tag:blogger.com,1999:blog-90640218430061042872024-03-13T03:03:17.454-07:00Breastfeeding Without BSBringing some science--and common sense--to the world of breastfeeding blogs.BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.comBlogger60125tag:blogger.com,1999:blog-9064021843006104287.post-46909908786287341192019-06-11T05:34:00.000-07:002019-06-11T05:34:19.963-07:00I love glass baby bottles<div>
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Oh the joy of a breastfed baby who will accept bottles! <b><a href="http://breastfeedingwithoutbs.blogspot.com/2012/07/how-to-have-bottle-refusing-baby-and.html">After my experience with my first baby</a></b>, I was <i>that</i> close to just not bothering with bottles at all this time round. Having seen Little Squish accepting a dummy with my own eyes, however, I warily decided to buy a couple of bottles and let her have a go. Wow, what a difference it makes! Cup feeding and spoon-feeding EBM are all very well, but they are messy and slow. Being able to leave baby for several hours at a time without worrying is just so liberating. Thank you, Little Squish. It's very very much appreciated.<br />
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When buying bottles, I unhesitatingly chose glass, same as the first time round--and it seems that glass has been coming back into fashion, because our regular baby store had both plastic and glass options, produced by the most popular mainstream baby bottle brand in Japan (Pigeon, in case you are wondering. They do breast pumps as well). My mother was not keen on the idea ("What happens when she starts grabbing them from you and chucking them on the floor?") but then, she is of the generation that grew up during the era of old-school glass bottles which probably broke as soon as you look at them, and was no doubt very grateful to switch to plastic. These days, glass bottles are practical, and I think they are by far the nicer choice.</div>
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Glass bottles look, smell, taste, feel and even <i>sound</i> nicer (yes, really--glass items make nice clinky noises when you get them in and out of the fridge or lift them with sterilizer tongs. I care about this. Doesn't everyone? No? Okay, maybe it's just me). Pumping milk is one hell of a pain; it's easier to feel motivated if you have beautiful, gleaming, sparkly-clear glass bottles to line up rather than crappy blurry-looking plastic ones. I <i>hate</i> the way plastic bottles look after they've been washed and sterilized several times--they get all beat up and cloudy looking, with little scratches all over them, and if they've ever accidentally been washed with dinner items they sometimes get those lovely orangey tints that we see on old plastic tupperware containers. Doesn't look pretty or hygienic, and you wonder about contaminants getting into your precious milk. </div>
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As for formula (I have been making use of some formula this time round, but that will be the subject of a future post): Nowadays, "The Powers That Be" decree that carers must use hot water (70 degrees or so) when making up formula, to kill any <i>Enterobacter sakazakii</i> that could be lurking in the non-sterile milk powder. I am not particularly woo-woo, but even I don't particularly like the idea of preparing a hot drink in a plastic container--even one that's BPA-free. Come to think of it, I don't like the idea of drinking out of plastic containers myself. I use stainless steel water bottles and glass tumblers. I think babies deserve the same sort of containers when they drink stuff. Most baby bottles have been free from BPA since around 2010-ish, but just because a bottle is BPA-free does not mean that it is free from <b><a href="https://www.babycenter.com/0_are-plastic-baby-bottles-safe_14387.bc#articlesection4">everything that might be concerning when combined with hot liquids</a></b>, and you do kind of wonder what "they" (plastic manufacturers etc.) have put in there to replace the BPA. By the way, the cloudiness that appears on plastic bottles that have been washed a few times (especially if they have been through the dishwasher) is something new: old-school Bad Plastics containing BPA used to stay clear and transparent, and that was actually the whole reason why BPA used to be added to baby-bottle plastics. Now it's been removed and everyone has dull cloudy-looking bottles. So the change that made plastic baby bottles safer has actually made them look dodgier, strangely enough. </div>
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Glass bottles are <i>not</i> as fragile as some people seem to imagine. The glass is special extra-tough shatter-proof stuff; I've dropped my glass bottles a few times and never shattered or chipped a single one--and we have hardwood floors. I mean, if you (or more likely, your child) well and truly slammed one against a wall, it might break; the fact that glass bottles are a bit more fragile and the fact that they are heavier, do make it harder for babies to hold their own bottles or may make you more reluctant to encourage them to do so. Then again, not everyone is bothered about this, and certainly there is no evidence that bottle-holding is some sort of essential "milestone" or important for development in any way. Indeed, there is actually a school of thought which suggests that babies should not be encouraged to get independent with bottles by holding them, as this encourages habits like wandering around with a bottle; the idea is that if a baby has to lie passively and get bottle-nursed, this means that as they get older and more mobile, their growing sense of independence will cause them to naturally lose interest in the bottle and bottle-wean themselves. I suspect this argument is overkill, but it's probably a good general rule that bottle usage should be gradually restricted anyway as babies get older and grabbier, and having more fragile bottles might be a simple way of ensuring that this happens.</div>
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Finally, glass bottles are better for the environment. They can be recycled properly at the end of their life, or even gifted to another person since they stay clean and fresh no matter how many times they are used (Pigeon sells separate teats, which is handy). All in all, glass looks like the right choice for baby bottles, and I suspect they will become the norm over the next few years, especially with the negative connotations that the word "plastic" has developed in this age of environmental concerns.</div>
BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com61tag:blogger.com,1999:blog-9064021843006104287.post-14731879094690453602019-04-26T07:16:00.000-07:002019-04-26T07:16:05.572-07:00When manual pumps are best<div class="separator" style="clear: both; text-align: center;">
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Because Baby Seal for a very very long time was going to be an only child, I went ahead and gave away most of the baby stuff (I hate clutter--if there is a medical word for the opposite of a hoarder, then that's me. I throw stuff away almost compulsively). This means that when I got pregnant again, I had to start again with different things...well, except for the cases where I got some old stuff back from the friend I'd gifted it to...<br />
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This is annoying, but in some ways it can be quite nice to start afresh and discover stuff that's different and better. I love having a proper newborn <a href="http://breastfeedingwithoutbs.blogspot.com/2013/05/yes-we-still-need-strollers.html"><b>pram</b></a> that faces me, for example (and feel quite guilty for making Baby Seal face away from me in that crappy sit-up-and-beg rattler....). And then there is the breast pump. With my first, I--in a spirit of "nothing but the best for my baby!!!"--invested in a Medela double-electric breast pump; I had of course read all those online articles assuring me that, as a mother on maternity leave, I could "get by" with a manual pump, but who wants to "get by"? Surely it stood to reason that a double electric pump must be better. After all, it costs more. This time round, however, I got gifted an unused manual pump, and reluctantly decided to use this until I had the time and energy to purchase something better.</div>
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In fact, I've ended up sticking to the manual one, and I honestly think that manual pumps are sometimes the best solution if you are staying at home or on maternity leave. </div>
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My abiding memory of that bulky double-electric showboat that I had first time round, was the perennial puzzle of "...but <i>when</i> do I pump? I am taking care of this baby all day long and feeding her constantly."</div>
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With a small manual pump, the problem largely solved itself. Because it was so simple to sterilize and set up, doing so didn't feel like a burdensome task and I was motivated to get it set up every day. As for fitting in a pumping session? Feed the baby at one side, then switch her to the other while pumping the first, then switch back and pump the second breast. A small single-side pump makes this much more practical. Because a single manual pump is small and light and you are not tethered to one spot, you can also hold the pump and express with one hand while you walk around taking care of stuff in the house--many's the morning when I have basically pottered around the room working the breastpump with one hand while making beds and rinsing crockery with the other. (No, I am not convinced by the new Elvie-type contraptions which fit into your bra and supposedly allow you to pump hands-free and move about at the same time; the online reviews I have seen mostly confirm my suspicion that such devices neither pump efficiently nor allow much freedom of movement.)</div>
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Also, when you get overly full at night due to a baby who sleeps through unexpectedly or nods off during a nighttime feed after only finishing one side, pumping will help you stay comfortable while also allowing you to <a href="http://breastfeedingwithoutbs.blogspot.com/2013/10/white-elephants-in-freezer-pros-and.html"><b>sock some milk away</b></a>, and I personally have found a manual pump to be way better--quieter and less disruptive of sleep. With my first I used to hand-express into a towel, but why throw that milk away if it can be saved?<br />
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Finally, strange though it may sound, some women actually respond better to manual pumps, and I think I may be one of them. I have absolutely no idea why. Perhaps it's psychological, perhaps it's because the rhythm of hand-pumping is closer to the way a baby feeds at the breast, or perhaps it's because with manual pumping you are more likely to "get your hands in there" and use compressions and so on to help out, rather than relying on the machine to do all the work for you. But there you go.<br />
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No doubt this is one of those Your Mileage May Vary thing, and I know that many women struggle with aching hands when using a manual pump. But to anyone who is at home for the first few months of their baby's life, it may be worth starting out with a manual pump only, and then switching to an electric model if and when desired, rather than investing in an expensive pump <a href="http://breastfeedingwithoutbs.blogspot.com/2012/07/how-to-have-bottle-refusing-baby-and.html"><b>that you may not end up using all that much</b></a>. </div>
BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com4tag:blogger.com,1999:blog-9064021843006104287.post-27232204744117526602019-04-18T05:07:00.002-07:002019-04-18T05:07:38.979-07:00Well, I'm back at last!Well, I had assumed that the blog was pretty much done and dusted--been there, done that, no longer breastfeeding. Don't get me wrong, breastfeeding is a fascinating subject, but when you are no longer in the trenches (the long watches in the night, the mornings spent making beds with one hand and pumping milk with the other etc. etc.), other concerns tend to take over--like children's education, your own career, the state of the world in general and so on.<br />
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And then one surprise pregnancy took me hurtling back into the world of lactation. With Little Seal now almost 8 years old, it's quite an odd feeling to be back here, once again, nursing away. And how much things have changed over the past near-decade! Some of the gadgets are new and people are arguing about different things online--Perfect Prep machines, hands-free breast pumps that let you express milk on the expressway itself, and of course the ubiquitous apps for keeping track of feeds and naps (in "my day" we used to just stick a rubber band on our wrists. I feel old). Some of the weaning advice has changed a bit too.<br />
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With all these new ideas come new bits of nonsense to explode and explore. For my own satisfaction, and to stop myself going round the bend after spending the evening holding Little Squish to my breast on one side while assisting with Little Seal's maths homework on the other, I will be taking a look at some of these things. Let the bullshit-blasting commence....!BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com5tag:blogger.com,1999:blog-9064021843006104287.post-18064166955632601032016-03-08T23:32:00.000-08:002016-03-08T23:32:05.358-08:00The white gold rush: Why Chinese shoppers are going all-out for foreign formula<div class="separator" style="clear: both; text-align: center;">
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I'm lucky enough to live in a neighborhood that is attractive and interesting enough for people to actually pay to come and visit it (i.e. Tourist Central). Japan has seen almost uninterrupted growth in its tourist trade in recent years, especially Chinese visitors. Chinese tourists tend to be quite serious shoppers and the tills are ringing from dawn till dusk in the massive Don Quixote <b>(*1)</b> store that was built here last year in anticipation of growing numbers of tourists. Don Quixote is a.... well, rather quixotic store selling consumer goods of all kind and designed to look like a kind of shopping jungle; very much a store that says Buy Buy Buy! Except, interestingly, in the case of baby goods: the shelves of nappies and formula have signs saying "One pack only per shopper," and the tins of formula now have little security beepers sealed in with tough plastic which the checkout assistant has to remove with a Stanley knife.<br />
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Middle-class Chinese families have been going out of their way to avoid Chinese-made formula ever since the <b><a href="https://en.wikipedia.org/wiki/Protein_adulteration_in_China">melamine scandal of 2008</a></b>, in which some babies were killed and many more hospitalized after a shady manufacturer decided to doctor its formula mix with melamine to disguise the low protein levels. The fact that Chinese tourists are eager to buy Japanese formula in spite of worries a few years back about <b><a href="http://www.wsj.com/articles/SB10001424052970204770404577081573935404162?mg=id-wsj">radioactive contamination</a></b> in the wake of the 3/11 earthquake tells you something about just how bad the reputation of Chinese formula is. Meanwhile, many middle-class women prefer not to breastfeed or find it difficult; they may want to get back to to work as soon as possible to fund their children's education, and there is a lack of provision for pumping in most Chinese workplaces. Hence the development of a sizable <b><a href="http://www.vice.com/read/the-people-making-money-off-chinas-grey-market-for-australian-baby-formula">"grey market"</a></b> in which Chinese students, tourists and ad hoc entrepreneurs sweep the shelves for formula in places like Hong Kong, Australia and Japan, and then sell the tins in China for several times the price originally paid for them; at the more informal level, many visiting Chinese like to pick up formula as a gift for friends who have babies.<br />
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The thing about China is that the sheer, steamroller-like volume of people we are talking about means that a shortage of pretty much anything in that country (whether it's brides or baby milk) is likely to have repercussions for the rest of the world, and parents in Australia, New Zealand and Europe have been taking to <b><a href="http://www.takepart.com/article/2016/03/01/why-china-buying-up-australia-baby-formula">social media </a></b>to vent about being confronted with empty formula shelves and Chinese shoppers toting baskets crammed with tins and tins to take back to China. Chinese parents' desperation to acquire any formula that isn't Chinese is understandable; so, however, is the frustration of parents in countries which have done a better job at ensuring food safety. Last year in Japan, a punch-up developed in an Akachan Hompo between two groups of Chinese tourists who were trying to buy up as many <b><a href="http://en.rocketnews24.com/2014/10/22/three-chinese-men-arrested-in-japan-for-buying-too-many-diapers/">diapers</a></b> as possible <b>(*2)</b>, while other Japanese stores are now rationing formula/nappies and even interrogating foreign-looking women at the till ("What are you buying these diapers for?"). In Australia and Europe, women of East Asian background are increasingly reporting hostile reactions from shop assistants if they try to buy several tins of formula at a time. Tensions are running high.<br />
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My first thought upon hearing of this trade was "Why don't the manufacturers just export formula to China?" However, it appears that there is a distinct ranking in terms of formula desirability: formula purchased overseas is top, followed by imported foreign formula purchased at an import store in China, and then, finally, formula manufactured in China by a foreign-affiliated company. Given the extremely high prices that are being charged for foreign formula and China's perennial issues with fake stuff, I suspect there are concerns that someone somewhere may have just slapped a foreign label onto a can of Chinese formula, while China's very serious pollution problems make many Chinese feel that even formula manufactured within a foreign-owned factory located in China is risky. Plus, when it comes to gifts I suppose there is a special value in receiving something that you know someone has dragged through customs and carried back home in a suitcase on a bouncing bus: "This is special and limited in supply, and I made the effort just for you." In any case, I guess that Australian or Japanese formula manufacturers have to limit the amount they export if they do not want to face a social media backlash from parents frustrated at shortages in their local supermarkets.<br />
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"Well, why not just produce more formula?" is the obvious response to all this. Long-run, I think that <i>is</i> the plan, and dairy industries in Australia and other countries have been enthusiastically <b><a href="http://www.abc.net.au/news/2015-06-14/chinese-dairy-boom-heralds-golden-era-for-farmers/6539444">gearing themselves up for expansion</a></b> over the next couple of decades to meet Chinese demand for high-end milk products.<br />
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In the short-run however, it's not quite as simple as that. Formula is not just plain old cow's milk and contains an ever-increasing number of complex ingredients, which must be sourced according to rigid and complicated guidelines. The rules governing infant formula production are (not surprisingly) very strict indeed, and a producer would have to be pretty daft to risk cutting corners; the lesson of China's infant formula debacle is that for formula manufacturers, if you slip up even once, you will probably never win parents' trust again. Finally, cow's milk-based formula production requires specialist equipment, such as spray dryers (to dry the milk into powder). Australia's stray dryers are working at maximum capacity and constructing new ones requires huge amounts of investment. Meanwhile, Japan's dairy industry is in no situation to increase output; we can't even guarantee domestic butter supplies. The crux of the problem lies in the extremely high standards that parents (understandably) have for the milk they feed to their babies; these standards lead Chinese parents to do whatever they can to avoid Chinese formula, but they also make it hard to greatly increase the formula supply in a hurry. This article <b><a href="http://www.dairyinnovation.com.au/di-blog/why-isn-t-australia-easily-able-to-make-more-infant-formula-if-the-demand-is-so-high">here</a></b> has more.<br />
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Ultimately, the answer is for China to clear up its pollution issues, lack of pumping rights in the workplace and food safety frameworks so that a) Chinese families are able to trust Chinese-made formula again, and b) more babies can be fed breastmilk for longer, which will help to take the edge off China's exploding demand for foreign-made formula. In the meantime, let's hope that the dairy industries of Australia, Japan and elsewhere succeed in ramping up supply so that parents in these countries do not face empty shelves when they go to the store for milk to feed to their babies.<br />
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<b>(*1) </b>Do try Don Quixote if you ever come to Japan--it's crazy, tremendously fun and the products and customer service are top-notch. And the signs are all hand-made. The shop is deliberately designed to display all sorts of things at random, kind of bursting out of every corner--novelty penknives next to cosplay costumes etcKitKats, that kind of thing.<br />
. It is also a good place to pick up snacks with weird flavors, like green tea caramels and peach-flavored <br />
http://japandaily.in/don-quixote-you-can-obtain-practically-everything-if-you-go-there<br />
http://japan-magazine.jnto.go.jp/en/1112sp_ranking.html<br />
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<b>(*2)</b> As someone who has used Japanese nappies, I can confirm that they are very, very good indeed, especially Merries which are apparently <i>the</i> most sought-after brand among the Chinese. Chinese nappies are said to be pretty dire, and there are worries about dodgy chemicals reacting with the skin on babies' behinds (Alternatively, maybe the parents are sensitive to Sino-Japanese political tensions and are enjoying the idea of Japan getting crapped on... who knows?).<br />
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<br />BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com10tag:blogger.com,1999:blog-9064021843006104287.post-60965579735220684282015-12-09T17:41:00.000-08:002015-12-09T17:41:48.355-08:00Offering a breast across the species barrierAnother one of my occasional forays into what might loosely be termed <strong><a href="http://breastfeedingwithoutbs.blogspot.jp/2013/01/are-three-breasts-better-than-two.html">"weird stuff"</a></strong> (nursing from extra breasts, nursing by males etc.) This time, a look at the odd world of human women who choose to breastfeed other animals.<br />
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My recent search for "Amazon" (yup, it's Christmas shopping time again!) brought up a quirky news items about an indigenous group called the Awa in Brazil where the women <strong><a href="http://www.dailymail.co.uk/news/article-3342357/Pushed-brink-extinction-extraordinary-photos-Awa-Amazon-tribe-one-nature-breastfeed-SQUIRRELS.html">often adopt wild animals and breastfeed them like babies</a></strong>. ("It highlights how far we have come from where we were. They are so close to nature. In fact, it is not even close--they are part of nature," goes the spiel.) <br />
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This bit of news was presented as a new and unique finding, but in fact cross-species nursing is a well-attested anthropological fact. Hawaiian women used to nurse puppies along with their children, as did Australian Aboriginal women with their beloved dingoes. Ainu women in Japan used to suckle bear cubs, bears being sacred to their culture. Indigenous women in the Americas breastfed bear cubs, monkeys, oppossum rats and deer. In Papua New Guinea (PNG), women still sometimes continue their traditional custom of adopting and nursing piglets, especially in the <strong><a href="https://en.wikipedia.org/wiki/New_Guinea_Highlands">Highlands</a></strong> region, though I did not see this during my own travels in PNG many years ago.<br />
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Cross-species nursing does seem to be commoner in cultures which have historically faced population pressures (PNG and the Pacific region being just two examples), and my hunch is that this may not be a coincidence. Population growth has long been a problem for the New Guinea Highlands due to the salubrious climate afforded by its high altitude, and especially since the arrival of the sweet potato in the 18th century which caused a big increase in population. The lack of large fauna and the low protein content of the sweet potato and other local crops result in chronic protein deficiency. Limiting births has therefore been a major concern for this part of the world, and is believed to be a key reason for some of the more unusual aspects of traditional Highland culture--the superstitions that required men to eat, work and sleep more-or-less separately from their wives in men's longhouses, the foregoing of sex for up to two years following childbirth (the mysterious process of birth, like menstruation, was believed to be polluting and dangerous to men), as well as abortion and the abandonment of newborns, which caused mothers terrible grief. <br />
