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.

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,
(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)

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.