Saturday, August 31, 2013

Why we need "feeding rooms," not "breastfeeding rooms"

It's a funny thing about Japanese breastfeeding; breastfeeding rates here are high, yet you will rarely see a woman actually nursing. I remember pondering this question in pre-motherhood days and being very puzzled by it. Later on, however, I understood how things worked after I was initiated into the mysteries of the popular Japanese institution of the junyuushitsu (“breastfeeding room”).

These rooms, commonly found in stations, department stores, shopping centers and other facilities, vary considerably; some are little more than a small cubicle with a couple of chairs, while others are quite spacious rooms equipped with sofas and equipment ranging from vending machines to taps emitting water heated to 70 degrees C (accompanied by a little sign assuring users that the water in question was bottled and filtered—my brief period of nursing-room use was shortly after the TEPCO nuclear meltdown in Fukushima, following which parents were warned not to use tapwater in babies’ bottles after briefly elevated levels of radioactivity were reported). As this implies, the larger junyuushitsu are often used by bottle-feeding parents as well; breastfeeding mothers using these rooms have the option of disappearing into a curtained-off cubicle if they aren't happy about being visible to any dads who might be on the couch giving a bottle.

I made sparing use of these rooms back when Little Seal was a baby, mostly in the newborn days when I was nervous about breastfeeding her in public; even after I had gained more confidence, there were times when there was something to be said for making an all-in-one stop (feed + diaper change) without having to shell out US$6.00 on a cup of coffee. That said, I usually fed wherever I happened to be, albeit with a nursing cover.

Why breastfeeding rooms are controversial
Breastfeeding rooms have been cropping up all over the place in the Western world too, and are an increasingly common sight in shopping malls and transportation hubs. One Vermont company is even using crowdsourcing to build free-standing "lactation stations":  "Mothers deserve a clean, comfortable, private place to pump and nurse – not a bathroom." While on the face of it, such rooms appear to be a supportive measure for breastfeeding, they’ve always been accompanied by controversy.

"They seem to prefer the idea of hiving off bf mothers into corners so they're invisible to the rest of the population....." "The potential problem with this is that, once these areas are set up, members of the public and/or service station staff might start trying to send all bf-ers to these areas - 'Excuse me, didn't you know there's a private area for that?' - and before you know it we'll be segregated into some dank area that smells of soiled nappies, and where the dirty crockery is never removed," grumbled commenters on one discussion regarding a government proposal to establish nursing rooms at motorway stations in the UK. The commenters are expressing a commonly-held view that breastfeeding rooms actually discourage breastfeeding by sending out unwelcome messages--that breastfeeding is inherently shameful and should be hidden away, that it can only be done in special places and that women who are out and about should be required to spend their time hunting for nursing rooms—and by giving ammunition to those who harass women for nursing in public.

I don’t think these are idle concerns at all. I have seen numerous discussions in which a woman’s right to breastfeed her baby in a café or restaurant was shot down on the grounds of “There are mothers’ rooms where you can do that kind of thing. Why can't you just feed in there?” Here's the thing, though: if I am having lunch or a coffee, I’d prefer to feed my baby where I am, thank you, rather than leave my friends and drag myself off to some separate area, as though I were committing some disgusting act, while my meal gets cold. And trying to get your errands done with a baby (who may feed as often as every 1.5-2 hours in the newborn period) is tough enough without having to plan the whole outing around the availability of nursing rooms. Or drag yourself, stroller and shopping up and down the corridors of some God-forsaken shopping center or railway station trying desperately to find the nursing room, while your hungry infant wails and everyone glares at you.

And yet… I don’t think nursing rooms can simply be written off as A Bad Thing, either. Some women are always going to be too shy to feed in locations where others can see them—especially in the newborn days when trying to latch can feel like assembling a particularly fiddly piece of flatpack furniture. Some babies go through distractible phases and try to rubberneck everything in sight, which can make feeding a nightmare. Sometimes the need for a feed strikes when you not in a café but in the middle of the supermarket or something—even the most chirpy lactivist might feel more comfy feeding on a chair rather than sitting herself on the floor next to the fruit and veg. We also have more mothers who pump exclusively nowadays; I completely support mothers' right to pump in public, but I think we need to be realistic about the fact that very few women are actually comfortable doing this. Trying to find clean and private places to pump on-the-go can be a nightmare for EPing mothers, who often resort to toilet cubicles. In short: I like the existence of breastfeeding rooms. But I don’t want mothers to be chased into them.

