked up by several lactivist blogs and pages, including Best for Babes on 9 January 2013 which repeated the statement uncritically: "Big news for lactation pros and HIV-positive mamas!"

Why you should always read the original paper
Best For Babes is apparently not alone in writing odd headlines for articles they link to. On 29 January of the same year, the Kellymom Facebook page made the following post:
"The US Academy of Pediatrics Committee on Pediatric AIDS has come out with a paper saying breastfeeding should be accepted by HIV-infected women in the US under certain conditions..." 
followed by a link to the AAP's latest guidelines on Infant Feeding and Transmission of Human Immunodeficiency Virus in the United States. Now, this is what the guidelines actually say:
"An HIV-infected woman receiving effective antiretroviral therapy with repeatedly undetectable HIV viral loads in rare circumstances may choose to breastfeed despite intensive counseling. This rare circumstance (an HIV infected mother on effective treatment and fully suppressed who chooses to breastfeed) generally does not constitute grounds for an automatic referral to Child Protective Services agencies. Although this approach is not recommended, a pediatric HIV expert should be consulted on how to minimize transmission risk, including exclusive breastfeeding... 
and the opinion of the good doctors is and remains that "in the United States, where there is access to clean water and affordable replacement feeding, the AAP continues to recommend complete avoidance of breastfeeding as the best and safest infant feeding option for HIV-infected mothers, regardless of maternal viral load and antiretroviral therapy" due to the risks from infection and from drug penetration into the mother's milk. Anyone who does not actually click on the link and comb through the article (=85% of people on Facebook) is going to come away with the impression that doctors in countries like the States have now basically given HIV-positive mothers the green light. (Kellymom is no doubt fully aware that this is what will happen, and spins articles this way for precisely this reason.)

More recently, Kellymom enthusiastically heralded the arrival of a new issue of La Leche League International (LLLI)'s online magazine with a feature on "Breastfeeding for HIV-Positive Mothers." This piece contains all the usual smoke-and-mirrors stuff common to other lactivist resources on HIV. It makes vague references about exclusive breastfeeding being protective, while being coy about the fact that EBF is only protective in comparison with mixed feeding--when compared with formula feeding, it is still more likely to pass on HIV. It cites the Courtoudis study, which is the one and only (small) study where the breastfed babies were no more likely to get HIV that the formula-fed ones, but then completely fails to cite all the other studies (such as the Mashi study (8)) which all show that formula fed babies are less likely to get HIV. It repeats the misleading spin on the AAP's and BHIVA/CHIVA's stance on HIV which I described above.

It's disappointing to see Kellymom linking to this kind of thing. Then again, what can you expect from a website whose own HIV page is such a mess? The "HIV/breastfeeding" stuff on Kellymom consists of the following (see here and here):
(1) an article on ARV regimes for women in East Africa (irrelevant to the vast majority of Kellymom's readership);
(2) an article on the increased risk of transmission with mixed feeding in Zambia (again, irrelevant) which Kellymom has, confusingly, chosen to subtitle "Prolonged Breastfeeding Protects Kids From HIV" (the article does not say this);
(3) a broken link which appears to have once led to yet another set of recommendations aimed at the developing world;
(4) the bizarre "AnotherLook at breastfeeding and HIV/AIDS" page, which contains a Mothering Magazine article by the AIDS denialist (and, for that matter, germ theory denialist) David Crowe.

I think my "favorite" bit of Crowe's article--which is a nest of pseudoscience and conspiracy theories--is the bit where he decides to raise a glass to one Christine Maggiore for her brave stance against the evil establishment: "Christine Maggiore defied the authorities and, perhaps because she was a public figure with a wide support network, was able to continue to publicly breastfeed her two children." Readers, the well-known AIDS denialist Christine Maggiore is dead. Of AIDS. So is her daughter Eliza--quite probably because she consumed her mother's infected milk. I don't know if Crowe included this reference as some sort of unpleasant joke or because he thinks that his readers don't know how to Google stuff, but I really do have to wonder why on earth Kellymom thinks that it is remotely acceptable to have links to this kind of stuff on their website.

Conclusion
The swing back towards recommending breastfeeding for most women in developing countries is a huge achievement for public health and child survival. Nevertheless, the risk of HIV transmission via breastmilk remains, as does concern about the impact of ART drugs which penetrate the milk. Breastfeeding is therefore not recommended for women in developed countries with the exception of asylum seekers of uncertain status.