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I suspect that adopting and breastfeeding pet animals could have evolved as yet another way of limiting births; in women who work physically hard much of the day and eat meager diets, frequent suckling at the breast substantially reduces the chances of conception, thus spacing out pregnancies. Most people in developed countries have a "yuck" reaction of the sight of a woman allowing an animal to suck on her breast, and Christian missionaries have done their best to stamp out the practice along with many other Highland customs. But perhaps we could also see PNG women's cross-species nursing as rather a smart strategy by women who were doing their best to make their own lives easier and safer, and ensure better nourishment for their existing children. And let's face it, a piglet is a lot easier to take care of than a baby!<br />
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In addition to preventing the appearance of additional mouths requiring feeding, you can of course go one better by actually eating the animal itself. Although the Awa apparently refrain from eating animals that have ever been nursed by a woman, PNG villages are often not so solicitous and it is normal for breastfed pigs to be slaughtered and eaten at some stage; given that protein shortages in this part of the world were historically so severe that cannibalism of dead <em>human</em> relatives or enemies was commonplace, this is perhaps not surprising.<strong><em> <a href="http://www.amazon.com/Islands-Clouds-Travels-Highlands-Guinea/dp/0864423691">Islands in the Clouds</a></em><a href="http://www.amazon.com/Islands-Clouds-Travels-Highlands-Guinea/dp/0864423691"> by Isabella Tree</a></strong> (a fascinating book, if you are interested in this part of the world) describes the slaughter of a pig thus nurtured in a Highland village, the ceremony being punctuated by cries of grief from the woman who was losing her "baby." <br />
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Pet-keeping is often seen as being exclusively a product of developed societies, but the affection that the women of PNG and elsewhere lavish on their beloved "fur-babies" is real and moving. That basic impulse--"It's so cute--I want to look after it!" ensures that isolated cases of cross-species nursing continue to crop up even in societies where such practices are no longer the norm, as we see in the occasional "well-who'd-have-thought-it" news feature on a pet-owner or wildlife-worker who has chosen to save the life of a baby animal by offering a breast across the species barrier. Breastfeeding animals may be a bit weird, but the stories and motivations that lie behind it are both interesting and touching.<br />
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BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com6tag:blogger.com,1999:blog-9064021843006104287.post-40544387260186222682015-09-15T05:06:00.001-07:002015-09-29T04:51:26.277-07:00No-BS Book Reviews: "Work. Pump. Repeat" by Jessica Shortall<div>
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There are a lot of breastfeeding books out there, and quite a few that I wouldn't recommend to anyone who has to work outside the home in their baby's first year. So it's refreshing to come across a nursing-while-working book which I feel I could actually give to a new mother without worrying that I am going to send her off into a tailspin of anxiety and depression. The book is <a href="http://www.workpumprepeat.com/"><b>"Work. Pump. Repeat" by Jessica Shortall</b></a>, and I got an advance preview of it shortly before its recent release.<br />
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The most striking thing about the book is its briskly efficient use of floor-space. As the author tells us, she is not going to tell us about the football hold or lactation cookies, because there are about 2,500 breastfeeding books that do that already. Nor does she waste time on giving us reasons to breastfeed--if we've bought the book, we've probably made our decision by now. </div>
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As a result, almost the entire book is freed up for the most fantastically <i>detailed, practical</i> advice--real stuff, hands-on, mum-tested. The sort of stuff you hear on your favorite forums and Facebook groups, yet somehow never get round to actually copying and pasting into a single place so that you will have all the tips when you need them; it's all here, digested, sorted and put into readable form. Are you looking for advice on how to speed things up if your company has assigned a pumping room in another building? It's here. Practical hints on the best type of clothing to disguise milk leaks? Look no further. What to do if you have no alternative other than to pump in a toilet cubicle? Sorry you had to look for it, but there's detailed advice about that too (did you know that keeping some Post-it notes in your handbag can come in handy for this situation? If you are wondering why, read the book). </div>
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Pump choice, pump usage, bottles, freezers and getting your baby ready for taking breastmilk at daycare are discussed, followed by discussion on practical clothing choices, your rights at work, and how to handle your boss and coworkers. All sections are full of concrete, non-judgmental advice that has a "been there, done that" feel to it. The workplace section is really, really pragmatic. Shortall's research for the book included talking to large numbers of HR /management people, trying to work out what are the best tactics for the average Jane who does want to pump at work but cannot afford to antagonize her boss and lose her job/damage her career prospects with a "These are my rights!" attitude. And the book also gives practical tips on "guerrilla pumping"--how to get by at work as best you can if no proper accommodation is made for your needs. The book puts a lot of emphasis on the everyday realities of breastfeeding, with the workplace plan-of-action broken down in detail to include things like how and how often to wash pump parts, dealing with special and unusual pumping situations, flying with breastmilk, and how to approach HR to suggest improvements for pumping facilities. </div>
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Things I would have liked to have seen? I would have preferred slightly more specific info on the freezer storage times/nutritional value question, including differentiation between chest freezers versus regular freezers. I also think that the discussion on lipase/funky-tasting frozen milk would have been better placed closer to the beginning rather than in the troubleshooting section at the end; given the number of women who end up wasting hours and hours producing freezers full of undrinkable milk, every woman who is going to store serious amounts of the stuff should consider testing for lipase before she gets going. One final point is that I would have attached a brief health warning before advising mothers to read books like <i>The Womanly Art of Breastfeeding</i> and <i>The Nursing Mother's Companion</i>. Not that they aren't potentially useful resources too, but a working mother would be well advised to take some of their advice and philosophies with a pinch of salt, especially since some of it (like advising mothers to leave bottle introduction really late) could potentially sabotage one's ability to return to work and stay sane. Lactation consultants as a group perhaps need a health warning as well, for similar reasons.<br />
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Sometimes the book made me feel sad. Because when you're reading a section which gives hints about how to get your pump parts clean at work without anyone seeing them, or how to multitask while pumping to deflect criticism from coworkers about your constant "breaks," part of you thinks "Oh, that's a clever idea," and the other part of you thinks "This is so depressing. Because you have all these women working full time with tiny babies, driving themselves nuts trying to pump and store their babies food all day long, waking up all night long, and then having to hide their pump parts from coworkers because God forbid anyone should suffer the disgusting situation of glimpsing a clean breast pump." And it's just all so sad. But given that this is the crappy reality that US mothers face, I am glad that at least writers like Shortall are doing their bit to try and make things a bit easier for mums.<br />
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The other thing that makes the book a standout (other than the level of detail) is the emotional care that the author shows towards her fellow WOH breastfeeders. When she says that "this is a judgment-free zone" she really is not kidding. It is rare and refreshing to see a breastfeeding book that talks about formula choice, preparation and supplementation simply as another option, rather than as some kind of existential failure on a mother's behalf. Shortall also describes her own personal journey from exclusive-breastfeeding obsession to a more pragmatic approach with her second child, and it's clear that is part of the reason why she urges mothers to safeguard their mental health--advice that is not confined to an occasional vague disclaimer about "not judging people," but rather is something that is built into the very structure of the book, influencing all the advice it gives.<br />
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In short? Without a doubt, the best and most practical book for WOH nursing mothers that I've encountered, and an excellent buy or gift.<br />
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Here is an excerpt from Chapter 3 of the book. Enjoy.<br />
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<b><span style="color: #783f04; font-family: Verdana, sans-serif; font-size: large;">Pumping School</span></b><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<b><span style="color: #783f04;">Welcome to School</span></b></span><br />
<span style="color: #783f04; font-family: Verdana, sans-serif;">Pumping makes many women feel like farm animals. For me, it is everything actual nursing is not: sanitized, cold (sometimes literally, if you’ve just washed the parts or tend to keep them in the fridge at work in between sessions), and industrial. It was also totally and completely foreign to me, up until the first time I tried doing it, which is where Pumping School comes in.</span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<span style="color: #783f04;">Unless they make you pump in the hospital (which can happen), you might find yourself at home, with a baby and a very porn-star-esque pair of boobs, wondering who the hell is going to show you how to use this thing.</span></span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<span style="color: #783f04;">I needed someone who could see me with my shirt off to show me how to do it. So my best friend took me to Pumping School.</span></span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<b><span style="color: #783f04;">How to Get Taught</span></b></span><br />
<span style="color: #783f04; font-family: Verdana, sans-serif;">Between weeks three and six of your baby’s life, invite to your home a mother with recent experience with pumping breastmilk. This should be a woman with whom you are comfortable seeing both of your newly gigantic boobs. </span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<span style="color: #783f04;">Tell her that she is coming over to teach you how to use a breast pump. You should have your pump and its basic parts, breastmilk storage bags, and a Sharpie or other permanent marker. Time this date so your friend comes by just before the first morning feeding (or during, if she has a key or you have someone else to open the front door for her while you have a baby attached to you). If she has a toddler, suggest that she leave this lovely small person at home. </span></span><br />
<span style="color: #783f04; font-family: Verdana, sans-serif;">You’re going to feed your baby as normal, then pump immediately after the feeding. I recognize how silly and arbitrary a term like “first morning feeding” is. Just pretend that any feeding at or after 6:00 A.M. is the first one of the day, even if it isn’t and it makes you want to throw this book against the wall.</span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<span style="color: #783f04;">The reason you’d shoot for the first morning feeding for pumping is that your body is making more milk at this time of day. Also, it can help trick your body into making a bit more milk throughout the day. If for some reason you just can’t do this time of day, it is not the end of the world. </span></span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<span style="color: #783f04;">Once you’ve nursed, your friend will set you up with the pump—placing the parts onto your boobs if need be—and have you pump for the first time. She will show you how most pumps have an initial “letdown” setting, which pumps quickly and with less suction, to simulate the way your baby sucks when she is first on your breast. Your friend will show you how it then switches over to the general setting, resulting in slower and deeper suction cycles, again to simulate what your baby does once the milk starts flowing. </span></span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<b><span style="color: #783f04;">Break for Questions </span></b></span><br />
<span style="color: #783f04; font-family: Verdana, sans-serif;">Here’s what you might worry about in this process:</span><br />
<span style="color: #783f04; font-family: Verdana, sans-serif;">1.<span class="Apple-tab-span" style="white-space: pre;"> </span>If I pump after I feed the baby, will I have enough milk for the next feeding? Yes, you’ll be fine. Your breasts are always making milk and you don’t need to “fill up.” In fact, you will probably produce more milk that day because of the increased demand.</span><br />
<span style="color: #783f04; font-family: Verdana, sans-serif;">2.<span class="Apple-tab-span" style="white-space: pre;"> </span>Will there be any milk to pump since my baby just finished eating? Maybe. Maybe not. This first time around is just for practice, so don’t sweat it if all you see is a few drops.</span><br />
<span style="color: #783f04; font-family: Verdana, sans-serif;">3.<span class="Apple-tab-span" style="white-space: pre;"> </span>Am I really going to do this several times a day when I go back to work? Um, yes. That’s why you bought this book, honey. If you want to breastfeed after you’re back at work, you are probably going to pump a lot at work. It’s not fun, but it is doable. </span><br />
<span style="color: #783f04; font-family: Verdana, sans-serif;">4.<span class="Apple-tab-span" style="white-space: pre;"> </span>Who is going to hold the baby while I do Pumping School? Options: your Pumping School teacher, your spouse, a baby swing or chair, or the floor.</span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<b><span style="color: #783f04;">Back to School</span></b></span><br />
<span style="color: #783f04; font-family: Verdana, sans-serif;">During the first fifteen minutes or so (which aren’t going to feel awesome), you might produce a couple of drops, or you might produce 4 ounces and feel awesome. There is no definition of success, other than learning how to do it so it stops seeming so foreign and weird. (Note: It will never completely stop seeming foreign and weird.)</span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<span style="color: #783f04;">You are going to see, for example, that your nipples are stretching to a greater length than you thought possible (a friend described seeing his wife pumping for the first time as “two thumbs in a garden hose”). </span></span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<span style="color: #783f04;">You are going to wonder what will happen to your sex life if/when (it’s a “when,” trust me) your partner sees this process. It will be awkward, but you’ll both survive it.</span></span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<span style="color: #783f04;">You might be surprised to see what your breastmilk looks like. It can be thin and watery or thick and creamy. It can be white, yellowish, bluish, or greenish. In fact, it will be all of the above (which is normal) at different times of the day and over time.</span></span><br />
<span style="font-family: Verdana, sans-serif;"><span style="color: #783f04;"><br /></span>
<span style="color: #783f04;">Congratulations. You’ve just joined the most exhausted, most multitasking, most ass-kicking club of women in the world. </span></span><br />
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BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com8tag:blogger.com,1999:blog-9064021843006104287.post-81216768823680323262015-08-11T06:59:00.004-07:002015-08-11T06:59:21.796-07:00Fat vaginas and shrinking newborns in Japan<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGkU6PQeNzni3AAgAh7uGvK4TcmFYfR1T7p80b5ip0Tox2Md3O0y0_8YwtiSjzvoSjTcbrTwZ5iUxyVrANJMTODjlvdB80CPBTgs9Vtn1YmEK90q6Nn14ZJqCgqm9BvuJKj3dRyWONTlk/s1600/IMG_0328.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGkU6PQeNzni3AAgAh7uGvK4TcmFYfR1T7p80b5ip0Tox2Md3O0y0_8YwtiSjzvoSjTcbrTwZ5iUxyVrANJMTODjlvdB80CPBTgs9Vtn1YmEK90q6Nn14ZJqCgqm9BvuJKj3dRyWONTlk/s320/IMG_0328.jpg" width="240" /></a></div>
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<span lang="EN-US">When I got pregnant I weighed 53 kilos at
170cm (118 pounds, 5’8); I gained 13 kilos or 28 pounds over my pregnancy. My
daughter was born at just 2.6 kilos (5 pounds 11 ounces). By British or
US criteria my gain was fine, and indeed I found myself wondering
if I should have gained a bit more, judging by my baby’s rather modest size. Yet
by Japanese standards I had gained an excessive amount. Welcome to the insane
world of the incredible shrinking Japanese pregnancy.<o:p></o:p></span></div>
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<span lang="EN-US">Official guidelines in Japan recommend that
women gain 7-12 kilos if they are normal weight, and 9-12 kilos if they are
underweight—significantly lower than the guidelines of the UK and US. However,
these figures mask the reality that is going on in clinics and hospitals where
doctors routinely pressure women to gain even less than the official limits. “My
doctor told me I should stop eating all fruit and carbohydrates,” complains one mum
(whose weight gain was picture perfect according to the US guidelines). “I was
scolded by the nurses every time I went in; they said I wouldn’t be able to
push the baby out,” says another. Others reveal stories of doctors telling them
they should be <i>losing</i> rather than gaining weight during pregnancy, or informing
them that they would get a “fat vagina” unless they drastically restricted their calorie intake. No, I don’t know what a fat vagina looks like either. <o:p></o:p></span></div>
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<b>What are the trends in newborn weight?</b></div>
<div class="MsoNormal">
<span lang="EN-US">Perhaps part of the anxiety about gaining
too much weight comes from the widespread misconception in Japan
that average the average newborn is getting heavier. In fact, birthweights <i>did</i>
rise through the 1960s and 1970s in Japan, but from about 1980 the trend went into reverse, with birth weights falling by 125</span><span lang="EN-US">g in the
past 25 years. It seems that previous decades' anxieties about “babies getting too big”
may have lingered on into the present, distorting doctors’ and the public’s
perceptions.<o:p></o:p></span></div>
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<span lang="EN-US">To a certain extent it is understandable
that Japanese medical authorities became worried by fact that babies and
mothers were growing a bit heavier during the 1960s and 1970s. If a woman
genuinely does gain too much during pregnancy, it does indeed increase the risk
of difficult births, and this may be particularly true for Asian women. Asian
women who gain too much are significantly more likely to develop <b><a href="http://clinical.diabetesjournals.org/content/31/2/90.full">gestational diabetes</a></b> than other ethnicities. Big babies may be more likely to wreak havoc
on an Asian mother’s body, as there is also some evidence that women of Asian
ethnicity are <a href="http://www.reuters.com/article/2011/01/06/us-asians-delivery-idUSTRE70566G20110106" style="font-weight: bold;">more likely to sustain serious perineal tears in childbirth</a>. Nobody is quite sure why—perhaps it is because Asian babies are proportionally
larger compared to their relatively small mothers. In most developed/middle
income Asian countries, this problem is increasingly being circumvented through
very high cesarean rates (40-50% in countries like China and Vietnam). But the
Japanese remain emotionally and culturally committed to the idea of natural childbirth;
not surprisingly, a “Keep ’em small at all costs” mentality has tended to
develop. <o:p></o:p></span></div>
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<span lang="EN-US">I suppose there is a sort of “sunk-cost
fallacy” in such matters—if you have spent the last decade or two telling
women to severely restrict their weight, the possibility that this advice may have been harming babies may be too painful to
confront. Easier to keep telling yourself that your advice is correct and
always has been. It’s not like Japanese healthcare providers are exactly great at accepting
questioning at the best of time.</span></div>
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<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">Oh, and it’s very, very hard to get an
epidural in Japan, due to a critical shortage of anesthesiologists and the cultural belief that mothers are “supposed” to suffer in childbirth,
and this has probably also encouraged doctors and midwives (all of whom will have watched women suffering
in long, hard labors) to encourage mothers to keep their bellies and babies
small. In fact, a small baby does not always equal an easy birth--I know women
who’ve torn badly pushing out five-pounders--but when you are staring down the
barrel of a completely unmedicated labor with absolutely no way out of it, you
are naturally going to clutch at whatever straws are available to you
which might, maybe, just make things a bit easier. Add in standards of beauty
which demand insect-like thinness in women even before pregnancy, and you have a perfect storm for
extreme weight restriction in pregnant women. <o:p></o:p></span></div>
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<span lang="EN-US"><o:p><b>The consequences</b></o:p></span></div>
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<span lang="EN-US">Slowly, however, awareness is
growing</span> in Japan about the risks of too little weight gain in pregnancy. Japanese midwives are still heard to express enthusiasm about the idea of keeping fetuses small and then feeding them up after delivery, but as the doctor quoted in the Bloomberg article puts it, “Being born small and growing big is the worst possible scenario for risk of disease." Babies undernourished in the womb and born small may be at elevated risk of problems such as obesity and hypertension later in life, possibly because such undernourishment sends out signals that cause the fetus's body to prepare for famine conditions in the outside world (an extreme form of this was seen in the babies born after the <b><a href="http://www.news.leiden.edu/news/dutch-hunger-winter.html">Dutch Hunger Winter of 1944-45</a></b>, who have proven to be more prone to problems such as cardiovascular disease as adults). </div>
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<span lang="EN-US"><o:p><b>A need for balance</b></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US">It’s not that we need a complete
free-for-all either. Most women I know who gave birth in the UK report that
they were never weighed or given any advice on weight gain, a fact which
is almost certainly connected with the fact that the percentage of deliveries
assisted by forceps has doubled over the last 10 years as mothers start their
pregnancies heavier, gain more and have bigger babies. It’s completely
reasonable for healthcare providers to be honest with patients about the fact
that excessive weight gain increases the risk of difficult births, not to mention the fact that (in my own experience) women who gain huge amounts are more likely to feel uncomfortable during pregnancy and have an difficult psychological transition to motherhood afterwards. </span></div>
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<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">Nevertheless, there is
mounting evidence that excessively strict weight guidelines in Japan are