What about bottle feeders?
At first glance, providing special spaces for people to bottle feed (like the British department store John Lewis does) sounds a bit odd. But formula feeders may also find themselves sometimes dealing with distractible babies or having to give a bottle in an environment where there is nowhere to sit down. Whatever the reason, formula feeders surely also deserve the option of a quiet space where they don’t have to purchase a cup of tea. Unfortunately, this raises some tricky issues. Formula feeding, unlike breastfeeding, can be done by both men and women. Nobody wants to discriminate against fathers (God knows, the lack of changing tables in most mens' toilets is annoying enough); and yet the fact remains that many breastfeeding mothers use breastfeeding rooms precisely because they don't feel comfortable nursing when there are men around.

A modest proposal

Suggestion: Dump the idea of “breastfeeding rooms” and instead shift towards the concept of “feeding rooms" or "parent and baby rooms" where all parents are welcome, along the lines of the larger junyuushitsu I see in Japan and the generalized "baby rooms" which are sometimes found in the United States and Britain. And—this is important—the sign on the door should contain a message along the following lines:

Parent and Baby Room
Parents are welcome to breastfeed/bottle feed babies anywhere in our facilities; this room provides a quiet space for those who prefer privacy.

What feeding rooms need to have:

  • “Essential”

- Chairs where both breastfeeders and bottle feeders can sit in comfort and feed their babies
- Small curtained-off booth/area with a chair, exclusively for breastfeeding/expressing mothers who prefer privacy
- Table (where bottles can be mixed and prepped)
- Handwashing facilities
- Electrical outlet (for electric breastpumps)

  • Not essential, but “nice to have”

- Tap dispensing hot water heated to 70 degrees C
- Vending machine with drinks, snacks and baby supplies—baby wipes, ready-to-feed (RTF) formula cartons, disposable diapers and hand sanitizer
- Magazines, pleasant décor and a bit of general nice ambience

I really feel that establishing rooms along these lines--rather than "breastfeeding rooms"-- could solve several problems simultaneously. They would, obviously, provide a quiet space for breastfeeding, pumping and formula feeding parents. By shifting the emphasis towards “supporting all parents/providing a relaxing space” rather than “hiding breastfeeding,” they could resolve the awkward questions that are raised about breastfeeding and women’s right to do it in public. And a clear, visible statement affirming women’s right to nurse anywhere in the shopping mall/station/airport etc. would help ensure that the existence of feeding rooms does not become a tool for harassing nursing mothers; anyone who walks past the door and sees the sign will get a bit of education on mothers’ nursing rights, rather than simply registering the existence of the room and interpreting this to mean that mothers are “not supposed” to breastfeed anywhere else. Finally, the provision of a curtained-off space within the room would mean that shy mothers and exclusive pumpers get the privacy they need. 

A couple more things: Whoever is in charge of designing baby rooms… please, please consider separating the baby changing facilities from the feeding areas. If they really have to be in the same room, for God’s sake make sure the bin is regularly emptied and the room is a decent size and well ventilated. No parent should have to feed their child in a stinking room next to a (usually overflowing) nappy bin, or express milk in an environment with feces hanging around (contrary to popular belief, baby poo contains similar bacterial concentrations levels to adult feces and can carry pathogens that spread disease). As I discussed previously, there is good evidence that breastmilk expressed in cleaner conditions stays safer for longer. Oh, and while you’re at it, please install chairs without arms; I don’t know what idiot decided that it’s easier to feed a baby in an armchair, but they clearly haven’t based this decision on experience. And could the sign on the door include a picture of a bottle and the International Breastfeeding Symbol, or something neutral, like a picture of a baby? 
I’m aware that all this may sound a little demanding. Still, installing a vending machine with bottled drinks and baby supplies might help cover some of the cost. Also, in the brave new world of online shopping that we now live in, brick-and-mortar retail is having to undergo a certain amount of reorganization; less focus on boring and functional provisioning, more emphasis on the fun and leisure aspects of shopping. Making sure that shopping is not a ghastly experience for parents is one obvious thing that malls and department stores can do to encourage parents to shop in their stores; shoppers these days expect nicer treatment as a reward for turning up. Supporting parents of all feeding styles and genders would be a win-win for everyone concerned.

Friday, August 9, 2013

Bullshitometer: Is it OK to leave breastmilk out of the fridge for several hours?

Information on storing expressed breastmilk (EBM)--particularly the question of how long you could leave it outside the fridge--wasn't something I really focused on back in the days when I actually used a breastpump--probably because as a freelancer I was lucky enough to have very little need for pumping. Scrutinizing milk storage guidelines is something mums tend to do if they are away from the baby a lot, because they are trying really hard to use every last drop.