Further reading:
(1) Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival, Iliff et al, AIDS
(2) WHO Guidelines for PMTCT & Breastfeeding
(3) Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study, Coutsoudis et al, The Lancet
(4) Premastication: A Possible Missing Link? Mark J. DiNubile, Clinical Infectious Diseases
(5) Infant Feeding and Transmission of Human Immunodeficiency Virus in the United States,
COMMITTEE ON PEDIATRIC AIDS, Pediatrics
(6) Position statement on infant feeding in the UK, BHIVA/CHIVA Writing Group
(7) Understanding International Policy on HIV and Breastfeeding: a comprehensive resource, World Alliance for Breastfeeding Action (WABA)
(8) Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana: a randomized trial: the Mashi Study, Thior et al, JAMA



Monday, October 27, 2014

The earthquake


Even when you live in a country like Japan which experiences minor tremors on a frequent basis, the sensation of a big quake--like the one that rocked Japan on 11 March 2011--is something you are never really prepared for. Feeling the ground suddenly liquidize itself under you while the walls on either side groan and rattle is fundamentally frightening in a way that is hard to put into words. Floors are not supposed to move about.

I spent the evening of 11 March alone--the phone line was down, and my husband was God knows where. It grew darker. The building still shook every now and again. I camped out on the elevator landing,  my cat in a cat carrier next to me in case we suddenly needed to make a dash for it.

Fortunately the internet connection cable was long enough to extend into the hallway, and the connection started working after a while. "Just as well the shock didn't send me into labor," I Facebooked via my laptop, attempting jocularity. "I suppose I had better make sure of my route to the hospital for next Thursday, when my cesarean's booked..." I was exactly 38 weeks pregnant at this time.

At 5:15 on the following morning, I woke up and realized my waters had broken.

Thankfully, there was one train line operating. We crowded in for the 45-minute journey to Hiro, then walked the rest of the way. You couldn't get a taxi for love nor money, of course. I don't remember much about the operation except that they were in a bit of a hurry--the cord suddenly started slipping out and I ended up head down on the table with a mask over my face. "Take deep breaths for the baby." Then suddenly, she was out. I saw her, just for a second, shortly before another aftershock sent the room rattling around us.

Everybody's looking for the sun... 
People strain their eyes to see...
But I see you and you see me
And ain't that wonder? 

*********

The next few days were the strangest time of my life. Because I couldn't walk very far, I stayed in my room--a private room, very quiet and peaceful. My husband stayed the first day, but then had to pile into the office to cover the shifts of his colleagues who were unable to get into Tokyo. Thank God for my mother-in-law, and for the kind, kind nurses, who seemed to float around the hospital surrounded by glowing halos of peace and serenity. They always spoke so softly and evenly, as if their very voices had undergone intensive carework training. And they never stopped smiling, even when I was calling them out in a panic in the middle of the night about the baby, about my latch, about my stitches, about everything.

Well, not quite everything. There was, of course, the word that I was starting to hear echoing around the TV news reports, Facebook, newspaper articles, like an ominous drumbeat in the back of my consciousness. "Fukushima." It was the word I would not say--not to the nurses, not to my mother-in-law. Saying the word out loud would have made it real--dragging the whole ugly mess right into the middle of the softly-sunshiny hospital room.

*

Nighttime. Best to get to bed early--that's what they always say.

The phone rings: "You're still in Tokyo? Oh, okay. You have heard about how you're supposed to keep the windows shut? Okay, just thought I'd let you know. Me? No, I'm in Singapore. Rajiv put me straight on a plane... Oh no, Em, I'm sure you'll be fine! How's the baby?"

Head down again. Need to sleep. Mother-in-law silhouetted in the doorway, rocking and rocking the baby.

Jolted out of sleep a few hours later by another phone call. "It's Marie here." Ah--my "highly strung" friend. "I'm sorry, I know it's the middle of the night. But I need to talk... No, I'm in Osaka now. Em, I keep having this thing where my heart starts beating like crazy and suddenly I can't breathe? Like something tight round my chest... and I keep thinking that the room is shaking even when it isn't? I've been wondering--d'you think I could be having a nervous breakdown? Is this what it feels like?"

I manage a few more hours of sleep.

Text message, early hours of the morning: "I saw the news last night, and I just thought, you want me to put some formula in the post for you? Dunno when it will arrive. Would be no bother. Let me know. Take care love. Chin up."

Text message from yet another friend saying she's probably going to leave Japan for good. "I just feel like it's time. I think a lot of people will be leaving, actually."