putting the health of babies at risk, and making pregnancy--which is supposed to be one of the happiest times in a mother's life--into a period of unnecessary anxiety, guilt and embarrassment for women. While a certain amount of caution regarding weight gain is probably advisable for Japanese women in particular, given ethnic factors relating to gestational diabetes and the problem of perineal trauma, the advice to restrict weight in pregnancy seems to have become unnecessarily extreme and to have taken on a life of its own. For mothers' and babies' sake, it's time for Japanese healthcare providers to swallow their pride and review their policies on gestational weight gain.<o:p></o:p></span></div>
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<span lang="EN-US"><b>Further reading:</b></span></div>
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<b><a href="http://www.bloomberg.com/news/articles/2010-10-28/diets-by-112-pound-pregnant-women-spur-wave-of-underweight-babies-in-japan">Diets by Pregnant Women Spur More Underweight Babies in Japan (Bloomberg)</a></b></div>
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<b><a href="http://ajw.asahi.com/article/behind_news/social_affairs/AJ201204300044">Babies born in Japan getting smaller (Asahi)</a></b></div>
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<span class="MsoHyperlink"><span lang="EN-US"><o:p><span style="text-decoration: none;"><b><a href="https://www.med.or.jp/english/journal/pdf/2010_05/285_289.pdf">Problems of Underweight in Young Females and Pregnant Women in Japan </a></b></span></o:p></span></span></div>
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<!--EndFragment-->BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com4tag:blogger.com,1999:blog-9064021843006104287.post-28765945286069759312015-06-21T04:19:00.001-07:002015-06-21T04:19:16.392-07:00Is there a need for more nuance in the vaccine "debate"?<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-54-X4eyb1PotpqMOuSp2G2iQdNWpoC_sna5L97HVnd5Fuk1ZkXQGoaE3hSsYzV5WcWR04M94VuU_M6Jl6zC5YuErGAu39rQV48fKaXxIVaaH5Q2T_NzEhjtt8ETOn_S3KTKCCUT7z_s/s1600/IMG_0565.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-54-X4eyb1PotpqMOuSp2G2iQdNWpoC_sna5L97HVnd5Fuk1ZkXQGoaE3hSsYzV5WcWR04M94VuU_M6Jl6zC5YuErGAu39rQV48fKaXxIVaaH5Q2T_NzEhjtt8ETOn_S3KTKCCUT7z_s/s320/IMG_0565.jpg" width="240" /></a></div>
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<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0">Alice Dreger--an academic whose gutsiness in taking up controversial issues I have a lot of respect for--has recently written an article on yet another hot-button topic: </span></span><b><a href="http://www.weebly.com/uploads/1/4/9/8/14987834/dreger_on_vaccines_and_largent_new_statesman.pdf">A heretic in</a></b><br />
<b><a href="http://www.weebly.com/uploads/1/4/9/8/14987834/dreger_on_vaccines_and_largent_new_statesman.pdf">the academy: What if not all parents who question vaccines are foolish and anti-science?</a> </b>on the book <b><a href="http://www.amazon.com/Vaccine-The-Debate-Modern-America/dp/1421406071"><i>Vaccine</i></a></b>, by Mark Largent.<br />
<br />
Prof. Largent is basically in favor of vaccination and wants to increase coverage; however, he also criticizes some of the doctors, journalists and bloggers who have pushed the pro-vaccine line. Largent suggests that some of these people have made things more difficult by adopting all-or-nothing arguments about vaccination, as though refusing the chickenpox vaccine were the same as refusing the polio vax. He points out (correctly) that the US vaccination schedule is not based exclusively on medical evidence but is also influenced by commercial interests. He suggests a distinction between hard-core anti-vaccinators versus parents who are merely a bit anxious or who reject one or two vaccines, stating we might have more luck if we showed empathy with their worries. Dreger, describing Largent's ideas, also adds some personal stories about the gut-level fear she felt about the number of needles coming towards her child, in spite of her own strong conviction that vaccination is safe and necessary.<br />
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By using terms like "zealots" to describe some of the pro-vax people, Largent and Dreger aren't certainly out to win any friends, and both have already attracted <b><a href="http://scienceblogs.com/insolence/2015/06/05/in-which-pro-vaccine-advocates-are-portrayed-as-frenzied-self-righteous-zealots/">some fierce criticism</a></b> among science-based-medicine blogs on the grounds that they are going soft/pandering to parents who believe stupid things about vaccines. I do know what they mean, sort of. I personally was never one of those parents who felt gut-level "anxiety" about needles being stuck in my child, so Dreger's description of her own fears didn't resonate with me at all. The number of vaccines which are given to children in the United States certainly does sound like a lot at first glance... then again, I live in Japan with its relatively "light" vaccine schedule (Japan tends to be incredibly conservative about new vaccines and tends to panic and ban any shot that is even rumored to have created an adverse reaction); this has<b> not</b> been a roaring success. Japan has long been known as an "exporter" of measles due to frequent outbreaks--and as someone with no hearing in one ear due to mumps I was horrified to learn that the mumps vax is still not standard here, and that mumps regularly makes the rounds in Japanese universities.<br />
<br />
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0"><b>And yet</b></span></span></span><br />
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0">That said, when the writer uses the phrase "vaccine zealot," honestly, I do know what she is talking about. Examples:</span></span></span><br />
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0"><br /></span></span></span>
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0"><b>1) </b>A mother posts online asking for advice about the chickenpox which her child has contracted. When it transpires that the mother had not vaccinated her child against this virus, a horde of posters descend on her and subject her to a lot of incredibly harsh, personal criticism faintly tinged with hysteria. After a while, another poster points out that there is a bit of controversy over the population-level effects of the chickenpox vaccine, which is why the British National Health Service (NHS) does not routinely offer it. The pro CP-vaccine posters, instead of admitting that the issue is somewhat nuanced, merely buzz even more angrily, all but accusing the original poster of wanting to murder immune-compromised children. </span></span></span><br />
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0"><b>2)</b> A mum on a Facebook group announces that there have been a few cases of whooping cough in her state--the other side of her state from where she is living--and that she intends to avoid all unnecessary movement outside her home and stay indoors with her baby (not immune-compromised) for the immediate future. She receives responses of the "We are all praying for you!" type, as though the kid were already on its deathbed.</span></span></span><br />
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0"><b>3) </b>In an argument about the measles, mumps and rubella (MMR) vaccine, a poster correctly states that measles can potentially kill and cause serious complications--but cites statistics taken from developing countries, suggesting that a measles epidemic in the United States would kill up to 10% of those infected. The other posters on the discussion mostly know that this is bullshit but don't dare point this out, because this would risk giving ammunition to all the anti-vax posters who are on the same thread. (</span></span></span><b><a href="http://www.npr.org/2015/01/30/382716075/measles-is-a-killer-it-took-145-000-lives-worldwide-last-year">This article</a></b> goes one further, claiming that more than half (!) of those infected with measles last year died of it, which if true would make measles deadlier than smallpox...!)<br />
<br />
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0">Okay,<b> 1)</b>: Although the chickenpox vax is safe and effective, there's genuine concern that widespread vaccination of children against CP could be a factor behind recent increases in painful shingles among the elderly/immune-compromised in some countries (see <b><a href="http://www.webmd.com/vaccines/features/shingles-chickenpox">here</a></b>). </span></span></span>Whether these things are really connected is very debatable; I personally decided to do the CP vax after weighing up the pros and cons. But "weighing up" is the key phrase here: I mean, I wouldn't spit venom at anyone who decided not to. If I had been some vaccine-hesitant parent reading through that thread, the overwhelming impression that I would have come away with would have been: "Vaccine-promoters are kinda selective with the truth and may cover up things which might call their case into question. Oh, and they also appear to be excitable and a little nuts."<br />
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Regarding <b>2)</b>: It's sensible and wise for parents to keep an eye on disease outbreaks in one's locality. On the other hand: if some lady announced that she was going to barricade herself in her home due to fear of child-abduction-by-strangers, I suspect that most of us would tell her ever-so-gently to "get a grip," and the risk of whooping cough multiplied by the disease's mortality rate has got to be similar. Worry about very small risks has to be balanced against the benefits of fresh air and having children spend time with friends and family.<br />
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<b>3)</b>: Measles kills and blinds on an alarming scale in kids with Vitamin A deficiency and a heavy disease burden (chronic parasite infestations etc.). In developed countries, measles kills at a rate of <b><a href="http://2020science.org/2015/02/03/risk-dying-catch-measles/">perhaps 1 per several thousand cases</a></b>. I know most pro-vax blogger etc. absolutely <b><i>hate</i></b> the "Brady Bunch" comparison, but honestly, <b><a href="http://www.atlasobscura.com/articles/1970s-parents-were-anti-vaxxers-too">there <i>is</i> some truth</a></b> to the fact that by the 1960s and 1970s serious complications were rare enough that parents often didn't take measles all that seriously (hence it took quite a long time for the measles vax to catch on).<br />
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The reason why we should inoculate against measles is not because an outbreak would cause overflowing graveyards--it wouldn't. It's because nowadays we have very high standards for children's safety, so even a 1 in several thousand risk is worth eliminating, especially considering how incredibly safe this vax is. We wouldn't copy 1960s parents when it comes to car seat usage, either. And 1960s parents didn't know that measles may be connected to later illnesses in children due to "wiping clean" the body's immunity record (see below). Then you've got the issue of immune-compromised kids. There is no need for exaggerated figures when it comes to measles--the factual reality of the disease is already quietly worrying enough.<br />
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0"><br /></span></span></span>
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0"></span></span></span><br />
<b>To be an activist, first be a "factivist"</b><br />
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<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body">As someone with a disability caused by a VPD, I feel a certain sense of urgency about </span>the need to increase vaccination rates. If we want to do this, we need to make sure we're actually changing people's minds, not just grandstanding.<br />
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body">
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><br /></span>
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body">I don't know exactly what Largent says, as I haven't read his book. If he is descending into the nonsense of "let's present both sides of the argument" then he's talking out of his backside, </span>because there <b>is </b>basically only one sensible argument here. But if he's talking about the need for sticking to the facts and maintaining a courteous tone in debate, then </span>I'm with him. <br />
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body">
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><br /></span><span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body">As Andrew Maynard of the above linked blog post says <i>"</i></span></span><i>[T]o use data that not only feel wrong, but are not backed up with evidence, only serves to undermines trust in public health experts. Anti-vaccine proponents are smart enough to realize this. Each time the data on infectious diseases and risk are spun beyond their legitimate bounds, anti-vaccine proponents are given a helping hand in winning the hearts and minds of concerned parents."</i> When pro-vax people start to overreach--even by a little--it undermines the credibility of everything we say ever after.<br />
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"Courtesy" is important too--not frosty politeness through gritted teeth, but genuinely empathizing with people's worries. And for the love of God, <i>please</i> stop the aggressive dogpiling of people on discussion threads (I'm sure I've been guilty of participating in these in the past, too). Most people who hesitate about vaccination are not hardened anti-vax types, but worried parents who don't know who to trust. If we can talk to them as if we genuinely care about them and their kids, we might be surprised at how willing they are to listen.<br />
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body">
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><br /></span></span></div>
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0"><b>Further reading:</b></span></span></span><br />
<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0"><br /></span></span></span>
<a href="http://www.weebly.com/uploads/1/4/9/8/14987834/dreger_on_vaccines_and_largent_new_statesman.pdf"><b>A heretic in </b><b>the academy: What if not all parents who question vaccines are foolish and anti-science? (Alice Dreger) </b></a> (Dreger's book, <i><b><a href="http://alicedreger.com/GMF">Galileo's Middle Finger</a></b></i>, is worth a read too.)<br />
<b><a href="http://www.amazon.com/Vaccine-The-Debate-Modern-America/dp/1421406071"><i>Vaccine </i>(Mark Largent): </a></b>The subject of this post, but I haven't read this one yet, myself.<br />
<b><a href="http://scienceblogs.com/insolence/2015/06/05/in-which-pro-vaccine-advocates-are-portrayed-as-frenzied-self-righteous-zealots/">In which pro-vaccine advocates are inappropriately portrayed as frenzied, self-righteous “zealots” (Respectful Insolence): </a></b>The counter-argument<br />
<b><a href="http://www.sciencemag.org/content/348/6235/694">Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality (Science)</a></b><br />
<b><a href="http://2020science.org/2015/02/03/risk-dying-catch-measles/">What is the risk of dying if you catch measles? (2020 Science)</a></b><br />
<b><a href="http://www.webmd.com/vaccines/features/shingles-chickenpox">Shingles & Chickenpox: </a></b>What's the Link? Simple discussion<br />
<b><a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)16715-9/fulltext">Why is measles still endemic in Japan? (The Lancet)</a></b><br />
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<span data-ft="{"tn":"K"}" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body"><span class="UFICommentBody" data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0"><span data-reactid=".1u.1:4:1:$comment10152858172512093_10152863531202093:0.0.$right.0.$left.0.0.1.$comment-body.0.$end:0:$text0:0"></span></span></span><br />
<br />BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com7tag:blogger.com,1999:blog-9064021843006104287.post-20457759363002823802015-05-07T05:46:00.001-07:002015-05-07T05:46:53.660-07:00What to expect when you wean your child at the age of 4.2 years<div class="separator" style="clear: both; text-align: center;">
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When I had my baby, I <b><a href="http://breastfeedingwithoutbs.blogspot.jp/2012/02/going-with-flow.html">didn't quite expect</a></b> that I'd be breastfeeding her for longer than 12 months. If you'd suggested to me that the duration of our nursing "relationship" might be reckoned in years rather than months, I'd have laughed and told you to stop talking nonsense.<br />
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And yet it wasn't until a few months ago that I nursed my child for the last time. She was just past her 4th birthday--actually, not so far from the famous "4.2 years" which is sometimes bandied about as the global average for the duration of breastfeeding (not true, as I pointed out in <b><a href="http://breastfeedingwithoutbs.blogspot.jp/2011/10/bullshitometer-no-average-age-of.html">another post</a></b>). Well, it may not be the global average, but it was the average for <i>my</i> children--or child, rather, since I have just the one child and there probably won't be any more of them.<br />
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I carried on nursing for this long mostly because I was simply taking the path of least resistance--I didn't mind nursing her and had no particular reason to stop. I stopped nursing her for pretty much the same reason. She had been losing interest for the last year or so, and I have other ways to relate to my child. She's old enough to do fun things with, now--we can chuck a ball around, we draw together and sound out simple words, she is developing a keen interest in baking and crafts, especially trying to "make" dresses for her dolls out of tissues and play-dough. I can see she will be into knitting and needlework in a few years' time.<br />
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After I had realized that she had basically stopped nursing, I was happy enough but felt slightly bothered, somehow, that I couldn't remember when the "last time" was. So when (a couple of weeks later, shortly after her 4th birthday) she asked to nurse again, I agreed and let her, simply because I wanted that sense of closure. I said to her "This is the last time, though, because you're a big girl now." She said "Yes, Mummy," very calmly and demurely. And we nursed that one last time. And that was it.<br />
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That was now several weeks ago. No weird hormonal changes or breast oddities so far. In fact, not-nursing-a-preschooler is pretty much exactly the same as nursing-a-preschooler (it had been so sporadic for that last year, after all). I haven't even stopped producing milk. I can still squeeze a drop or two out, even now--a couple of months later. Sometimes I wonder if that will ever go away.<br />
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And I'm still interested in infant feeding politics, and I can't see that changing any time in the future either. That interest has to compete with other sources of interest these days, of course--education-related stuff is the new obsession, and my interest in politics has picked up a lot as well in the past year. But I'll still be keeping the blog going, and in fact I'm aiming to get my act together and start posting a bit more regularly. Some time in the next couple of weeks or so, I will be putting a post together on "the real advantage of nursing a child past 12 months." Watch this space.<br />
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<br />BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com7tag:blogger.com,1999:blog-9064021843006104287.post-89855943941353842132015-02-05T03:44:00.001-08:002015-02-05T03:44:45.233-08:00Pumping cultures, nursing cultures: Japan, Britain and the United States<div class="separator" style="clear: both; text-align: center;">
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I am a British blogger, who lives in Japan... and I follow a lot of motherhood-related stuff in the States, because a lot of my favorite blogs and parenting groups/forums are US-based. There are lots of differences in breastfeeding culture between the three countries that one could potentially talk about--differences in attitudes to supplementation, newborn procedures, cultural oddities like beliefs about alcohol and diet while nursing--but one aspect where one sees big differences is attitudes towards pumping and bottlefeeding expressed milk.<br />
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Breastfeeding advocacy has always had an ambiguous, push-me-push-me attitude towards expressing--is it a "good" thing that replaces formula in bottles, or is it a "bad" thing that competes with the act of nursing directly at the breast? You might imagine that cultures which make it easy to nurse your baby directly will also be places that make it easy to pump and bottlefeed your breastmilk. In fact, that's often not the case, as we shall see. A quick disclaimer--the following discussion is mostly based on my personal experiences of these breastfeeding cultures both online and in real life, so this time I don't have a lot of data to back me up. If anyone does have any data that disproves anything here, speak up!<br />
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<b>United States</b><br />
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My "main" mums' board when Baby Seal was tiny was predominantly American, and one thing that stood out was the amount of time spent talking about pumping. The United States is almost unique among developed countries in that maternity leave is still not considered standard; unless you are exiting the workforce for a bit, you will probably be back at work about six to eight weeks after giving birth. For US breastfeeders, therefore, pumping is a continual source of conversation, commiseration, competition and <b><a href="http://breastfeedingwithoutbs.blogspot.jp/2013/10/white-elephants-in-freezer-pros-and.html">anxiety</a></b>, and US-centric breastfeeding blogs and pages tend to spend a lot of time talking about women's pumping rights at work.<br />
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To a certain extent, the normalization of pumping and bottle-feeding EBM has bled over into the experiences of stay-at-home mothers in the US, who often sock away quite substantial amounts of milk in the freezer "just in case," or with the hope of donating it at some point. The custom of carrying bottles of expressed milk around in public for feeding the baby with also seems to be commoner in the US than elsewhere, probably because public breastfeeders are more likely to get hassled (although, like everything else American, this is very regional). Exclusive pumping seems to be commoner in America too--on British fora like Mumsnet, women who want to feed their babies this way are often advised to look on American fora and Facebook pages for advice. Perhaps widespread car ownership also tends to make exclusive pumping a bit more doable in the US than elsewhere, because you can pump in the car and because a car makes it easier to tote bottles, ice packs and heavy-duty breast pumps around with you. A few women even opt for exclusive pumping due to personal choice.<br />
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<b>Japan</b><br />
Complete contrast here. Although you won't actually see many women nursing publicly in Japan, Japanese culture seems to be far more accepting of <b><a href="http://breastfeedingwithoutbs.blogspot.jp/2013/08/bullshitometer-is-it-ok-to-leave.html">the "nursing relationship"</a></b> than the States. But while Japanese culture is fairly nursing-friendly, this does not extend to pumping. You can get breastpumps in Japan, of course, and increasing numbers of women use them. But relatively few women work outside the home when their babies are small, due to maternity leave and the fact that so many women leave the workforce for many years or permanently once they have children. Using babysitters also seems to be relatively uncommon.<br />
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As a result, the culture of pumping and bottle-feeding EBM has not become rooted in Japanese culture in the way it has in the States. Quite a lot of women do give the odd bottle, but more often than not there will be formula in the bottle--a fact facilitated by the fact that Japanese mothers seem less likely to place a strong premium on breastfeeding exclusively. It's the same story with the pumping side. If you are one of the minority of women who goes back to work early, don't expect much provision or understanding for your pumping needs if you want to pump. I mostly work from home, but was asked to take on an on-site once-a-week position when my daughter was six months old. When I nervously broached the subject of pumping, they were nice enough but said that there was nowhere in the company where I could express milk. Given that the company in question consisted of a 37-storey megablock, I found that hard to believe--but it was clear that my prospective employers were having difficulty envisaging what I was asking for, because they had never received such a request. In the end, I turned down that particular job for unrelated reasons, but it was an awkward moment.<br />
