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.