*

By the end of the second day, I'd worked out a sort of system for not losing my mind. There was a discussion thread on my favorite website, Ravelry, that had some actual nuclear engineers chipping in and offering some useful links, including the Atomic Insights website written by a nuclear industry insider; I kept these carefully bookmarked on my phone, along with some PG Wodehouse audiobook stories. Whenever I could feel the panic bubbling up inside me, I would click on the Ravelry discussion and the Atomic website and gulp their words down, like a big cold glass of water when you are dying of thirst--"This is not Chernobyl. Fukushima is not having a meltdown. Most radioactivity in the environment comes from natural sources..." Blah, blah. Good, good. I need to hear that. Deep breathing. Then I would do PG Wodehouse for an hour or so--just lose myself in the plot and pretend I am a long, long way away from here (Some women comfort-eat when they are stressed. I comfort-read). I discovered, through trial and error, that if I put this series of procedures into practice as soon as the panic started to surge, I could buy myself a few hours of calm before the next attack.

Baby Seal is asleep now, long eyelashes fanning her soft cheeks. She looks peaceful. Sometimes I wonder if I am poisoning her with every mouthful she sucks from me.

*

I learned fairly quickly that you should stay away from Facebook at all costs. By Day 3 it was a frenzied rumormill--people drinking iodine, saying the Big One was about to hit Tokyo and collapse everything like a house of cards... that the government is lying, and the media is stitched up, and anyone not getting out of the city nownownow is going to find themselves stuck in a hideous, Katrina-like crush, right at the end of everything, like rats in a trap, no way out--

Friends sent me goodwill messages and asked about the baby. Most couldn't visit, of course. I sent chirpily upbeat replies. It's important to act normal.

You can turn on the TV, of course--I had one in my room--but I wouldn't if I were you. Water bursting through the streets, cars swirling around like Tonka Trucks in a filthy black whirlpool.... Change channels, quickly. Japan's national TV station seems to have suspended a lot of its normal TV schedule and started showing a sort of "relaxing filler programming" instead--easy-listening Japanese folksongs played against meaningless backdrops of peaceful mountain scenery and fields of rippling golden wheat, that kind of thing. The sort of thing that the North Korean government probably shows to pacify its citizens right before they test-drive a few nuclear missiles.

*

Sitting on the bed next to my baby, heart pounding, staring at the striped cotton bedspread, scratching at it with my nails. My God, my God, what are you doing here? Only an idiot would stay when you know that everyone is going to die. My God, you had a baby, and you can't even manage the basic step of keeping your baby safe, you cannot even get that right, you useless. fucking. waste. of. space--

*

I think it was around the morning of Day 4 that I basically lost it. Sometimes, when you are speaking your non-native language all day, you reach a point where trying to explain yourself gets too exhausting, and when a kind nurse touches your hand and asks you how you are doing, you just sit there and cry. So that's what I did.

"It's okay. We've been watching you, we know that you're stressed. Muri ni shinakute ii desu yo [don't push yourself to the limit]. Why don't we just take her to the nursery for a while--maybe tonight as well? It's fine, everyone does it."

And I cried even more, not because I actually needed the baby to go to the nursery and not because the nurse's words would do anything about the earthquake, the swirling bodies, Fukushima--but because I was hurting with thankfulness that these people, whom I had never met before, were watching over me. That they cared about what was going on inside my head.

*********

Many women experience an earthquake of some kind when they become mothers. For some women it might be an actual earthquake; for others it's an agonizing labor that lasts for days, or a horrific birth injury, or a baby that screams and screams and screams and will not stop. What helps us through these times is the kindness of others--sometimes people we know, sometimes virtual strangers. I could not have got through those first few days without the endless kindness of my blessed, saintly mother-in-law--and the nurses who looked at me and saw past the foreign face, the language barrier, and saw someone who was having a hard time. They showed me that they cared about me--not just my baby, but me.

Whatever policies hospitals choose to put in place for new mothers, I hope that they never lose sight of one thing: that a woman who has just given birth is a person, not a childcare-providing machine or a pair of lactating tits on a stick. Because no matter how long a woman lives, she will never, ever forget how she was treated by those around her when she first became a mother, and whether they let her know that her feelings mattered as well.



Names have been changed in this post.

Wednesday, August 13, 2014

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

NO BABIES HERE, PLEASE
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."

NO BABIES HERE, PLEASE

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."
NO BABIES HERE, PLEASE
Issues
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.

Conclusion
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.