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And then there's the question of getting milk into the baby. Like many things in Japan, the process of sending EBM to daycare is based on lots of silly rules and the most unbelievable inefficiency. In theory, public daycares are supposed to accept EBM; in practice, many of them outright refuse, or put enormous pressure on parents to send formula. If they do accept EBM, the majority insist on the milk being frozen first. Some daycares further stipulate that the milk has to be frozen BUT also pumped <b>within the last week</b> (which means that you basically have to pump, freeze the milk, and then almost immediately dig it out of the freezer to thaw it in the fridge). Apparently, even NICUs often insist on using frozen EBM rather than fresh. I have no idea why the Japanese are so obsessed with freezing EBM--are they under the impression that the freezing process "kills germs" or something? It doesn't, of course (and thawed frozen breastmilk is actually <b><a href="http://breastfeedingwithoutbs.blogspot.jp/2013/08/bullshitometer-is-it-ok-to-leave.html">more prone to spoilage</a></b> than milk that's never been frozen, because the freezing process zaps some of the natural microbicidal compounds). Given the critical shortage of daycare spots in big cities in Japan, it's unlikely that we'll see women demanding that daycares change these ridiculous rules any time soon--most women who have got a spot are too busy feeling relieved and grateful to raise many complaints, and content themselves with writing fake dates on their bags of frozen milk.<br />
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<b>Britain</b><br />
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In Britain, as in America, it would be pretty much unthinkable for a daycare to refuse to handle expressed breastmilk. On the other hand, British women, like their Japanese counterparts, tend not to work full time when their babies are young because most take maternity leave. So pumping has never made quite the inroads into British culture that it has in the States (which is perhaps why the slightly awkward word "express" seems to be the commoner verb to use), although the majority of breastfeeders do own a pump and use it now and again. On British (and Australian) discussion fora, quite a lot of breastfeeding advocates encourage women not to make <i>any</i> use of pumping and bottlefeeding at all, on the grounds that conveying milk this way is unnecessary, might mess up the mother's supply and/or create a preference for artificial teats in the baby, and is less healthy/optimal than direct breastfeeding. I think it would be a rare American lactivist who was so negative about pumping and bottlefeeding; so many American breastfeeders work full-time that she would risk alienating a large percentage of her target audience, and if you overemphasize the difficulties of maintaining breastfeeding through pumping and bottlefeeding to mothers who are going to WOH anyway, they might just give up and decide to use formula instead.<br />
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Pumping breastmilk to avoid breastfeeding in public is also far less common in the UK than in the US, because although breastfeeding rates in the UK are low, breastfeeding in public seems to be more acceptable than in the States. In any case, the reality is that when you are with your baby and breastfeeding him or her round the clock, it is really difficult to fit "pumping a bottle and feeding it to the baby" into the routine, and if a baby does not get a bottle regularly--several times a week, at minimum--there is a high chance that he or she will eventually reject bottles altogether (<b><a href="http://breastfeedingwithoutbs.blogspot.jp/2012/07/how-to-have-bottle-refusing-baby-and.html">as I discovered to my cost</a></b>). Consequently, it seems that a large percentage of breastfed babies in the UK will not drink from bottles, and this seems to have contributed towards a <b><a href="http://breastfeedingwithoutbs.blogspot.jp/2014/08/when-breastfeeding-arguments-arent.html">general feeling</a></b> on British parenting boards that breastfed babies "can't be left" for any length of time.<br />
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<b>Conclusion</b><br />
Living in Japan, it's certainly easy for me to be irritated by aspects of the culture which are interconnected with the difficulties of expressing and bottling breastmilk. Japanese culture tends to emphasize the importance of the mother-child bond; this can be liberating in some ways (very few people here will look down on you for breastfeeding a toddler or even letting them share your bed), but it's also connected with the fact that Japan has been very slow to get women into the workplace--something which is now a big problem for Japan given its shrinking workforce and its resistance to accepting large-scale immigration. The cultural squeamishness towards breastmilk that's been separated from the mother's body and the lack of legal protection for pumping at work means that many women are not able to pump their milk or feed it to their babies if they want, which deprives them of choice; others (as outlined above) are forced to go through unnecessary and time-consuming procedures which add to their burden. While maternity leave provision is a good thing, I think we should also recognize the fact that some women <i>want</i> to return to work while their babies are small--and they have every right to do so and leave pumped milk if they wish. I don't think that the cultural resistance towards using babysitters does Japanese marriages any good, and I'm not a fan of seeing cranky babies being toted around to smoky restaurants late at night, as is frequently seen here in Tokyo.<br />
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On the other hand, normalization of pumping can also become a trap in its own way. There is a danger that each technological innovation can become something that merely shifts the goalposts of what mothers are expected to be able to achieve. Since breastpumps have been invented, women have increasingly been expected to combine breastfeeding and working outside the home (whereas their mother's generation, if they worked outside the home when their babies were small, just shrugged their shoulders and used formula); more efficient breastpumps have raised the bar higher, with working women increasingly expected not only to "breastfeed" but to "breastfeed <i>exclusively</i> without formula supplementation"; with bigger freezers, better designed storage containers and more affordable double-electric pumps, even women who are not working outside the home may increasingly feel that it is expected and normal to pump "just-in-case" stashes or donate milk. And writers like Olivia Campbell may have a point when they suggest that this technological fix (<b><a href="http://breastpump.media.mit.edu/">ever higher-performing breastpumps</a></b>) has enabled American society to avoid confronting the issue of maternity leave, opting instead to place a double burden (working <i>and</i> pumping) on the shoulders of fragile postpartum mothers. Similarly, because most people in the US are aware that pumping and bottle-feeding EBM is a "thing," this can lead to more pressure on mothers to carry bottles of pumped milk around with them, and can become an excuse for negativity towards women who are trying to nurse their babies in public ("Come on, lady--they invented breastpumps for a reason!! Why don't you just pump a bottle before you leave the house??").<br />
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Considering each of the above countries in turn, I think my own country--the UK--probably represents the best overall balance for respecting women's right both to feed at the breast and to pump when they need or want to--although I do wish that there was a bit more awareness in the UK of the fact that bottles are not the only way to get breastmilk into a bottle-refusing baby. I hope that each of these countries can work towards achieving a cultural consensus that will allow women and babies to take advantage of the best aspects of both direct nursing <i>and</i> pumping/bottlefeeding--without either becoming something that places unnecessary burdens on women or restricts their freedom.<br />
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<b>Further reading</b><br />
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<b><a href="http://www.newyorker.com/magazine/2009/01/19/baby-food">Baby Food: If breast is best, why are women bottling their milk?</a> (Jill Lepore, New Yorker)</b><br />
<b><a href="http://www.healthytippingpoint.com/2012/09/why-i-pump-and-why-you-shouldnt-feel-bad-for-me.html">Why I pump and why you shouldn't feel bad for me</a></b> (Healthy Tipping Point)<br />
<b><a href="http://www.psmag.com/business-economics/unseen-consequences-pumping-breast-milk-94181">The Unseen Consequences of Pumping Breast Milk</a></b> (Olivia Campbell)<br />
<br />BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com11tag:blogger.com,1999:blog-9064021843006104287.post-37888127745830361322014-12-03T03:00:00.001-08:002014-12-03T03:00:08.562-08:00No-BS breastfeeding resources updatedFinally 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.BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com3tag:blogger.com,1999:blog-9064021843006104287.post-70061088274651693372014-11-02T05:18:00.000-08:002014-11-02T19:36:07.983-08:00Bullshitometer: Women with HIV should not breastfeed their babies<div class="separator" style="clear: both; text-align: center;">
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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....<br />
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<b>Full circle</b><br />
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.<br />
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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 <b><a href="http://breastfeedingwithoutbs.blogspot.jp/2013/03/we-cant-wait-for-clean-water.html">the rough end of formula feeding in the developing world</a></b> 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.<br />
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJ_ghBlvwu2A1u1Aln4wvqeIP8x0HilgNTs94qV3WVwW4Bbom-o5PxK-7QkMQ2N_4zKzbF1tw3dIpkLWMgvIRyX57TRqHTiKUI6HyghUllHDUCsihZSlTdcSZpEylc699CjuK3fbjOrb8/s1600/Mavundu.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJ_ghBlvwu2A1u1Aln4wvqeIP8x0HilgNTs94qV3WVwW4Bbom-o5PxK-7QkMQ2N_4zKzbF1tw3dIpkLWMgvIRyX57TRqHTiKUI6HyghUllHDUCsihZSlTdcSZpEylc699CjuK3fbjOrb8/s1600/Mavundu.JPG" height="240" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">This is what formula feeding in resource-poor environments looks like. </td></tr>
</tbody></table>
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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 <em>and</em> 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<span style="font-size: xx-small;"> (1)</span>.<br />
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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<span style="font-size: xx-small;"> (2)</span>; moreover, sticking exclusively to breastfeeding (rather than adding in formula/solids) for the full six months lowered the risk further still<span style="font-size: xx-small;"> (3)</span>. 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 <span style="font-size: xx-small;">(4)</span> (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.<br />
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So, to bring the discussion full circle: what are the recommendations for HIV-positive women? Roughly speaking: <b>Women in the <i>developing</i> 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 <i>developed</i> countries are still advised to choose formula</b>--by the AAP<span style="font-size: xx-small;"> (5)</span>, by BHIVA<span style="font-size: xx-small;"> (6)</span> 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<span style="font-size: xx-small;"> (5)</span>. I wouldn't want my baby drinking HAART-laced milk; these are not very nice drugs at all.<br />
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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 <i>developed</i> countries as well. That, roughly speaking, is where the science ends and the woo starts.<br />
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<b>Hard cases</b><br />
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 <i>absolutely </i><em>refuse</em>, 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.<br />
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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.<br />
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Take the World Alliance for Breastfeeding Action (WABA) paper for example<span style="font-size: xx-small;"> (7)</span>. Under "Current infant feeding recommendations for resource-rich settings," the WABA paper says:<br />
<blockquote class="tr_bq">
<span style="font-size: x-small;"><i> "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."</i></span></blockquote>
This is what BHIVA<strong> actually</strong> says:<br />
<blockquote class="tr_bq">
<span style="font-size: x-small;"><i>"...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.<b> 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. </b>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."</i></span></blockquote>
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.<br />
<div>
<br /></div>
<div>
<b>Smoke and mirrors</b><br />
"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 <b><a href="http://lactationmatters.org/2013/01/08/wabahivresource/">New HIV and Breastfeeding Resource from the World Alliance for Breastfeeding Action (WABA)</a></b> in early 2013, which discusses the WABA paper mentioned above.<br />
<br />
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:<u><b> 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.</b> </u>That is <i><b>not</b></i> "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.<br />
<br /></div>
<div>
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 <b><a href="https://www.facebook.com/BestForBabes/posts/247657415366208">Best for Babes on 9 January 2013</a></b> which repeated the statement uncritically: "Big news for lactation pros and HIV-positive mamas!"<br />
<br />
<b>Why you should always read the original paper</b><br />
Best For Babes is apparently not alone in writing odd headlines for articles they link to. On 29 January of the same year, the <b><a href="https://www.facebook.com/kellymomdotcom/posts/511885702167778">Kellymom Facebook page</a></b> made the following post:<br />
<blockquote class="tr_bq">
<span style="font-size: x-small;"><i>"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..." </i></span></blockquote>
followed by a link to the AAP's latest guidelines on <b><a href="http://pediatrics.aappublications.org/content/early/2013/01/23/peds.2012-3543.full.pdf+html">Infant Feeding and Transmission of Human Immunodeficiency Virus in the United States</a></b>. Now, this is what the guidelines <b>actually</b> say:</div>
<div>
<blockquote class="tr_bq">
<i><span style="font-size: x-small;">"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 </span></i><i><span style="font-size: x-small;">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... </span></i></blockquote>
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.)<br />
<br />
More recently, Kellymom enthusiastically heralded the arrival of <b><a href="http://viewer.zmags.com/publication/17f8c1a9#/17f8c1a9/24">a new issue of La Leche League International (LLLI)'s online magazine</a></b> 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 <i>in comparison with mixed feeding</i>--when compared with <i>formula feeding</i>, 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<span style="font-size: xx-small;"> (8)</span>) 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.<br />
<br />
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 <b><a href="http://kellymom.com/blog-post/newest-recommendations-for-hiv-moms/">here</a></b> and <b><a href="http://kellymom.com/blog-post/breastfeeding-and-hiv/">here</a></b>):<br />
(1) an article on ARV regimes for women in East Africa (irrelevant to the vast majority of Kellymom's readership);<br />
(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 <b><i>not</i> </b>say this);<br />
(3) a broken link which appears to have once led to yet another set of recommendations aimed at the developing world;<br />
(4) the bizarre <b><a href="http://www.anotherlook.org/index.php">"AnotherLook at breastfeeding and HIV/AIDS" page</a></b>, which contains a Mothering Magazine article by the <b><a href="http://scienceblogs.com/aetiology/2007/06/11/david-crowe-way-beyond-hiv-den/">AIDS denialist (and, for that matter, germ theory denialist)</a></b> David Crowe.<br />
<br />
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 <i>dead</i>. 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.<br />
<br />
<b>Conclusion</b><br />
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.<br />
<br />
<br />
<b>Further reading: </b><br />
<b>(1) <a href="http://journals.lww.com/aidsonline/Fulltext/2005/04290/Early_exclusive_breastfeeding_reduces_the_risk_of.7.aspx/">Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival,</a></b> Iliff et al, <i>AIDS</i><br />
<b>(2) <a href="http://www.avert.org/who-guidelines-pmtct-breastfeeding.htm">WHO Guidelines for PMTCT & Breastfeeding</a></b><br />
<b>(3) <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(99)01101-0/abstract">Influence of infant-feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa: a prospective cohort study,</a> </b>Coutsoudis et al, <i>The Lancet</i></div>
<b>(4) <a href="http://cid.oxfordjournals.org/content/51/2/252.full">Premastication: A Possible Missing Link?</a> </b>Mark J. DiNubile, <i>Clinical Infectious Diseases</i><br />
<b>(5) <a href="http://pediatrics.aappublications.org/content/early/2013/01/23/peds.2012-3543.full.pdf">Infant Feeding and Transmission of Human Immunodeficiency Virus in the United States,</a></b><br />
COMMITTEE ON PEDIATRIC AIDS, Pediatrics<br />
<b>(6) <a href="http://www.chiva.org.uk/professionals/health/guidelines/mtct/feeding-statement.html">Position statement on infant feeding in the UK,</a></b> BHIVA/CHIVA Writing Group<br />
<b>(7) <a href="http://lactationmatters.org/2013/01/08/wabahivresource/">Understanding International Policy on HIV and Breastfeeding: a comprehensive resource,</a> </b>World Alliance for Breastfeeding Action (WABA)<br />
<b>(8) <a href="http://www.ncbi.nlm.nih.gov/pubmed/16905785">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, </a></b>Thior et al, <i>JAMA</i><br />
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<span class="Apple-style-span" style="color: #333333; font-family: Arial, Helvetica, sans-serif; font-size: 14px; line-height: 22px;"><br /></span>BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com207tag:blogger.com,1999:blog-9064021843006104287.post-86946240908036130612014-10-27T05:00:00.001-07:002014-10-27T05:00:41.269-07:00The earthquake<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBBZ1OKZrjuyIg9LHV8vYGrmnVW82Y88GSQW9ehtKEPPvuizaJSsAw1iR27VkUuISwo_JV__sEbpRJw-v4f_ERsN1Em9llycUdFa_UkDjxnnJS0LInPqgcDQ4o1uujPFrFxsXIJcCre58/s1600/P4263374.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBBZ1OKZrjuyIg9LHV8vYGrmnVW82Y88GSQW9ehtKEPPvuizaJSsAw1iR27VkUuISwo_JV__sEbpRJw-v4f_ERsN1Em9llycUdFa_UkDjxnnJS0LInPqgcDQ4o1uujPFrFxsXIJcCre58/s1600/P4263374.jpg" height="320" width="240" /></a></div>
<br />
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.<br />
<br />
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.<br />
<br />
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.<br />
<br />
At 5:15 on the following morning, I woke up and realized my waters had broken.<br />
<br />
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.<br />
<br />
<i>Everybody's looking for the sun... </i><br />
<i>People strain their eyes to see...</i><br />
<i>But I see you and you see me</i><br />
<i>And ain't that wonder? </i><br />
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*********</div>
<br />
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.<br />
<br />
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.<br />
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*</div>
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<br /></div>
Nighttime. Best to get to bed early--that's what they always say.<br />
<br />
The phone rings: "You're still in Tokyo? Oh, okay. You <i>have</i> 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?"<br />
<br />
Head down again. Need to sleep. Mother-in-law silhouetted in the doorway, rocking and rocking the baby.<br />
<br />
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?"<br />
<br />
I manage a few more hours of sleep.<br />
<br />
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."<br />
<br />
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."<br />
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<div style="text-align: center;">
*</div>
<div style="text-align: center;">
<br /></div>
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 <b><a href="http://atomicinsights.com/">Atomic Insights website</a></b> 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.<br />
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<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
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.</div>
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<div style="text-align: center;">
*</div>
<div style="text-align: center;">
<br /></div>
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 <i>nownownow</i> 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--<br />
<br />
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.<br />
<br />
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.<br />
<br />
<div style="text-align: center;">
*</div>
<div style="text-align: center;">
<br /></div>
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 <i>doing</i> 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, <i>you useless. fucking. waste. of. space--</i><br />
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<br /></div>
<div style="text-align: center;">
*</div>
<div style="text-align: center;">
<br /></div>
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.<br />
<br />
"It's okay. We've been watching you, we know that you're stressed. <i>Muri ni shinakute ii desu yo</i> [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."<br />
<br />
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.<br />
<br />
<div style="text-align: center;">
*********</div>
<br />
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.<br />
<br />
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.<br />
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<i>Names have been changed in this post.</i>BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com3tag:blogger.com,1999:blog-9064021843006104287.post-9963461998808043542014-08-13T11:56:00.002-07:002014-08-13T11:56:36.963-07:00When breastfeeding arguments aren't actually about breastfeeding (Part 2: "No babies" is not anti-breastfeeding discrimination)<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRzFHeEdj7OG-dBrORI33wqrSMT7yl852P7JsCVCpC96ppVAyDOMp0U0VLJw42lAgBUzuNXFXUkhbjUYzecNputDOboy5vixtBFPorTRkHTWXJ9T4wHlhXQjgvdU38spR2Q2U2cUsobMc/s1600/P4231385.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRzFHeEdj7OG-dBrORI33wqrSMT7yl852P7JsCVCpC96ppVAyDOMp0U0VLJw42lAgBUzuNXFXUkhbjUYzecNputDOboy5vixtBFPorTRkHTWXJ9T4wHlhXQjgvdU38spR2Q2U2cUsobMc/s1600/P4231385.JPG" height="240" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><b>NO BABIES HERE, PLEASE</b></td></tr>
</tbody></table>
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A few weeks ago, <b><a href="http://breastfeedingwithoutbs.blogspot.co.uk/2014/06/when-breastfeeding-arguments-arent_19.html">I talked about</a></b> 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.</div>
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<b><a href="https://au.news.yahoo.com/vic/a/17250630/mum-banned-from-breast-feeding-at-hair-salon/">Mother "banned from breastfeeding at hair salon"</a></b></div>
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<b><a href="http://www.mumsnet.com/Talk/_chat/a2066645-Friend-turned-away-from-speed-awareness-course-due-to-bf">My friend was turned away from speed awareness course due to bf</a></b></div>
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<b><a href="http://www.mumsnet.com/Talk/am_i_being_unreasonable/a2104207-To-take-breastfed-DD-with-me-to-training">Should I take my breastfed baby with me to a training session?</a></b></div>
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<b><a href="http://abcnews.go.com/Business/breastfeeding-mom-expelled-national-restaurant-association-trade-show/story?id=23779288">Restaurant Association Expels Breastfeeding Mom From Convention</a></b></div>
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<b><a href="http://www.mumsnet.com/Talk/am_i_being_unreasonable/a1377521-Full-price-babies-at-the-Olympics">Breastfeeding babies and the Olympics</a></b></div>
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<b><a href="http://www.mumsnet.com/Talk/am_i_being_unreasonable/a1677176-for-flouting-hospital-no-sibling-rule-for-ebf-baby">Mother ignoring no-sibling hospital rules because her baby is breastfed</a></b></div>
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<b><a href="http://www.mumsnet.com/Talk/am_i_being_unreasonable/a1927112-In-wanting-to-take-a-breastfeeding-baby-to-Chelsea-flower-show">Taking a breastfed baby to the Chelsea Flower Show</a></b></div>
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<b><a href="http://www.mumsnet.com/Talk/am_i_being_unreasonable/a2132636-To-want-to-set-the-record-straight-about-the-Cedar-Falls-Nurse-In">Cedar Falls health spa won’t make exception for breastfed toddler</a></b></div>
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<b><a href="http://community.babycenter.com/post/a51030616/mom_brings_baby_to_mosh_pit.">Breastfeeder gets kicked out of mosh pit </a>(words fail me…)</b></div>