So I always treated breastmilk as highly perishable, and pumped it on the day it was to be given or occasionally froze a bit for a few days. When I accidentally left a freshly-expressed container on my desk for a few hours once, I chucked it. I wasn't too sure what the guidelines were, but breastmilk is raw milk.... right? And I certainly wouldn't drink a bottle of raw milk that had been hanging around in the fridge for days, nor would I drink a glass that had been on the counter for more than a short time. (Well, okay, I don't think I'd drink raw milk period, but that's a side issue.) 

So I was a bit surprised and wary when I started coming across information—fellow online discussion group members, backed up by Kellymom, La Leche League and all the usual sources—stating you could leave a container of EBM at room temperature for up to eight hours, and for several days in the fridge. Could this really be true? After all, we all know that a bottle of formula can't be left out at room temperature for more than a couple of hours...

What the guidelines say
I could be forgiven for being a bit suspicious of the claims of Kellymom and LLL et al in this area, since a) they’ve made a few dodgy claims in the past; and b) the evidence basis underpinning these claims seemed to be a bit, well, weak. It consisted of some studies--see Hamosh et al, Igumbor et al, here, Ajusi et al, Sosa et al, Olowe et al, and Slutzah et al for examples--which either expressed some breast milk and measured what happened to the naturally-present bacteria after several hours at various temperatures, or deliberately contaminated some EBM with specific bacteria in order to see what happened ("challenge studies"). The studies show some quite impressive results, with bacteria appearing to grow unexpectedly slowly or even dying off in the breastmilk, while no such results were seen for infant formula. Unfortunately, we are talking about a limited number of studies involving, in most cases, only a small number of samples; some of the studies are also quite old, dating back to the 1980s in some cases.

However, I concluded my suspicions may have been a little hasty after perusing Handling and storage of expressed breast milk, a set of guidelines issued by the Microbiological Safety Division of the Food Standards Agency of the United Kingdom and used by the National Institute for Health and Care Excellence (NICE)—and as such, likely (I felt) to represent a more neutral and trustworthy viewpoint on the subject. Based on its review of the evidence in existence, the guidelines state: "Many studies have looked at the growth of bacteria in EBM under different storage conditions in both tropical and temperate climates… Many of the studies in this area are relatively small and are often difficult to compare directly due to design and methodology. However, collectively they provide a reasonable body of evidence in support of the bacteriostatic behavior of EBM during several hours under ambient conditions and several days at refrigeration temperatures." Similar conclusions were reached by the Center for Disease Control (CDC) and the Academy of Breastfeeding Medicine (ABM). In other words, it looks as though Kellymom et al are basing their assertions on a handful of rather small studies because that really is pretty much all we have to go on right now, not because they are cherry picking. 

Advice on how long one can leave breastmilk at room/refrigerator temperature varies quite a bit from source to source. Around 3-8 hours at room temperature, and 3-8 days in the fridge are typical recommendations from sources such as LLL, Kellymom, Medela, Ameda and the CDC, but I have seen suggestions ranging from "up to two hours at room temperature, up to two days in the fridge," to Jack Newman's suggestions of up to 8-12 hours at room temperature and 8-11 days in the fridge.  

“Room temperature" can mean different things. Unsurprisingly, the higher the surrounding temperature the faster bacteria multiply (as the Igumbor study noted). The ABM protocol suggests EBM may be stored for up to 8 hours at lower temperatures, but only up to 3-4 hours at 27-32 degrees C, while the Hamosh study states that breast milk "should not be stored at 38 degrees C."

Surprisingly, fridge temperature can vary as much as room temperature. From the NICE guidelines: “The last comprehensive domestic refrigerator survey in the UK was carried out in 190. The mean temperature found ranged from -1 degree C to 11 degrees C over a 7-day period, and the overall mean temperature was 6.6 degrees C, with nearly 70% of fridges operating at more than 5 degrees C. Variation was found in performance between fridges and within each fridge over time. Different temperatures were also recorded in different parts of single fridges.” Other surveys cited by the guidelines tell a similar story. This matters, because assumptions that EBM is safe in the fridge for several days are based on studies that examined breast milk place in refrigerators that really had been set to the correct temperature.

As stressed by the ABM protocol, “Studies show that human milk containing fewer bacteria at the time of expression develops less bacterial growth during storage and has higher protein levels compared to milk that has an abundance of bacteria.” As shown above, the ABM suggests that the upper limit for storage (6-8 hours at coolish room temperatures) is only acceptable if the milk is "very clean." This is echoed by the NICE guidelines, which emphasize the need for "attention to hygienic preparation."