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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."</div>
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Laws against breastfeeding discrimination typically protect the mother's right to breastfeed her child <i>anywhere where she and her child are permitted to be</i>; a closer look at the above instances reveals that the problem was basically <b>the presence of the child</b>, 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.</div>
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<b>Where it gets a bit complex</b></div>
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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.”</div>
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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 <b><a href="http://www.mumsnet.com/Talk/am_i_being_unreasonable/a1630859-to-not-want-my-friend-to-bring-her-6mo-to-our-Christmas-meal">leaving a 6mo for just a couple of hours</a></b> is basically impossible because "the baby is exclusively breastfed."</div>
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Issues</div>
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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).</div>
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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.</div>
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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.</div>
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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.</div>
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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 <i>thinking</i> 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 <i>true</i>, 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.</div>
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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.</div>
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<b>Conclusion</b></div>
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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.”</div>
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BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com2tag:blogger.com,1999:blog-9064021843006104287.post-29713697178887844362014-06-27T00:10:00.001-07:002014-07-16T13:10:25.780-07:00Why I am (surprisingly) in favor of banning the bags<div class="separator" style="clear: both; text-align: center;">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhC5jRawIItGZmtBqa4pjEbLx4hpn6UtRkIw3V6g8IIaNTyeZZubYwbRlWe_8UkEdxcWqGejGWRWvxoRv0ci_upKXAr0g8vIeXOUKLfRN6EC7u0OUWzHchMSnyUYFbp4VQFeNXF13A9IXY/s1600/P3170074.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhC5jRawIItGZmtBqa4pjEbLx4hpn6UtRkIw3V6g8IIaNTyeZZubYwbRlWe_8UkEdxcWqGejGWRWvxoRv0ci_upKXAr0g8vIeXOUKLfRN6EC7u0OUWzHchMSnyUYFbp4VQFeNXF13A9IXY/s1600/P3170074.JPG" height="240" width="320" /></a></div>
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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.</div>
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<b>Paying for the label</b><br />
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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.</div>
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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.</div>
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This is <i>not</i> 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 <i>un</i>sweet 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.</div>
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even though your baby does fine on generic.<br />
Yes, this is my kitchen. No, it isn't normally as clean as this. </td></tr>
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<b>Can I trust my doctor?</b><br />
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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 <i>know</i> 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.</div>
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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 <em>anything</em> 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 <i>bottled water </i>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.</div>
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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.</div>
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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 <b><a href="http://health.usnews.com/health-news/health-wellness/articles/2014/06/18/how-to-choose-the-right-baby-formula">this one</a></b> (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.</div>
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<b style="text-align: left;">Formula = Breast pads</b></div>
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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<i> having something taken </i><em>away</em> 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. </div>
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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.</div>
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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. </div>
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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.</div>
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<b>Further reading</b></div>
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<b><a href="http://www.pediatricsconsultant360.com/sites/default/files/PerrigoReprintFinalVersionsmall.pdf">Supplement to Consultant for Pediatricians (February 2014): A Comprehensive Overview of Store Brand Infant Formula/</a></b><b><a href="http://www.pediatricsconsultant360.com/sites/default/files/PerrigoReprintFinalVersionsmall.pdf">Guiding Parents in Formula Selection: How Do Store Brands Compare to National Brands?</a> </b> 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.</div>
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BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com1tag:blogger.com,1999:blog-9064021843006104287.post-71735129245693708462014-06-19T22:06:00.001-07:002014-06-19T22:06:05.134-07:00When breastfeeding arguments aren't actually about breastfeeding (Part 1: Alcohol and breastfeeding)<br />
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What do the following headlines all have in common?<br />
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<b><a href="http://thestir.cafemom.com/baby/163553/drunk_moms_baby_dies_during">Drunk Mom's Baby Dies During Breastfeeding</a></b><br />
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<b><a href="http://thestir.cafemom.com/in_the_news/122095/breastfeeding_mom_kills_baby_while">Breastfeeding Mom Kills Baby While Drunk</a></b><br />
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<b><a href="http://thestir.cafemom.com/baby/146329/mom_suffocates_baby_while_breastfeeding?next=11">Mom Suffocates Baby While Breastfeeding, But It Could Have Been Prevented</a></b><br />
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"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.<br />
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From the first story:<br />
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<i>...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.</i></blockquote>
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.<br />
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Second story:<br />
<blockquote class="tr_bq">
<i>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. </i></blockquote>
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.<br />
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Story No. 3:<br />
<blockquote class="tr_bq">
<i>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.</i></blockquote>
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.<br />
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<b>Alcohol and breastmilk</b><br />
There is a paucity of really good data on breastfeeding and alcohol, but Linda Geddes' book <b><a href="http://www.amazon.co.uk/Bumpology-myth-busting-pregnancy-parents-be/dp/059306996X">Bumpology</a></b> (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 <i>heavily</i> (we're talking <i>several</i> 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.<br />
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But even if you neglect to take this precautionary stance, your baby is <i>not</i> 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.<br />
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(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.)<br />
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<i>Beer.....mmmmmm</i></div>
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<b>BreastsBreastsBreastsBreastsBreasts</b><br />
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, <i>suffocating to death</i>.<br />
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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, <b><a href="http://www.mommyish.com/2013/11/29/nosy-sanctimommy-waitress-fired-calls-cops-drinking-breastfeeding-mom/">having the cops called on them</a></b>. (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.")<br />
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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 <i>not</i> 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.<br />
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<b>Further reading</b><br />
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<b><a href="http://www.lindageddes.com/118/mulled-wine-but-youre-breastfeeding">Mulled wine? But you're breastfeeding... </a></b> Linda Geddes (Bumpology) on alcohol and breastfeeding<br />
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<b><a href="http://www.phdinparenting.com/blog/2009/7/8/you-should-not-be-drunk-while-caring-for-your-baby.html">You should not be drunk while caring for your baby</a></b> (from PhD in Parenting)<br />
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<b><a href="http://www.thefreelibrary.com/Alcohol+and+lactation%3A+a+systematic+review.-a0148138195">Alcohol and lactation: a systematic review</a> </b> 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.<br />
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<br />BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com4tag:blogger.com,1999:blog-9064021843006104287.post-63465967535408744892014-05-07T05:36:00.001-07:002014-05-14T04:48:38.271-07:00Why don't Gypsy and Traveller women breastfeed?<br />
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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.<br />
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(By the way, given the controversial nature of both Travelers <i>and</i> 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....)<br />
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<b>Britain's Travelers</b><br />
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 <i>Irish</i> 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.<br />
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<b>Travellers and breastfeeding</b><br />
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 <b>(*1)</b>) 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 <b><a href="http://www.mumsnet.com/Talk/telly_addicts/a1869894-Big-fat-gypsy-christenings">here</a></b> and <b><a href="http://www.thealphaparentforum.com/viewtopic.php?f=9&t=424">here</a></b>), 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.<br />
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<b>Cultural taboos</b><br />
Ethnological studies of Romani Gypsy and Irish Traveller women universally indicate quite negative attitudes towards breastfeeding among both men and women.<br />
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<span style="font-size: x-small;"><i>"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’." <b>(*2)</b></i></span></blockquote>
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<span style="font-size: x-small;"><i> "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." <b>(*3)</b></i></span></blockquote>
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<span style="font-size: x-small;"><i>“I don’t like the thought of [breastfeeding] and I was not gonna get my bits [sic] out." <b>(*4)</b></i></span></blockquote>
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 <i>must</i> 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 <b>(*5-*8)</b> 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. <br />
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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.<br />
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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."<br />
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(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.)<br />
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<b>Which is easier--breast or bottle?</b><br />
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."<br />
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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.<br />
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<i><span style="font-size: x-small;">We have loads of people </span></i><i><span style="font-size: x-small;">come round and the baby would have starved cos I wouldn’t have fed it with people there </span></i><i><span style="font-size: x-small;">or husband. That’s wrong.</span></i></blockquote>
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<i><span style="font-size: x-small;">I just couldn’t try it. I know it's good for the baby but we don’t do things like that and we </span></i><i><span style="font-size: x-small;">have so many family coming round... the men would have had to stay out of the house.</span></i></blockquote>
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, <a href="http://paveepoint.ie/pdf/SocialInclusion.pdf" target="_blank"><b>low levels of reading ability</b></a> 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.<br />
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<span style="font-size: x-small;"><i>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. <b>(*1)</b></i></span></blockquote>
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.<br />
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<b>A way forward</b><br />
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.<br />
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<i><span style="font-size: x-small;">"They kept on at you about that. They tried to push you into it. I didn't want to. They kept </span></i><i><span style="font-size: x-small;">on about it." <b>(*4)</b></span></i></blockquote>
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<i><span style="font-size: x-small;">"I would rather they let you have the choice but they make as if you have to. They made me </span></i><i><span style="font-size: x-small;">feel bad and they wouldn't even tell me where the formula was kept." <b>(*4)</b></span></i></blockquote>
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."<br />
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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 <i>wanted</i> 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 <i>the age at which they first get pregnant</i>, 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.<br />
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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<b> (*9)</b>. 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 <b>(*10)</b>, 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<b> (*11)</b>.<br />
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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.<br />
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<b>Further reading</b><br />
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*1: <b><a href="http://www.google.co.jp/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCUQFjAA&url=http%3A%2F%2Fcore.kmi.open.ac.uk%2Fdownload%2Fpdf%2F1441322.pdf&ei=_IkMU6bNNYWtlAXV5oHIAg&usg=AFQjCNF8AyQNj1BnlBApW016cMSp2Q7-AQ&sig2=QAAiTSx_ONbzuEHt04u3dQ">The infant feeding practice of Gypsy and Traveller women in Western Cheshire Primary. Care Trust and their attitudes towards breast and formula feeding</a></b></div>
*2: <b><a href="http://ja.scribd.com/doc/104560307/Irish-Traveller-women">Irish Traveller women</a> (</b>Ellen D'Arcy)<br />
*3: <b><a href="https://www.blogger.com/"><span id="goog_1412110823"></span>Gypsies and travellers: cultural influences on health<span id="goog_1412110824"></span></a></b><br />
*4: <b><a href="http://www.google.co.jp/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CCUQFjAA&url=http%3A%2F%2Fwebarchive.bromleypct.nhs.uk%2Fwww.bromley.nhs.uk%2FEasySiteWeb%2Fgetresource9259.doc%3FAssetID%3D1286%26type%3Dfull%26servicetype%3DAttachment&ei=FocMU7fNGITvlAWC64C4Dg&usg=AFQjCNGoGq_qcMiBsfKDmIXAuSKzDdmZCQ&sig2=PnSI6sC1xV72iYwX5bpEjw&bvm=bv.61725948,d.dGI">The Experience of Maternal Health services by the Bromley Gypsy Traveller Community</a></b><br />
*5: <a href="http://ling.uni-graz.at/~rombase/cgi-bin/art.cgi?src=data/ethn/belief/ladz.en.xml" style="font-weight: bold;">Taboo and shame (Ladž) in traditional Roma communities</a><br />
*6: <b><a href="http://www.policy.hu/vincze/RESEARCH%20PAPER.html">Social exclusion at the crossroads of gender, ethnicity and class. A view through Roma women's reproductive health</a></b><br />
*7: <b><a href="http://www.biomedcentral.com/1471-2458/10/509">Risk factors for childhood malnutrition in Roma settlements in Serbia</a></b><br />
*8: <b><a href="http://thegypsychronicles.net/romanipen/">Purity and impurity in the traditional Romani family</a></b><br />
<b><a href="http://www.travellerstimes.org.uk/downloads/lifestyle_history_and_culture_24052010111520.pdf">Gypsies and Travellers: Their lifestyle, history and culture</a></b><br />
*9: <b><a href="http://www.guardian.co.uk/lifeandstyle/2011/feb/25/truth-about-gypsy-traveller-life-women">The big fat truth about Gypsy life</a></b> (<i>Guardian</i>)<br />
*10: <b><a href="http://jech.bmj.com/content/65/Suppl_2/A29.1.abstract">Traveller infant mortality is persistently higher than the general population in the All Ireland Traveller Birth Cohort study</a></b><br />
*11: <b><a href="http://www.gypsy-traveller.org/wp-content/uploads/2010/08/poverty-needs-assessment-report-youth.pdf">Child Poverty Relating to Gypsy and Traveller Children and Young People in Sussex </a></b><br />
<br />
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: http://en.wikipedia.org/wiki/Galactosemia<br />
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<br />BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com6tag:blogger.com,1999:blog-9064021843006104287.post-72938959606356803222014-03-29T05:08:00.001-07:002014-05-14T04:51:00.350-07:00Bottles for toddlers, nursing for toddlers<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTVQ4os95T3mGAlfs7UQY8GPLJfmovP5w8qBKamDfYF9h16OQwV4GSp7KqW5jPMI1k38YPjwQ8gVEOTkc8wC-L7D_9Vo0fqhpMCPiQozOcMZ9_2x9ed4tXY71wghHNyA61sXzoa8_RBsk/s1600/P2111014.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTVQ4os95T3mGAlfs7UQY8GPLJfmovP5w8qBKamDfYF9h16OQwV4GSp7KqW5jPMI1k38YPjwQ8gVEOTkc8wC-L7D_9Vo0fqhpMCPiQozOcMZ9_2x9ed4tXY71wghHNyA61sXzoa8_RBsk/s1600/P2111014.JPG" height="240" width="320" /></a></div>
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 <i>and</i> 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.<br />
<br />
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?<br />
<br />
<b>Bottle problems</b><br />
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" <b><a href="http://adc.bmj.com/content/89/2/154.full#ref-26">as a social problem</a></b>, and many public health authorities actually carry out <b><a href="http://www.ncbi.nlm.nih.gov/pubmed/11424513">"bottle-to-cup" campaigns</a></b> 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).<br />
<br />
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 <b><a href="http://adc.bmj.com/content/89/12/1121.full">dental malocclusion</a></b> 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).<br />
<br />
Does doing-bottles-past-12-months <i>have </i>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 (<b>before</b> 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.<br />
<br />
<b>What about breastfeeding?</b><br />
Honestly, I think breastfeeding a toddler is a little different to bottles for a couple of reasons.<br />
<br />
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1A9UI81cQ_Q6KAFZlyxG98WBcCC6diDD12LsKIHBBHIVFqYUH5d_X4WviwwE2R0POiROu3owgPWrnP_JbpwrwpTM1TIoTD1QTtfwHGRp4P7c7aAbRWG47anS8mmznJIlkoixUtX3XpCw/s1600/P8140560.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh1A9UI81cQ_Q6KAFZlyxG98WBcCC6diDD12LsKIHBBHIVFqYUH5d_X4WviwwE2R0POiROu3owgPWrnP_JbpwrwpTM1TIoTD1QTtfwHGRp4P7c7aAbRWG47anS8mmznJIlkoixUtX3XpCw/s1600/P8140560.JPG" height="240" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The expression on this mummy sheep's face somehow<br />
makes me feel that nursing has been "extended" <br />
a bit longer than she's comfortable with...</td></tr>
</tbody></table>
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. (<b><a href="http://umepublication.um.edu.my/filebank/published_article/2045/371.pdf">This interesting article</a></b> 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?)<br />
<br />
But I think the big difference between breastfeeding and bottle usage during the toddler years is that breastfeeding is by its nature <b>self-limiting</b>. 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.<br />
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<br /></div>
I do think, however, that a partial exception should be made for <b>nighttime</b> nursing; if mothers bedshare, night-nursing is the one type of nursing which really <i>can</i> 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 <i>need</i> to eat all night long.<br />
<br />
<b>Conclusion</b><br />
I talked about this a bit in <b><a href="http://breastfeedingwithoutbs.blogspot.jp/2012/03/cows-milk-and-law-of-lowest-common.html">a previous post</a></b>, 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.<br />
<br />
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.<br />
<br />
<br />BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com0tag:blogger.com,1999:blog-9064021843006104287.post-52219862496710451122013-11-18T22:11:00.000-08:002013-12-01T00:41:09.151-08:00Bullshitometer: Rice cereal edition<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtZdC8EJuchOKqTWWAY7wDMsYxq1ro0og0g1RXlfrQmb33PMqQyYLrxDg2-wI5-Eoxb_fP6TsIg9ZcmGdlFzgUxfyNHRXREISI6XeuY0ltZ7k2uKs87wPkWXjD_bH27xJgmdMJyZRNMww/s1600/P7191597.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: center;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtZdC8EJuchOKqTWWAY7wDMsYxq1ro0og0g1RXlfrQmb33PMqQyYLrxDg2-wI5-Eoxb_fP6TsIg9ZcmGdlFzgUxfyNHRXREISI6XeuY0ltZ7k2uKs87wPkWXjD_bH27xJgmdMJyZRNMww/s320/P7191597.JPG" width="320" /></a><br />
Rice cereal is widely used in many countries as a first food for infants, either stirred into a bottle or mixed with breastmilk/formula and fed with a spoon. Hang around any discussion group with mothers of babies and you're sure to hear someone talking about how they plan to "skip the rice cereal" or "start giving baby rice." Debates on the subject can get very heated--astonishingly heated, really, when you consider that this is basically an innocuous-looking white powder that most babies probably only eat in very small amounts anyway.<br />
<br />
Some people have been assured by their doctors that it is hazardous to give babies anything other than rice cereal as a first food. Other people believe that rice cereal is harmful, and that the only reason we are told to start with it at all is due to the machinations of the good old formulaandbabyfoodmilitaryindustrialcomplex. Still others hint that giving cereal is okay... as long as it's organic, or homemade, or brown/wholegrain, or is something other than rice. So, who's telling the truth? As there are so many claims that are made about rice cereal, I'll break them down into "In favor" and "Against." As you'll see, sometimes the bullshitometer verdict is of the "It Depends" variety.<br />
<br />
<br />
<b><span style="color: blue;">Claims made in favor of rice cereal</span></b><br />
<br />
<b><i>Rice cereal will make your baby sleep longer at night</i></b><br />
<b>Bullshitometer verdit: <span style="color: red;">Basically false</span></b><br />
It appears that this particular myth is still doing the rounds. However,<b><a href="http://archpedi.jamanetwork.com/article.aspx?articleid=514762"> the sole randomized control study</a></b> that I have been referred to found that cereal at bedtime makes no difference to babies' sleeping patterns. (If your baby has gastrointestinal reflux, however, it's a different story: see below.)<br />
<br />
<b><i>Only rice cereal should be given at first, because it's hypoallergenic</i></b><br />
<b>Bullshitometer verdit: <span style="color: red;">False</span></b><br />
Rice <i>is</i> one of the foods least likely to provoke an allergic reaction, so some parents find it a "reassuring" first food. Howev<span style="text-align: center;">er, it's a bit of a stretch to imply that this means parents should give rice first, or give nothing but rice for the first few months.</span><br />
<br />
About 10 years ago, there was a spate of advice from medical bodies which basically told mothers and mothers-to-be to avoid foods associated with allergies--no peanuts during pregnancy, no eggs for baby until 12 months, etc. As far as I can tell, this advice was never based on any actual data, but rather on a vague sense of panic that Allergies Are Increasing And We Must Do Something About It. Since then, most of the "avoid allergens!" advice has been dropped, and the American Association of Pediatricians and Britain's National Health Service now state that other than a few exceptions like honey, there is no particular reason to delay any food beyond six months. For every (small, unsatisfactory) study which seems to indicate that delaying the introduction of wheat or egg reduces the risk of allergy, there's another (equally inconclusive) study which hints tantalizingly that <i>early-ish</i> introduction of the allergen in question might be better--see <a href="http://www.ncbi.nlm.nih.gov/pubmed/19000582"><b>here</b></a> and <b><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2860070/">here</a></b>, for example. When the <b><a href="http://www.eatstudy.co.uk/">EATS study</a></b> results come out in 2015, we'll have a better idea. Till then, there seems to be no reason to stick exclusively to rice cereal in the early weaning stage.<br />
<br />
<b><i>Rice cereal is rich in iron</i></b><br />
<b>Bullshitometer verdit: <span style="color: red;">True</span></b><br />
Fortified rice cereal is a good source of iron; indeed, that's a large part of the reason why it's recommended by doctors. I discussed the importance of iron <b><a href="http://breastfeedingwithoutbs.blogspot.com/2012/09/bullshitometer-food-before-one-is-just.html">here</a></b>. It's the fortification that gives baby rice its iron, by the way, so if you make your own "rice cereal" at home it won't provide the same benefit. Nor do many organic cereals, because generally if any food is fortified artificially it can't be called "organic."(NB: I am told that this is actually not the case in the US, so this may be one of those #regional things.)<br />
<br />
<b><i>Rice cereal helps with reflux</i></b><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTVQ4os95T3mGAlfs7UQY8GPLJfmovP5w8qBKamDfYF9h16OQwV4GSp7KqW5jPMI1k38YPjwQ8gVEOTkc8wC-L7D_9Vo0fqhpMCPiQozOcMZ9_2x9ed4tXY71wghHNyA61sXzoa8_RBsk/s1600/P2111014.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em; text-align: center;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTVQ4os95T3mGAlfs7UQY8GPLJfmovP5w8qBKamDfYF9h16OQwV4GSp7KqW5jPMI1k38YPjwQ8gVEOTkc8wC-L7D_9Vo0fqhpMCPiQozOcMZ9_2x9ed4tXY71wghHNyA61sXzoa8_RBsk/s320/P2111014.JPG" width="320" /></a><b>Bullshitometer verdit: <span style="color: red;">Somewhat true</span></b><br />
Thickening formula or expressed breastmilk with rice cereal is popular advice for helping babies suffering from acid reflux. A <b><a href="http://pediatrics.aappublications.org/content/122/6/e1268.short">2008 meta-analysis</a></b> found that thickening feeds was helpful for reflux--although only moderately so.<br />
<br />
<br />
<span style="color: blue;"><b>Claims made against rice cereal</b></span><br />
<br />
<b><i>Rice cereal can cause constipation</i></b><br />
<b>Bullshitometer verdit: <span style="color: red;">True</span></b><br />
Rice cereal can indeed constipate some babies. This is sometimes attributed to its being white and refined, but the real culprit appears to be the iron with which it is fortified. It's the reason why "traditional" weaning regimes like that of Gina Ford include a lot of loosening fruits like prunes and pears.<br />
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<b><i>Rice cereal is bland and taste of nothing (or even "Rice cereal tastes and smells disgusting")</i></b><br />
<b>Bullshitometer verdit: <span style="color: red;">Sort of true, but...</span></b><br />
I don't think anyone is ever going to claim that baby rice is as flavorful as, say, a plate of hummus or a Thai curry. That said, the rhetoric one sees about "How can people give their babies slop that tastes of wallpaper paste!?!" seems a bit unfair on poor old rice cereal.<br />
<br />
For a start, there's surely room for both intensely and subtly flavored foods in our diets, and I doubt many parents give their babies nothing but rice. Plus... at the risk of pointing out the bleedin' obvious, rice cereal mixed with breastmilk tastes primarily of--surprise, surprise--<i>breastmilk</i>. Given that lactivists are so big on the idea that breastmilk takes on all these interesting flavors from the mother's diet and so on, it seems a bit odd to simultaneously insist that <i>cereal mixed with breastmilk</i> tastes of absolutely nothing. To make matters even more confusing, crunchy forums are full of mothers who say that rice cereal shouldn't be given because it's tasteless, yet consider rice <i>cakes</i> (for self-feeding) to be A-OK. I'm not sure what the reasoning is here--that rice magically acquires lots of exciting flavor when you puff it up and press it into a styrofoam disc? Given that rice itself doesn't really taste of anything, I feel confident saying that if a serving of breastmilk-mixed-with-cereal smells or tastes<i> disgusting</i>, it's probably something to do with the breastmilk. Unfortunately, some mothers' milk acquires fishy/metallic flavors when stored for any length of time.<br />
<br />
One <b><a href="http://www.drgreene.com/whiteout-faq/">Dr. Greene</a></b>, by the way, has made claims that rice cereal is not only bland but will give your child a <i>lifelong preference</i> for bland, starchy foods, based on the curious idea that the babies will "imprint" on the cereal, like a duckling fixating on the first moving object it sees. I think it makes sense to expose babies to lots of interesting flavors, but there is not a shred of evidence to support his idea that giving a baby any cereal whatsoever is going to do terrible things to their palate. Anyway, if you find cereal a little bland, there's nothing to stop you mixing it with other things.<br />
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<b><i>Rice cereal is indigestible because babies can't digest grains until they are a year old/two years old/until their molars come through etc.</i></b><br />
<b>Bullshitometer verdit: <span style="color: red;">False</span></b><br />
The idea that we should avoid giving babies grains has become increasingly popular in the last few years in parallel with the rise of so-called "paleo" diets which limit the consumption of starchy cereals. A much-shared article from Food Renegade <b><a href="http://www.foodrenegade.com/why-ditch-infant-cereals/">"Why Ditch The Infant Cereals?"</a></b> is typical of this genre:<br />
<blockquote class="tr_bq">
<i><span style="font-size: x-small;">In order to digest grains, your body needs to make use of an enzyme called amylase. Amylase is the enzyme responsible for splitting starches. And, guess what? Babies don’t make amylase in large enough quantities to digest grains until after they are a year old at the earliest. Sometimes it can take up to two years. You see, newborns don’t produce amylase at all. Salivary amylase makes a small appearance at about 6 months old, but pancreatic amylase (what you need to actually digest grains) is not produced until molar teeth are fully developed! First molars usually don’t show up until 13-19 months old, on average.</span></i> </blockquote>
I do not have the time to go through every single scientific and historical error in the entire Food Renegade article, so, briefly: contrary to what Food Renegade claims, <b><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1029173/pdf/archdisch00545-0062.pdf">pancreatic amylase</a></b> starts to be produced by infants from about one month of age, and is present in substantial amounts by a few months later. What's more, <b><a href="http://ajcn.nutrition.org/content/39/4/584.short">salivary amylase</a></b> (which is present in your saliva) starts being produced from around birth and is at around two-thirds of adult levels by three months of age. Finally, expressed breastmilk itself is full of amylase. There's <b><a href="http://pediatrics.aappublications.org/content/70/2/235.short">also</a></b> <b><a href="http://www.nature.com/pr/journal/v17/n1/abs/pr19833a.html">evidence</a></b> that breastmilk amylase continues to be active even when it's in your baby's stomach. Food Renegade claims that pancreatic amylase is the only one that will digest grains, but this is false; salivary, pancreatic and breastmilk amylase are all alpha-amylases and all will break down the starch in cereals.<br />
<br />
If you're lactating and are feeling bored today, you can actually try this out for yourself: pump, and mix your freshly expressed milk in a bowl with enough rice cereal or flour to make a thick goo. Wait five minutes, and look at it again. It will have gone runny or sloppy, because the amylase in your milk is actually predigesting the starch in the cereal. Very young babies may have difficulty digesting cereal, but if your baby is four months or older you shouldn't need to worry.<br />
<br />
<b><i>Rice cereal is nutritionally void</i></b><br />
<b>Bullshitometer verdit: <span style="color: red;">False</span></b><br />
The iron with which infant rice cereal is fortified is useful to babies--especially since it's one of the few things they won't get from breastmilk. Rice cereal won't provide much else other than iron, true--but then, it doesn't really <i>need</i> to: breastmilk/formula meets all other nutritional needs except perhaps zinc.<br />
<br />
<b><i>Rice cereal in a bottle can cause choking</i></b><br />
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitlToa6PLh97C4noRcQ1k8Vy4Wj6xHA4NIsEONIsFMUdOm75N7-_a89z46b4E_sMtk0shfz9S4otDdvZ0i_VrkHSUX2fF6XQA1FvBoQ-jcd-pp7k0PPh7VpoXFth2m5UKI9xUGQpZm55k/s1600/P8292820.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto; text-align: center;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEitlToa6PLh97C4noRcQ1k8Vy4Wj6xHA4NIsEONIsFMUdOm75N7-_a89z46b4E_sMtk0shfz9S4otDdvZ0i_VrkHSUX2fF6XQA1FvBoQ-jcd-pp7k0PPh7VpoXFth2m5UKI9xUGQpZm55k/s320/P8292820.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">No TinyTears™ dolls were harmed in the<br />
making of this photograph</td></tr>
</tbody></table>
<b>Bullshitometer verdit: <span style="color: red;">Perhaps somewhat true</span></b><br />
Cereal-thickened milk in a bottle is often said to be a "choking risk" for infants. Now... I am nitpicking a little, but the concern about thickened liquids is not choking but <i>aspiration</i> (choking = something completely blocking your windpipe; aspiration = something getting into your windpipe that shouldn't be there). OK, now I've got that off my chest (pardon the pun), what's the risk of aspiration from cereal in a bottle?<br />
<br />
Well, not much, judging from a trawl through Google Scholar, which produced only discussions of cereal-thickened milk being used to <i>prevent </i>aspiration of milk. However, occasionally medical professionals have expressed a preference for alternative thickeners to cereal for this reason. The concern is that because the cereal forms irregular lumps in the milk, carers may be tempted to make the hole in the bottle teat excessively large to allow the milk to pass through, which in turn may cause excessive flow from the bottle, increasing the risk of aspiration. This may be a particular concern with breastmilk because the action of amylase makes the thickening action unstable and unpredictable. So some medical professionals now prefer thickening gels/carob bean gum, which are not broken down by amylase (see <b><a href="http://pediatrics.aappublications.org/content/111/4/e355.short">here</a></b>). Hopefully these alternative thickeners will become more widely available; in the meantime, it seems wise for parents to feed thickened breastmilk with care, resist the temptation to make the teat hole too large, and never prop bottles.<br />
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<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-VRGngW1kRIYbNS75SfSzcXND5Rdpc7nuZE1bX-zVazM6E7FtRK0HLYLYyoJsLDZHIPexpUh4yIC19qmZcrRv2OdkCf30gbwL52r_xNME5NX324pbWRWgOdW036hsNG7Mnx48ci4ehEw/s1600/P7301672.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto; text-align: center;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-VRGngW1kRIYbNS75SfSzcXND5Rdpc7nuZE1bX-zVazM6E7FtRK0HLYLYyoJsLDZHIPexpUh4yIC19qmZcrRv2OdkCf30gbwL52r_xNME5NX324pbWRWgOdW036hsNG7Mnx48ci4ehEw/s320/P7301672.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Mmm…. red meat. Yum yum.</td></tr>
</tbody></table>
<b><i>There are better sources of iron than rice cereal</i></b><br />
<b>Bullshitometer verdit: <span style="color: red;">True, but...</span></b><br />
You will sometimes hear people say that "The iron in rice cereal is poorly absorbed." This is sort of true, but needs to be understood in context. Only about 4% of the iron in rice cereal is absorbed, but that's because <i>all</i> non-haem iron is absorbed poorly, not because there's something uniquely crap about rice-cereal iron. Iron from beans, quinoa, peanut butter etc. is also absorbed at around 4%. But because the infant cereal is fortified with so much iron, the absolute amount that the baby ends up getting is far higher than for these natural foods. The WHO guidelines specifically recommend iron-fortified foods on the grounds that without them, it may be difficult for babies to get enough iron in practice (<b><a href="http://www.who.int/nutrition/publications/guiding_principles_compfeeding_breastfed.pdf">see p.25</a></b>).<br />
<br />
Haem iron--the sort found in meat and eggs--is absorbed at a much higher rate, and there's loads of it, plus zinc which babies may also need. If parents have the time to prepare meat purees they should by all means do that, and pediatric authorities <b><a href="http://www.ncbi.nlm.nih.gov/pubmed/16456417">increasingly recommend</a></b> meat as <b><a href="http://www.internalmedicinenews.com/fileadmin/content_pdf/ped/archive_pdf/vol43iss11/70296_main.pdf">superior</a></b> to cereal. Honestly, though, I can kind of see why doctors push the rice cereal. Rice cereal is inexpensive, easy and innocuous to feed, whereas not everyone has the time/inclination to make their own meat purees, and as for jarred meat-based babyfoods.... well, I think many parents understandably feel a bit reluctant to feed their infant shelf-stable liquidized meat products of indeterminate origin that smell rather like dog food. So if pediatricians just completely ditched the rice-cereal recommendations, I think what would actually happen is that a lot of babies wouldn't get either cereal <i>or</i> meat, and anemia would probably increase substantially as a result. <br />
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<b><i>Rice cereal contains arsenic</i></b><br />
<b>Bullshitometer verdit: <span style="color: red;">Contains a kernal of truth, but...</span></b><br />
There has been a bit of concern in parenting circles about arsenic in rice cereal, ever since <b><a href="http://www.consumerreports.org/cro/magazine/2012/11/arsenic-in-your-food/index.htm">a Consumer Reports article on this subject</a></b> back in 2012. I'll confess straight-up that I live in a country with a rice-based diet and the world's highest life expectancy, which probably biases my own views somewhat. So I'd like to hand this over to <b><a href="http://www.kevinmd.com/blog/2013/05/worry-arsenic-rice.html">KevinMD and his excellent blog.</a></b><br />
<br />
The Consumer Reports has some sensible advice and information about arsenic in general. But then the report goes all alarming, with a great big table showing the amounts of arsenic in some common rice products, the excessively high ones being shown in <span style="color: red;">scary red font.</span><br />
<br />
Here's the thing, though: in this table, "excessive" arsenic is defined as anything exceeding 5ppb, this being the Environmental Protection Agency's maximum permitted level <b>for water</b> (not rice or any foodstuff). As KevinMD points out, the reason why the levels for any-sort-of-contamination in water are set so incredibly low is because people drink many large cupfuls of fluid a day; any given foodstuff is consumed in far smaller amounts, so it doesn't make any sense to subject foods to the same standards. Of course, ideally nobody wants<i> any</i> arsenic in their food, but as the report itself points out, vegetables and fruits contribute more arsenic to our diets than rice; what's more, all foods contain tiny amounts of poisons/carcinogens--manmade and natural--and trying to completely eliminate them is futile.<br />
<br />
For example: two of the rice-y foodstuffs that the Consumer Reports article comes down the hardest on are rice milk and brown rice syrup (a form of sugar). Here's the funny thing: I can remember when people were choosing rice milk as a <b>healthy drink</b>--because they were afraid of soya milk because of the phytoestrogens, and afraid of cow's milk because it was, well, cow's milk. And brown rice syrup was being lauded a few years ago as a healthy alternative to the dreaded high fructose corn syrup. Rice itself became more popular a few years back due to worries about gluten. If we now have to start avoiding rice because it's "bad," we'll have to eat more of something else instead...quinoa, perhaps, or sweet potatoes. Before long, there'll be a media scare story about each of those foods as well and we'll have to replace them with yet another food. And so on. We can either choose to live our lives constantly bouncing around from food to food in an effort to avoid the latest <i>killer de jour</i>, or we can take the approach that there is not a food on the planet that does not contain <b>something</b> that might kill you if you somehow contrived to eat several kilos of said food at a single sitting, and that the solution is to eat a varied diet with a little of everything. Same goes for babies. Same goes for rice cereal.<br />
<br />
(For what it's worth, even the Consumer Reports article doesn't actually advocate that people stop eating rice or feeding it to babies altogether--that's just what some worried mums on the internet have been telling each other to do.)<br />
<br />
<b>Overall bullshitometer verdict</b><br />
Overall, there doesn't seem to be any super-strong case in favor of or against rice cereal. It can be used for reflux (but other thickening agents may be slightly better); it can provide iron (but meat-based baby foods may be slightly better). There seems to be little evidence to support any of the other claims, either positive or negative.<br />
<br />
Given this somewhat underwhelming reality, why do people talk about rice cereal as much as they do on the parenting boards? I'm guessing that it's because rice cereal has become one of those "materno-political" issues: when mothers say things like "We don't do rice cereal in our family" or "We're giving two servings of rice cereal every day just as the pediatrician tells us" they aren't really talking about the white powdery stuff itself, but are making a statement about what "type" of mother they are. If we took the time to look at the data and see how pallid the evidence is on either side, I reckon we'd all argue about these things less and parenting boards would be more peaceful places.<br />
<br />
<b>Further reading:</b><br />
<a href="http://www.raisehealthyeaters.com/2012/10/the-case-for-rice-cereal/" style="font-weight: bold;">The Case for Rice Cereal</a><b>: </b>What it says.<br />
<br />
Almost immediately after hitting "publish" I noticed, with mortification, that one of my favorite bloggers, Science of Mom, published her own blog post on starch/amylase in infancy about two weeks ago! I can only assure anyone who has spotted this that there was no copycat intention here--I have had a draft version of this post hanging around for months and kept meaning to finalize the damn thing and publish it, and having been busy with school choices the last couple of weeks I have not been able to keep up with my favorite bloggers at all. Anyway, I thoroughly recommend her fascinating post which looks at amylase in more detail than I am able to. Cheers. BFWOBS.<br />
http://scienceofmom.com/2013/11/08/amylase-in-infancy-can-babies-digest-starch/<br />
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<br />BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com6tag:blogger.com,1999:blog-9064021843006104287.post-69831791333808102212013-10-28T06:28:00.002-07:002014-06-19T22:07:29.930-07:00"Las Dos" and breastfeeding diversity<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYywb3IcDonjNVR5VbgVjOGg6YOQfiLFRDbMqTn_WVHg-7ERDzfofQS9dVGA2j21Ex020UMvjDcpxNdPVmRUkQtYPhbSEohPnEy2XHEUQgtBwT7Lvewsqs7V0Y6dmv-aEnZqNhLiToqgM/s1600/P2111014.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhYywb3IcDonjNVR5VbgVjOGg6YOQfiLFRDbMqTn_WVHg-7ERDzfofQS9dVGA2j21Ex020UMvjDcpxNdPVmRUkQtYPhbSEohPnEy2XHEUQgtBwT7Lvewsqs7V0Y6dmv-aEnZqNhLiToqgM/s320/P2111014.JPG" height="240" width="320" /></a></div>
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<br />
<b>"Las Dos" </b><br />
"Las dos" (meaning "both") is a phrase used among many Hispanic women to describe the common practice of using formula supplementation alongside breastfeeding--not necessarily out of dire need but more as a matter of preference or culture. Many Hispanic women feel that "las dos" offers them and their babies the best of both worlds--they feel that their milk may not be enough, that formula will offer extra vitamins or that breastfeeding is just more convenient this way.<br />
<br />
"Las dos" was recently discussed by the breastfeeding advocacy site <b><a href="http://www.bestforbabes.org/booby-traps-series-las-dos-and-other-cultural-barriers-to-breastfeeding">Best for Babes</a></b>, picking up from a <b><a href="http://massbreastfeeding.org/handouts/">2010 poster campaign run by the Massachusetts Breastfeeding Coalition</a></b> (scroll down to see). The posters urged Hispanic women to breastfeed exclusively, with the legends "Both Breast and Bottle? No!" and "If you give me formula, you won't produce enough milk for me/Your milk is full of important vitamins" in Spanish or English, accompanied by either a worried-looking baby or a picture of smiling breasts versus a bottle with a frowny face. Not a lot of room for ambiguity there, then.<br />
<br />
The Best for Babes write-up covers the familiar territory: "But the problem with doing 'las dos' is that it deprives the baby of the benefits of exclusive breastfeeding, and it creates problems with the mother’s milk supply." ("<i>It creates problems</i>," mind you; not "It's possible it could create problems" or "It can create problems for certain women" or "Excessive supplementation creates problems.") We all know roughly what the argument is here: because breastfeeding is supply and demand, giving any formula at all is apt to lead the mother down the "slippery slope" of ever-increasing formula usage. Best for Babes suggested that women who practice "las dos" do so because they don't know better--a suggestion echoed by the study linked to on the same page, <a href="http://online.liebertpub.com/doi/abs/10.1089/bfm.2011.0039?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3Dpubmed&" style="font-weight: bold;">"Las Dos Cosas: An Analysis of Attitudes of Latina Women on Non-Exclusive Breastfeeding."</a> (But don't worry; the study noted that "Women consistently demonstrated a willingness to learn from health professionals" about the need to avoid supplementation. So that's alright then.)<br />
<br />
<b>How true are the claims?</b><br />
Now, the whole debate about the benefits of exclusive breastfeeding and how much greater these are compared to supplementing is a complicated one and I won't go into it in full here. I'll just say this: Exclusive breastfeeding to six months matters a lot in developing countries where a single serving of porridge/formula etc. made with contaminated water can kill a vulnerable baby. In developed countries, the benefits are likely to be "modest" and much harder to quantify. <br />
<br />
I want to focus on the claim that adding-in formula causes supply issues (the "slippery slope" argument). The trouble is, the evidence that combo-feeding causes supply problems in Hispanic women is actually kind of weak. For one thing, there's the awkward fact that in spite of frequently preferring to add in some formula, Hispanic women consistently show the highest rates of breastfeeding of any racial group in the United States, as long as the criteria used is "any breastfeeding" rather than exclusive breastfeeding.<br />
<br />
What about if you compare Hispanic women who do supplement with those who don't? Linda Geddes looked at this area in her excellent book <b><i><a href="http://www.amazon.co.uk/books/dp/059306996X">Bumpology</a></i></b>. There's a dearth of evidence on the subject, but there is <b><a href="http://www.medscape.com/viewarticle/751077">a 2005 analysis of 6,788 mother/child pairs of various races</a></b> which found that "65% of the infants who were exclusively breastfed were still receiving any breastfeeding at 4 months compared with only 40% of the children who were fed a combination of breast milk and infant formula during the first week of life" but that "CBFF [combination breast milk and formula-feeding] is associated with shorter overall breast-feeding duration in white <i>but not Hispanic or black mother-baby dyads.</i>" So for the babies overall, supplementing with formula early on significantly increases the chance that the mother stops nursing altogether--but for the non-white babies, this seems not to be the case, with those who get formula supplements being just as likely to go on breastfeeding as those that do not.<br />
<br />