Raw (breast) milk
Breastmilk has a number of interesting compounds which either kill bacteria ("bactericidal") or stop them from multiplying ("bacteriostatic"), including secretory IgA, leukocytes, lactoferrin, lysozyme, lactoperoxide and lactobacillus bifidus growth factor. These appear to work to suppress the growth of bacteria in EBM; they don’t exist in formula, which is why a formula bottle can’t stay out of the fridge for too long. The way breastmilk can kill bacteria or stop them in their tracks is fascinating but much too complex to cover here; see "Further reading" for more information. 

It's important to bear in mind that thawed frozen milk has less bacteria-inhibiting power depending on how long it was frozen, because some of these compounds are significantly affected by the freezing process. This is even truer for pasteurized milk.

Many of these compounds also exist in raw (=unpasteurized) cow’s milk—and I'll be frank, part of the reason why I was initially skeptical of the idea that it was okay to leave EBM hanging around for hours at room temperature was because I would never dream of doing the same thing with raw cow's milk, even if I did choose to drink such stuff. I am assuming that this difference has to do with the cleanliness of the collection conditions, something stressed by the NICE and ABM guidelines. Women have—quite rightly—fought for the right not to be sent to toilet cubicles to pump their milk, whereas if you’re a cow, the world is your toilet because cows crap everywhere (including during milking) and cow manure splatters. Even the cleanest milking barn isn’t an setting where I would feel comfortable pumping milk for my child. 

Bullshitometer verdict
Is it okay to leave breastmilk at room temperature for several hours (or in the fridge for several days)? My answer is that, thanks to a number of useful bacteriostatic and microbicidal compounds found in EBM, the correct answer is probably a cautious “yes.” Turns out I probably could have used that forgotten container that I poured down the sink.

Some caveats. Firstly, “a few hours” means just that—not 8-12 hours as a few sources like Jack Newman have claimed. Given that Newman gives no evidence basis for such generous time periods and none of the studies that I have seen support them, I am going to go ahead and discount them (along with Newman's other helpful suggestion that we should just avoid the need for expressing in the first place by bringing our babies with us absolutely everywhere, including the cinema.... erm, no thanks, Jack). The ABM’s suggestions of [*Room temperature] 3–4 hours optimal, 6–8 hours acceptable under very clean conditions; [*Fridge] 72 hours optimal, 5–8 days under very clean conditions,” seem more reasonable and accord with the (admittedly rather limited) studies that have been performed.

Secondly, "room temperature" really means something not much higher than 30 degrees C; if mothers are planning to be out and about all day in hot weather, a cooler pack with ice sounds like a good plan.

The "store in the fridge for several days" thing requires a little caution too, simply because in the real world people's fridges are frequently nowhere near as cold as they should be. If mothers want to leave EBM in the fridge for several days, they would be wise to think about the age of their equipment, maintain the fridge properly, use a fridge thermometer and store EBM at the back of the fridge, not in the door (which is significantly less cold).

Finally, as discussed in the ABM protocol, the storeability of breastmilk depends a lot on how cleanly it is expressed. Over the past few years there has been a big increase in computer and cellphone usage at work and leisure, with many mothers fitting pumping sessions in between typing sessions--and keyboards are notorious for being covered in germs. Very careful handwashing would appear to be called for if we want to store breastmilk as long as permitted by the studies that have been cited. And for a number of reasons, exclusively-pumping mothers are a lot commoner than they used to be. So we also need consider ways to ensure that women have safe and clean places to pump not just in workplaces but also in shopping centers, stations and so on.

Finally: just a plea for more and better research on EBM storage and microbial safety! These experiments are surely not particularly complicated to undertake, and with more mothers expressing milk than ever before, there is clearly a need for more information. Really good, evidence-based guidelines would improve safety, increase mothers' confidence and perhaps encourage the acceptability of EBM among daycare nurseries that are currently reluctant to handle the stuff. 

Further reading
Good basic guidelines. It includes an interesting table allowing you to compare the time limits recommended for different storage conditions by all sorts of different sources, from UNICEF to the UK Association for Milk Banking.

ABM Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants (Original Protocol March 2004; Revision #1 March 2010)
A more detailed guide, including discussion of appropriate container type and issues such as thawing and refreezing.

Antimicrobial Activity of Breastmilk Against Common Pediatric Pathogens
Esperanza F. Rivera, M.D. and Ricarchito B. Manera, M.D.
A bit old, but this is a nice readable overview of EBM's bacteria-zapping properties.

Antimicrobial Factors in Milk
Illini DairyNET (the Online Resource for the Dairy Industry)
This one looks at cow's milk, and is an interesting comparison.

Effect of storage and heat on antimicrobial proteins in human milk.
T J Evans, H C Ryley, L M Neale, J A Dodge, and V M Lewarne
More detailed information on the extent to which freezing/heating EBM can alter its bactericidal/bacteriostatic powers.