It tends to be the same story across many ethnic minorities in majority-white countries (African-American women being an important exception (<span style="font-size: x-small;">Note 1</span>)). <b><a href="http://www.ncbi.nlm.nih.gov/pubmed/17079543">In the United Kingdom</a></b>, white women have the lowest breastfeeding rates of all racial groups (<span style="font-size: x-small;">Note 2</span>), while any-breastfeeding rates and predominant-breastfeeding rates are highest of all for African immigrant women (Zimbabwean, Somali etc.) followed by a tie between Asian (<span style="font-size: x-small;">Note 3</span>) and Afro-Caribbean women. But the exclusive-breastfeeding-to-six-months rate is low for all these groups because so many women do things like give formula till their milk comes in, add-in some formula even after that, or start solids before six months. Among <b><a href="http://www.nature.com/pr/journal/v45/n4-2/full/pr19991772a.html">Somali women</a></b> in particular, comparing breastfeeding cessation rates for combo vs exclusive feeders would be tricky because supplementing is so normal that it's hard to find a control group. And exceptionally high numbers of Somali women breastfeed--around 90-95%. In Japan too we have high rates of predominant breastfeeding yet low rates of exclusive breastfeeding--most women add in some formula.<br />
<br />
I once talked to a maternity ward nurse who worked in a London hospital where there were a lot of Somali mums, and I asked her if there was any conflict between the NHS's focus on exclusive breastfeeding versus the Somali mums' preference for supplementation. She laughed and said "The new nurses try and talk the mums out of supplementing at first. And then after a while they shut up, because they start to realize that the mums are a) taking no notice, and b) doing a good job of breastfeeding anyway, even though they're technically breaking all the 'rules.'"<br />
<br />
<b>Why might white women have more difficulties combo-feeding?</b><br />
If combo-feeding is indeed more difficult for white women than for other races, why would that be? There could be some kind of biological mechanism going on, but there could also be cultural explanations.<br />
<br />
One possibility is that among white women, adding-in formula is not a cause of breastfeeding issues, but rather is a "marker" for women who tend to have breastfeeding/supply issues anyway. The theory goes something like this: "White" breastfeeding culture (which tends to be dominated by books, lactation consultants and the LLL) places a strong emphasis on <i>exclusive</i> breastfeeding and this is presented to white women as the ideal. So women avoid adding-in formula unless things are going wrong, like supply issues, a baby who isn't latching well or the presence of formula-feeding families/friends who pressure the mother to add some bottles to "fill him up." So when you look at the two groups, the "exclusive breastfeeding" group contains mostly women who find breastfeeding easy anyway, and the "combo-feeding group" has lots of ladies who have supply issues and other problems or are surrounded by unsupportive formula feeders... and maybe it's<i> these</i> issues that are causing them to give up, not the "slippery slope" of the formula itself. Among Hispanic, Zimbabwean etc. women (so the theory goes), combo-feeding is not seen as second-best and so the decision to combo-feed tends not to be strongly correlated with the existence of breastfeeding "problems."<br />
<br />
Another possibility is that it's to do with confidence and normalization. If a Hispanic, Somali etc. woman thinks of breastfeeding as normal, when faced with issues she may take the pragmatic attitude of "Let's see if I can mix things up a little." A white Anglo woman may be surrounded by stronger external pressures to formula-feed--if she experiences difficulties she may be more likely to see breastfeeding itself as the cause of her worries, and feel that the best thing to do for her sanity is to cease nursing altogether. She may not have successful combo-feeders among her peers; if she is getting her breastfeeding knowledge and support primarily from online fora and lactation consultants, attempts to discuss combo-feeding may just result in lectures rather than practical advice. Perhaps white breastfeeding culture's emphasis on the "slippery slope"makes a struggling breastfeeder feel that attempts at combo-feeding are doomed to fail anyway and will just add to her stress.<br />
<br />
A final possibility is that certain childrearing practices make combo-feeding easier, or are <i>so </i>supportive of breastfeeding that they "make up for" any issues that combo-feeding might create. In <b><a href="http://breastfeedingwithoutbs.blogspot.com/2012/12/mothers-milk-and-others-milk-in-japan.html">my thoughts on breastfeeding in Japan</a></b>, I mused that the widespread practice of bedsharing (and frequent night-nursing) might be why widespread formula supplementation, low nursing-in-public levels and rigid, old-fashioned hospital routines don't seem to send Japanese women's breastfeeding into a tailspin. Bedsharing is commoner among Hispanic America, African immigrant, British Asian and Afro-Caribbean women than among white women, so perhaps this is worth looking into. Other practices like extended periods of post-partum rest following childbirth, common in several cultures, also merit investigation.<br />
<br />
<b>So much to talk about</b><br />
We have a situation where the highest breastfeeding rates in both the UK and the US are found among non-white ethnic minorities, and in the UK in particular white women are less likely than any other racial group to breastfeed...<b>and yet</b> mainstream breastfeeding advocacy remains very white. In general, breastfeeding advocates' response to the non-white minorities where breastfeeding rates are high has been either to a) Ignore them; or b) Complain that the minorities in question aren't breastfeeding "properly" (because they give solid foods too early or add in formula), and then advise the minorities in question on how to breastfeed in the "approved" way. The Best for Babes article does have some really interesting discussion on how American hospitals and ways in which hospitals have tried to cater to Cambodian-, Chinese- and Mexican-American women's needs, and mentions that Hispanic women initiate breastfeeding more often than white women, yet skirts over the fact that they are also much more likely to still be breastfeeding at six or 12 months. <b><a href="http://theleakyboob.com/2013/08/iola-kostrzewski-on-black-breastfeeding-week/">Black Breastfeeding Week</a></b> in the United States a few months ago provoked some great discussion about the barriers faced by African-American women hoping to breastfeed, but there was surprisingly little discussion of the fact that other groups of black women in America already have very high breastfeeding rates and are highly confident in their breastfeeding abilities.<br />
<br />
Wouldn't it be good if these women's voices were reflected more in conversations about infant feeding? I'm curious to know how women from Laos or Nigeria or Somalia feel about the breastfeeding advice they are getting in English-speaking countries. Is it helpful? Is it annoying? Does it allow for individual and cultural preferences? If breastfeeding rates are high among certain groups, wouldn't it be great to start analyzing <i>why</i> they are high? And combo-feeding can be a Godsend to women working outside the home; if we want to develop good guidelines on how to combo-feed, perhaps breastfeeding advocacy needs to be getting more input from groups of women who are already combo-feeding successfully...? <br />
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<b>What diversity really means</b><br />
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; text-align: center;"><tbody>
<tr><td><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQuZ2eKxphaHu85kD9qkpJAA1IlAqDhbt9hyphenhyphenBMOwPn3l77i7KHPQ3G3e_OvJdrYOMrJ7Gj-QmG7ZUdtOiHRJ5mhG_-UO3Slz5Yov9g6uT9PLprq4MbZLehUoFdcZy3kF07_rE2G-CUHMA/s1600/PA020756.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQuZ2eKxphaHu85kD9qkpJAA1IlAqDhbt9hyphenhyphenBMOwPn3l77i7KHPQ3G3e_OvJdrYOMrJ7Gj-QmG7ZUdtOiHRJ5mhG_-UO3Slz5Yov9g6uT9PLprq4MbZLehUoFdcZy3kF07_rE2G-CUHMA/s320/PA020756.JPG" height="240" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="font-size: 13px;"><i>So many ways to breastfeed---including, apparently, </i><br />
<i>with breasts made out of multicolored fun-fur</i></td></tr>
</tbody></table>
Although the question of "how much better is exclusive breastfeeding than combo feeding" is complex, in developed countries the differences are unlikely to be large enough to justify the Massachusetts Breastfeeding Coalition's approach of basically ordering everyone to exclusively breastfeed, without pausing to consider cultural<br />
differences and individual preferences, as though the feelings of mothers counted for absolutely nothing. And while the question of whether combo-feeding increases the risk of giving up breastfeeding is not 100% clear, there is enough uncertainty surrounding the issue that the blanket statements of the Massachusetts' advocacy materials--"Breast and Bottle? No!""If you give me formula, you won't produce enough milk for me"--sound pretty bossy and over-the-top.<br />
<br />
What we really need is more research on what's going on with combo-feeding and breastfeeding styles among women of various ethnic backgrounds. In the meantime, if some Hispanic women prefer to supplement, I suggest that the Powers That Be in hospitals and elsewhere <b>respect their choice</b> and give them the best advice we have at the moment--like making sure women have the basic facts straight (if a woman is combo-feeding purely because she thinks her baby won't get enough vitamins from breastmilk alone, it's surely reasonable to inform her that that's unlikely to be the case), teaching women how to keep an eye on their supply so that formula use does not keep creeping up and up, and making sure that women understand how to prep and feed bottles in an optimal manner--an area the <b><a href="https://www.facebook.com/photo.php?fbid=746723485344134&set=a.403262243023595.115266.134044953278660&type=1&theater">National Association of Hispanic Nurses</a></b> is now focusing on. True diversity is not about putting a few token non-white faces on display in breastfeeding books and blogs; it's about opening one's mind to the possibility that there could be many ways to breastfeed successfully.<br />
<br />
<span style="font-size: x-small;">(Note 1) I use "African-American" to refer to black people in the United States who trace their origins to African slaves in that country, while "Afro-Caribbean" refers to black people in the US and UK whose immediate origins are in the Caribbean rather Africa--i.e. they or their parents etc. migrated from there. I use "African immigrant" to refer to black people who migrated from Africa or whose parents or grandparents did so. I'm not thrilled with the term as I don't think someone who has lived in the UK/US all their life can be described to as an "immigrant," but I don't know of any other term that can be used to include all the people in this group.</span><br />
<span style="font-size: x-small;"><br /></span>
<span style="font-size: x-small;">(Note 2)</span><span style="font-size: x-small;"> </span><span style="font-size: x-small;">Except for Romani Gypsies and Irish Travellers</span><br />
<span style="font-size: x-small;"><br /></span>
<span style="font-size: x-small;">(Note 3) In the UK, most Asian people are of South Asian origin--i.e. their ethnic origins lie in places like Pakistan, India and Bangladesh--rather than East Asian as tends to be commoner in the US.</span><br />
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<br />BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com2tag:blogger.com,1999:blog-9064021843006104287.post-10986575426937743642013-10-03T21:25:00.002-07:002013-11-18T22:09:34.387-08:00White elephants in the freezer: The pros and cons of breastmilk stashes<div class="separator" style="clear: both; text-align: center;">
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Back in the glory days when Baby Seal was tiny, my "freezer stash" fluctuated, but basically consisted of two to three plastic containers stuffed at crazy angles around the frozen peas. For one thing, I had the tiniest freezer known to man and needed the space for<strike> ice cream </strike>healthy homemade casseroles and soups. When were you supposed to find time to pump, in between nursing all day long? In any case, I was lucky enough to work freelance at home. I doubt I would have "stashed" at all had it not been for a vague feeling that this was something you were Supposed To Do when you are breastfeeding. My due date club was full of people talking about having dozens or hundreds of ounces in the freezer. Stashing seemed like part of being a proper organized mother--you know, the kind who irons baby clothes and puts her name on the daycare waiting list at five weeks' gestation.<br />
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<b>The freezer culture</b><br />
The "freezer stash" culture seems to have started among mothers who work outside the home. The idea is: since most mothers find that a few pumping breaks stolen out of the working day just aren't enough to keep up with their babies' needs, you pump during your maternity leave to create a "bank" of frozen milk that you can draw on little by little once you're back at work. Once working, you top-up your stash by pumping at the weekends--or even late in the evening, after the baby is (finally!) in bed. However, in the US in particular, freezer stashes have recently started to become common even among stay-at-home-mothers. This seems a bit odd at first glance--does an evening-out a couple of times a week really require a freezerfull of breastmilk?--but the rationale is that you might be forced to wean for medical reasons, you milk could dry up or (gulp) you could be knocked down by a car and killed. Increased milk-sharing opportunities have perhaps added to the feeling that everyone should be creating a freezer stash ("After all, even if you never use it, someone else will always be able to!"). It's not uncommon these days to hear of women putting hundreds or thousands of ounces into the freezer; many are generous donors, helping out other mothers and hospitalized infants.<br />
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The idea seems to be that a freezer stash helps you avoid using any formula, and is strongly connected with modern breastfeeding culture's focus on exclusive breastfeeding and avoiding formula completely. That said, wanting to avoid formula isn't always about formula being inherently dangerous. Formula companies aren't very nice organizations and many people don't like the idea of giving them money. Then there is the "My baby may not accept formula if I try it later on" thing. There is the "I prefer not to do dairy products, and soy makes me nervous" thing. Finally, some mothers also envisage this as a way of getting extra breastmilky goodies into their child--they imagine a toddler drinking thawed EBM in a sippy or mixed with cow's milk.<br />
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<tr><td class="tr-caption" style="text-align: center;"><i>Beware of the scary freezer...</i></td></tr>
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<b>The dark side of the freezer (cue ominous music...)</b><br />
Conversely, stashing has some downsides too. What you might call "The Dark Side of the Freezer" (and no, I'm not talking about those ancient tupperware containers containing brown goo of unknown origin, or the ice-cubes that taste of stale fish when you add them to your gin and tonic).<br />
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<i>- Frozen breastmilk is significantly inferior to the fresh stuff </i><br />
The general assumption is that "even frozen breastmilk is always far, far better than formula." But the evidence is actually quite mixed. Frozen breastmilk has about the same amounts of fat, calories, sugar, protein and elements such as zinc as fresh, and many of its impressive immunological components such as lactoferrin, lysozone and IgA also stand up well to freezing. Freezing does, however, destroy cellular activity and antioxidant activity are greatly reduce to. <b><a href="http://fn.bmj.com/content/89/6/F518.abstract">(That said, frozen breastmilk still has more antioxidant activity than formula</a>)</b>.<br />
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However, the evidence about decreases in <i>vitamins</i> is less positive. A 1983 study found that <b>"Freezing and frozen storage did not significantly affect the levels of biotin, niacin, and folic acid."</b> But in a 2004 meta-analysis (Ezz El Din et al), <b>Vitamin C in milk was reduced by 56.9% by one week of freezing, Vitamin A by 48.1% and Vitamin E by 28.8%, </b>echoing a 2001 study (Buss et al) which found that <b>Vitamin C decreased to 63% of the starting values after one month and 38% after two months of freezing</b>; there was massive variation, with one sample having 97% of the Vitamin C it started off with, and another, zero. Confusingly, the findings of another study (Bank et al) indicated that breastmilk frozen for three months would provide a baby's recommended allowance of Vitamin C--but not of folic acid.<br />
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This doesn't mean frozen breastmilk risks giving your baby malnutrition; babies supplemented with bottles of the stuff do just fine. But then, well, babies supplemented with bottles of formula seem to do fine too. The question is, if frozen EBM is better than formula, then by how much of a margin is it better? Because this margin has to be weighed up against the substantial amounts of time and energy that go into creating large stashes.<br />
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<i>- What are the benefits of avoiding all formula?</i><br />
The freezer stash tends to be intertwined with anxiety about using any formula at all--a sort of icy buffer zone protecting your baby against the Great White Peril. Now, the PROBIT study (still the closest thing we have to a randomized controlled study of breastfeeding versus formula feeding) suggests that exclusive breastfeeding for the first few months confers some health benefits; however, the study looked at mothers who were mainly feeding from the breast, and it's not clear whether these benefits still apply when we are talking about milk that's been pumped, containerized, frozen (and sometimes scalded and cooled as well), frozen, thawed, transported and fed in a bottle.<br />
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And the calculation of the benefits must surely shift a bit once a baby starts solids at around 4-6 months. Much of the rationale for exclusive breastfeeding rests upon the theory of the virgin gut (=your baby's insides become irreversibly contaminated once you give a taste of anything except breastmilk); but even if you accept the virgin gut theory as fact, once you've started giving food your baby's virgin gut has been deflowered and taken round the block a few times--they are already having things that aren't breastmilk. If one is giving other dairy products like yoghurt, is there any particular reason not to add a little formula as well if today's pumping fell short of the required quota? I have looked and looked, and have not been able to find any evidence of negative health-related consequences of giving some formula to a baby who is already taking solids. I guess we all feel differently about these things, but... once I started giving Baby Seal solid foods, the "milk question" suddenly felt very different. All of a sudden, formula was just another food--and it was damn useful for mixing with her cereal.<br />
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<i>- Your stash might turn out to be unusable (I call these "White Elephant stashes")</i><br />
Every due date club has at least one mother who pumps away creating a big stash... only to discover her baby won't drink it when thawed because it tastes fishy, soapy or metallic. Some women have high levels of lipase (an enzyme which breaks down fat) in their milk, causing it to develop a strange taste when frozen. You can prevent this flavor by scalding the milk before freezing; unfortunately, most women don't think to test for lipase issues before they start stashing and therefore have no idea of the problem until they already have a freezer full of funky tasting milk. Scalding the milk after thawing makes no difference, by the way.<br />
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But even if you don't have lipase issues, babies used to fresh breastmilk often refuse to drink thawed frozen milk because it doesn't taste quite right--just as adults used to regular milk often wrinkle their noses at UHT. Other babies start refusing such milk as they get older. To add insult to injury, some of them are quite happy to drink formula instead. Finally, if you discover <i>after</i> you've built up a big stash that your baby's digestive issues are connected to allergens in your diet (dairy, wheat etc.), your stash is useless unless you can donate it to someone.<br />
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<i>- Your stash might be destroyed by a freezer breakdown, power cut or a freezer door accidentally left open</i><br />
Hours and hours and hours of hard work literally down the drain. This happens All.The.Time.<br />
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<i>- Going mad with the pump can jeapordize your current breastfeeding</i><br />
One well-known problem is that pumping heavily in the first few weeks can lead to oversupply and engorgement--yet women seeking to build freezer stashes are often advised to start pumping just days after giving birth.<br />
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<i>- Stashing costs time, effort and emotional energy</i><br />
Stashing is not just about the pumping itself. It's also about assembling equipment, cleaning and sterilizing, labelling and dating containers, defrosting your milk, stocktaking, organizing and rotating your stash, and doing fiddly things like mixing frozen milk with fresh in various ratios to train your baby to drink the frozen stuff. If you have lipase issues, you'll also need to scald and cool the milk before freezing. Time spent doing this is time which is not being spent taking a stroller walk in the fresh air, rolling around on the floor with your baby, enjoying a glass of wine and a trashy magazine, having a hot shower, chatting with your partner, catching up on sleep, or spending some time with an older child. To misquote Hanna Rosin, "A freezer stash is only free if your time is worth nothing."<br />
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You have to feel a bit sorry for American breastfeeders who work outside the home. Most of them get kicked out of hospital when their contractions have barely died away and are expected back at the workplace after a few weeks. And now there's this increasing expectation that they ought be spending a not-insignificant chunk of their brief maternity leaves plastered to the pump--right when they are trying to recover from childbirth and the shock of caring for a newborn. Breastfeeding is sold to women as being an emotionally rewarding experience--but where's the emotional reward in spending your free time trying to squeeze in extra pumping sessions, when you could be enjoying your baby or having a hot bath (or a cold beer)?<br />
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<i>- Freezer stashing can become competitive, obsessive and compulsive</i><br />
With modern, super-efficient double electric pumps, some women put very large amounts of milk into the freezer.<br />
<blockquote class="tr_bq">
<span style="font-size: x-small;">"I have about 1,000 oz and have donated 3,200 oz to other mom's. [My baby] is 14 weeks old. I was pumping a lot when she was in the NICU and then when I was still home with her I pumped after each nursing session for 20 minutes. I've been back to work for two months now. I pump before work, three times at work and once before bed. I pump between 45-55 oz per day and [my baby] only eats 8 oz while I'm at work."</span></blockquote>
Impressive though these amounts are, only a minority of women with particularly strong supplies are ever going to be able to pump and store that much milk. But when all these big figures are being quoted, before you know it everyone else is peering into their freezers and wondering if they should start trying to fit in a few more pumping sessions--especially when all the talk seems to imply that not having a stash is a really <i>scary </i>situation that actually places your baby in peril.<br />
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A lot of stash builders refer to themselves as "hoarders"; this is a joke, of course, but the banter does seem to be cover some genuine anxiety:<br />
<blockquote class="tr_bq">
<span style="font-size: x-small;">"I have a deep freeze just for milk. I worry each pump may be my last. I eat oats every morning and gallons of milk. My lo will be six months. I have donated over 5000 oz to a mom. I watch my milk drive away and then i worry i may need it for an unidentified issue. I have over 3000 frozen. I make 80 oz a day and I still worry. I need help."</span> </blockquote>
<blockquote class="tr_bq">
<span style="font-size: x-small;">"I just had my 3rd three weeks ago and have 1,000 oz in my deep freezer. I need to re-apply to donate but, I have to go back to work full time in 4 weeks and I get nervous I won't have enough. I call it a sick obsession! I don't LIKE pumping but, if I don't do it after every feeding I get paranoid I'm going to loose my supply. I'm a bit OCD when it comes to pumping."</span></blockquote>
Obviously these are extreme cases, but it's common for freezer stashing mothers to express ambiguous attitudes towards their stashes. (See this discussion at <b><a href="http://www.mothersinmedicine.com/2012/04/when-breastmilk-isnt-best.html">Mothers in Medicine</a></b>, for example.) Some mothers find themselves inexplicably reluctant to actually use the milk they've stashed and feel increasingly anxious as the stock dwindles. They may (like <b><a href="http://www.bravadodesigns.com/connect/graduation-class/jennifer-johnson-blog/milk-hoarder">this mother</a></b>) find themselves grilling their childcare providers about the amounts they've used and pressuring them to use as little as possible, even when there are still tons of milk in the freezer. Some eventually end up with gallons of unused milk that's beyond its use-by date. Others start feeling irritated if their baby doesn't finish every bottle because of the waste, or try to persuade babies to swallow milk that tastes and smells foul because they can't face the thought of throwing it away.<br />
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Of course the problem here doesn't lie with the mothers themselves; it lies in the fact that when lactation is turned into a numbers game (the number of ounces you express, the number of pumping sessions, the number of minutes you are allowed for pumping breaks, the number of containers in the freezer, the number of months they've been sitting in there), it's really easy for even the most level-headed mother to become a bit obsessive--especially when you add in the inevitable post-partum craziness and sleep deprivation, and the not-terribly-subtle scaremongering about formula that we see in mothers' groups.<br />
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<b>Keeping the White Elephants at bay!</b><br />
I would recommend that anyone thinking of creating a massive stash <b>rule out potential issues first, before they start to pump</b>, to avoid the frustration of a "White Elephant stash."<br />
- If your baby seems to have digestive issues/colic, hold off on stash building until you have ruled out <br />
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<tr><td class="tr-caption" style="text-align: center;"><i>Just say no to White Elephant stashes!</i></td></tr>
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the possibility of allergens in your milk.<br />
- Check whether you have lipase issues; if you do you will need to scald all your milk (see <b><a href="http://sdbfc.com/blog/2012/9/4/battling-and-resolving-excess-lipase-in-breastmilk.html">here</a></b> and <b><a href="http://theadequatemother.wordpress.com/2012/04/05/the-lipase-mini-saga/">here</a></b>).<br />
- Maintain your freezer by using a freezer thermometer and not overstocking (I now blush to think how clueless I have been in this respect).<br />
- Have a backup plan in case the freezer fails. And stick a SHUT THE DOOR note on the door!<br />
-Find whether you actually meet the requirements to donate milk.<br />
-Get your baby used to the flavor of frozen milk early on.<br />
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Conversely, employed mothers who don't want to create big freezer stashes need to be okay with using some formula. (Otherwise, they are just exchanging the stress of maternity-leave stashing, for the stress of "Help, help! It's late at night, my baby's screaming, and I need to pump because today I didn't pump enough milk for tomorrow's daycare...") At-home mothers who don't want to stash should remember that things like sudden hospitalization can prevent breastfeeding; better to keep some formula in the house, make sure that one's partner knows how to prepare formula properly, and introduce a little formula early on so that the baby will accept the flavor.<br />
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<b>Relishing the experience or shouldering a burden?</b><br />
I hope this post doesn't come across as excessively negative about freezer stashing. My intention, rather, was to try and redress the balance a bit. There is a lot of talk about big freezer stashes on breastfeeding fora, and many women find them very useful and beneficial; some are also incredibly generous, donating milk to other mothers and to babies in hospitals. But we should also find room to talk about <i>not</i> stashing (and minimal stashing) too, and the benefits and conveniences that that can bring.<br />
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Creating a stash is an option, not something breastfeeding mothers have to do. <i>No, even if they are employed full-time....</i> as long they are content with doing some formula as well. On breastfeeding fora, "having to use formula" often seems to be seen as a sign of failure or disorganization. But it's also possible to embrace such an approach as a conscious and deliberate choice: as an approach that seeks to maximize time spent with your baby, and to make breastfeeding as enjoyable as possible--a delicious experience to be relished rather than a burden to be shouldered.<br />
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The final point I'd like to end with is this: When we are comparing expressed breast milk and formula, we can't limit our conversation to what's actually in the bottle. We have to look at the wider context of how it actually got there and how much maternal time, labor and stress went into it. Womens' needs for free time, relaxation, sleep and enjoying motherhood need to be part of the discussion too. <br />
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<b>Freezing milk</b><br />
<b><a href="http://www.ehow.com/list_7563170_tips-refrigerator-freezers.html">Tips for refrigerator freezers</a></b><br />
<b><a href="http://www.bfmed.org/Media/Files/Protocols/Protocol%208%20-%20English%20revised%202010.pdf">ABM Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants</a></b><br />
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<b>Lipase issues</b><br />
<b><a href="http://theadequatemother.wordpress.com/2012/04/05/the-lipase-mini-saga/">The lipase mini-saga</a></b> from The Adequate Mother<br />
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<b>Frozen milk vs fresh</b><br />
<b><a href="http://fn.bmj.com/content/89/6/F518.abstract">Effect of storage on breast milk antioxidant activity</a> </b>Hanna et al, <i>Archives of Disease in Childhood. Fetal and Neonatal Edition</i>, 2004<br />
<b><a href="http://www.ncbi.nlm.nih.gov/pubmed/3969932">Effect of storage time and temperature on folacin and vitamin C levels in term and preterm human milk</a> </b>Bank et al, <i>The American Journal of Clinical Nutrition</i>, 1985<br />
<b><a href="http://applications.emro.who.int/emhj/1006/10_6_2004_815_821.pdf">Is stored expressed breast milk an alternative for working Egyptian mothers? </a></b> Ezz Al Din et al, <i>Eastern Mediterranean Health Journal</i>, 2004<br />
<b><a href="http://www.ncbi.nlm.nih.gov/pubmed/6835716">The effect of processing and storage on key enzymes, B vitamins, and lipids of mature human milk. I. Evaluation of fresh samples and effects of freezing and frozen storage</a></b> Friend et al, <i>Pediatric Research</i> 1983<br />
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<b><a href="http://www.nursingfreedom.org/2010/08/inadvertent-booby-traps.html">Inadvertent Booby Traps from Nursing Freedom</a>: </b>Some interesting discussion about the necessity of freezer stashes<br />
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In closing<br />
<b><a href="http://liberatingworkingmoms.com/2013/03/18/trying-and-failing-to-control-everything-and-how-it-led-to-happiness/">Trying and Failing to Control Everything and How it Led to Happiness:</a></b> I love this story!<br />
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<br />BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com8tag:blogger.com,1999:blog-9064021843006104287.post-13061213390127044632013-08-31T08:44:00.002-07:002013-11-18T22:08:20.723-08:00Why we need "feeding rooms," not "breastfeeding rooms"<div class="separator" style="clear: both; text-align: center;">
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It's a funny thing about Japanese breastfeeding; breastfeeding rates here are high, yet you will rarely see a woman actually nursing. I remember pondering this question in pre-motherhood days and being very puzzled by it. Later on, however, I understood how things worked after I was initiated into the mysteries of the popular Japanese institution of the <i><a href="http://www.google.co.uk/search?q=%E2%80%9D%E6%8E%88%E4%B9%B3%E5%AE%A4%E2%80%9D&tbm=isch&tbo=u&source=univ&sa=X&ei=RxwfUrKTHcGS0AWt9ICQDA&ved=0CEEQsAQ&biw=1328&bih=584" target="_blank"><b>junyuushitsu</b></a></i> (“breastfeeding room”).<br />
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These rooms, commonly found in stations, department stores, shopping centers and other facilities, vary considerably; some are little more than a small cubicle with a couple of chairs, while others are quite spacious rooms equipped with sofas and equipment ranging from vending machines to taps emitting water heated to 70 degrees C (accompanied by a little sign assuring users that the water in question was bottled and filtered—my brief period of nursing-room use was shortly after the TEPCO nuclear meltdown in Fukushima, following which parents were warned not to use tapwater in babies’ bottles after briefly elevated levels of radioactivity were reported). As this implies, the larger <i>junyuushitsu</i> are often used by bottle-feeding parents as well; breastfeeding mothers using these rooms have the option of disappearing into a curtained-off cubicle if they aren't happy about being visible to any dads who might be on the couch giving a bottle.<br />
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I made sparing use of these rooms back when Little Seal was a baby, mostly in the newborn days when I was nervous about breastfeeding her in public; even after I had gained more confidence, there were times when there was something to be said for making an all-in-one stop (feed + diaper change) without having to shell out US$6.00 on a cup of coffee. That said, I usually fed wherever I happened to be, albeit with a nursing cover.<br />
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<b>Why breastfeeding rooms are controversial</b><br />
Breastfeeding rooms have been cropping up all over the place in the Western world too, and are an increasingly common sight in shopping malls and transportation hubs. One Vermont company is even using crowdsourcing to build <a href="http://www.mamava.inlu.com/" target="_blank"><b>free-standing "lactation stations"</b></a>: "Mothers deserve a clean, comfortable, private place to pump and nurse – not a bathroom." While on the face of it, such rooms appear to be a supportive measure for breastfeeding, they’ve always been accompanied by controversy.<br />
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"They seem to prefer the idea of hiving off bf mothers into corners so they're invisible to the rest of the population....." "The potential problem with this is that, once these areas are set up, members of the public and/or service station staff might start trying to send all bf-ers to these areas - 'Excuse me, didn't you know there's a private area for that?' - and before you know it we'll be segregated into some dank area that smells of soiled nappies, and where the dirty crockery is never removed," grumbled commenters on <b><a href="http://www.mumsnet.com/Talk/breast_and_bottle_feeding/506861-new-gov-poilcy-breastfeeders-get-a-private-area-to-feed/AllOnOnePage" target="_blank">one discussion</a></b> regarding a government proposal to establish nursing rooms at motorway stations in the UK. The commenters are expressing a commonly-held view that breastfeeding rooms actually <i>discourage</i> breastfeeding by sending out unwelcome messages--that breastfeeding is inherently shameful and should be hidden away, that it can only be done in special places and that women who are out and about should be required to spend their time hunting for nursing rooms—and by giving ammunition to those who harass women for nursing in public.<br />
<br />
I don’t think these are idle concerns at all. I have seen numerous discussions in which a woman’s right to breastfeed her baby in a café or restaurant was shot down on the grounds of “There are mothers’ rooms where you can do that kind of thing. Why can't you just feed in there?” Here's the thing, though: if I am having lunch or a coffee, I’d prefer to feed my baby where I am, thank you, rather than leave my friends and drag myself off to some separate area, as though I were committing some disgusting act, while my meal gets cold. And trying to get your errands done with a baby (who may feed as often as every 1.5-2 hours in the newborn period) is tough enough without having to plan the whole outing around the availability of nursing rooms. Or drag yourself, stroller and shopping up and down the corridors of some God-forsaken shopping center or railway station trying desperately to find the nursing room, while your hungry infant wails and everyone glares at you.<br />
<br />
And yet… I don’t think nursing rooms can simply be written off as A Bad Thing, either. Some women are always going to be too shy to feed in locations where others can see them—especially in the newborn days when trying to latch can feel like assembling a particularly fiddly piece of flatpack furniture. Some babies go through distractible phases and try to rubberneck everything in sight, which can make feeding a nightmare. Sometimes the need for a feed strikes when you not in a café but in the middle of the supermarket or something—even the most chirpy lactivist might feel more comfy feeding on a chair rather than sitting herself on the floor next to the fruit and veg. We also have more mothers who pump exclusively nowadays; I completely support mothers' right to pump in public, but I think we need to be realistic about the fact that very few women are actually comfortable doing this. Trying to find clean and private places to pump on-the-go can be a nightmare for EPing mothers, who often resort to toilet cubicles. In short: I like the existence of breastfeeding rooms. But I don’t want mothers to be chased into them.<br />
<br />
<b>What about bottle feeders?</b><br />
At first glance, providing special spaces for people to bottle feed (<b><a href="http://www.mumsnet.com/Talk/breast_and_bottle_feeding/1082014-Why-does-John-Lewis-have-a-Bottle-Feeding-area/AllOnOnePage" target="_blank">like the British department store John Lewis does</a></b>) sounds a bit odd. But formula feeders may also find themselves sometimes dealing with distractible babies or having to give a bottle in an environment where there is nowhere to sit down. Whatever the reason, formula feeders surely also deserve the option of a quiet space where they don’t have to purchase a cup of tea. Unfortunately, this raises some tricky issues. Formula feeding, unlike breastfeeding, can be done by both men and women. Nobody wants to discriminate against fathers (God knows, the lack of changing tables in most mens' toilets is annoying enough); and yet the fact remains that many breastfeeding mothers use breastfeeding rooms precisely because they don't feel comfortable nursing when there are men around.<br />
<br />
<b>A modest proposal</b><br />
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<span lang="EN-US">Suggestion: Dump the idea of “breastfeeding
rooms” and instead shift towards the concept of “feeding rooms" or "parent and baby rooms" where all parents are welcome, along the lines of the larger <i>junyuushitsu</i> I see in Japan and the generalized "baby rooms" which are sometimes found in the United States and Britain. And—this is important—the sign on the door should contain a message along the following lines:<o:p></o:p></span></div>
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<br /></div>
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<span lang="EN-US"><span class="Apple-style-span" style="color: #073763; font-family: Verdana, sans-serif; font-size: large;">Parent and Baby Room</span></span></div>
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<span lang="EN-US"><span class="Apple-style-span" style="color: #073763; font-family: Verdana, sans-serif; font-size: large;">Parents are welcome to
breastfeed/bottle feed babies anywhere in our facilities; this room provides a quiet space for those who prefer privacy.</span><o:p></o:p></span></div>
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<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">What feeding rooms need to have:</span></div>
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<br /></div>
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</div>
<ul>
<li>“Essential”</li>
</ul>
<br />
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<span lang="EN-US">- Chairs where both breastfeeders and
bottle feeders can sit in comfort and feed their babies<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US">- Small curtained-off booth/area with a chair, exclusively
for breastfeeding/expressing mothers who prefer privacy<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US">- Table (where bottles can be mixed and
prepped)<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US">- Handwashing facilities<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US">- Electrical outlet (for electric breastpumps)<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
</div>
<ul>
<li>Not essential, but “nice to have”</li>
</ul>
<br />
<div class="MsoNormal">
<span lang="EN-US">- Tap dispensing hot water heated to 70
degrees C<o:p></o:p></span></div>
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<span lang="EN-US">- Vending machine with drinks, snacks and baby supplies—baby wipes,
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<span lang="EN-US">I really feel that establishing rooms along these lines--rather than "breastfeeding rooms"-- could solve several problems simultaneously. They would, obviously, provide
a quiet space for breastfeeding, pumping <i>and</i> formula feeding parents. By
shifting the emphasis towards “supporting all parents/providing a relaxing
space” rather than “hiding breastfeeding,” they could resolve the awkward
questions that are raised about breastfeeding and women’s right to do it in
public. And a clear, visible statement affirming women’s right to nurse anywhere in the
shopping mall/station/airport etc. would help ensure that the existence of feeding rooms does not become a tool
for harassing nursing mothers; anyone who walks past the door and sees the sign will get a bit of education on mothers’ nursing rights, rather than simply registering
the existence of the room and interpreting this to mean that mothers are “not
supposed” to breastfeed anywhere else. Finally, the provision of a curtained-off
space within the room would mean that shy mothers and exclusive pumpers get the
privacy they need.</span> </div>
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<span lang="EN-US">A couple more things: Whoever is in charge
of designing baby rooms… <i>please, please consider separating the baby changing
facilities from the feeding areas</i>. If they really have to be in the same room,
for God’s sake make sure the bin is regularly emptied and the room is a decent
size and well ventilated. No parent should have to feed their child in a
stinking room next to a (usually overflowing) nappy bin, or express milk in an
environment with feces hanging around (contrary to popular belief, baby poo contains similar bacterial concentrations levels to adult feces
and can carry pathogens that spread disease). As I discussed <b><a href="http://breastfeedingwithoutbs.blogspot.co.uk/2013/08/bullshitometer-is-it-ok-to-leave.html" target="_blank">previously</a></b>, there is good evidence that breastmilk expressed in cleaner conditions stays safer for longer. Oh, and while you’re at it, please install chairs <i>without
arms</i>; I don’t know what idiot decided that it’s easier to feed a baby in an armchair,
but they clearly haven’t based this decision on experience. And could the sign
on the door include a picture of a bottle <i>and</i> the <a href="http://www.breastfeedingsymbol.org/" target="_blank"><b>International Breastfeeding Symbol</b></a>, or something
neutral, like a picture of a baby? <o:p></o:p></span></div>
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<span lang="EN-US">I’m aware that all this may sound a little
demanding. Still, installing a vending machine with bottled drinks and baby supplies might help cover some of the cost. Also, in the brave new world of online shopping that we now live in, brick-and-mortar
retail is having to undergo a certain amount of reorganization; less focus on boring and functional provisioning, more emphasis on the fun and leisure aspects
of shopping. Making sure that shopping is not a ghastly experience for parents is one obvious thing that malls and department stores can do to encourage parents to shop in their stores; shoppers these days expect nicer
treatment as a reward for turning up. Supporting parents of all feeding styles and genders would be a win-win for everyone concerned.</span></div>
BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com7tag:blogger.com,1999:blog-9064021843006104287.post-75333641463659578392013-08-09T07:42:00.000-07:002014-06-19T22:08:51.848-07:00Bullshitometer: Is it OK to leave breastmilk out of the fridge for several hours?<div style="text-align: justify;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiD_0CgcmyrO423Zpf_Q6nbx6iqwvAm-WMrxdYsGbh54K0V6Fjr1EW4_ywi1mcHkcvZoZPT2iJuBrlDblrXLUYONvZlhqOLI0S8WRkvJi_Owz_H6aRmV39F7VKOtXKjwiVFIN5bWKT2lZY/s1600/P3171235.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiD_0CgcmyrO423Zpf_Q6nbx6iqwvAm-WMrxdYsGbh54K0V6Fjr1EW4_ywi1mcHkcvZoZPT2iJuBrlDblrXLUYONvZlhqOLI0S8WRkvJi_Owz_H6aRmV39F7VKOtXKjwiVFIN5bWKT2lZY/s320/P3171235.jpg" height="240" width="320" /></a><br />
<br />
Information on storing expressed breastmilk (EBM)--particularly the question of how long you could leave it outside the fridge--wasn't something I really focused on back in the days when I actually used a breastpump--probably because as a freelancer I was lucky enough to have very little need for pumping. Scrutinizing milk storage guidelines is something mums tend to do if they are away from the baby a lot, because they are trying really hard to use every last drop.</div>
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<span lang="EN-US" style="font-family: inherit; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">So I always treated breastmilk as highly perishable, and pumped it on the day it was to be given or occasionally froze a bit for a few days. When I accidentally left a freshly-expressed container on my desk for a few hours once, I chucked it. I wasn't too sure what the guidelines were, but breastmilk is raw milk.... right? And I certainly wouldn't drink a bottle of raw milk that had been hanging around in the fridge for days, nor would I drink a glass that had been on the counter for more than a short time. (Well, okay, I don't think I'd drink raw milk period, but that's a side issue.) <o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: inherit; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">So I was a bit surprised and wary when I started coming across information—fellow online discussion group members, backed up by Kellymom, La Leche League and all the usual sources—stating you could leave a container of EBM at room temperature for up to eight hours, and for several days in the fridge. Could this really be true? After all, we all know that a bottle of formula can't be left out at room temperature for more than a couple of hours...<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: inherit; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;"><b><span class="Apple-style-span" style="font-size: large;">What the guidelines say</span></b><o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: inherit; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">I could be forgiven for being a bit suspicious of the claims of Kellymom and LLL et al in this area, since a) they’ve made a few dodgy claims in the past; and b) the evidence basis underpinning these claims seemed to be a bit, well, weak. It consisted of some studies--see <a href="http://pediatrics.aappublications.org/content/97/4/492.abstract" target="_blank"><b>Hamosh et al</b></a>, <b><a href="http://www.ncbi.nlm.nih.gov/pubmed/11320771" target="_blank">Igumbor et al</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/2791942" target="_blank">here</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/3839527" target="_blank">Ajusi et al</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/3788872" target="_blank">Sosa et al</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/2449844" target="_blank">Olowe et al</a>, </b>and <b><a href="http://www.ncbi.nlm.nih.gov/pubmed/19783003" target="_blank">Slutzah et al</a></b> for examples--which either expressed some breast milk and measured what happened to the naturally-present bacteria after several hours at various temperatures, or deliberately contaminated some EBM with specific bacteria in order to see what happened ("challenge studies"). The studies show some quite impressive results, with bacteria appearing to grow unexpectedly slowly or even dying off in the breastmilk, while no such results were seen for infant formula. Unfortunately, we are talking about a limited number of studies involving, in most cases, only a small number of samples; some of the studies are also quite old, dating back to the 1980s in some cases. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: inherit;"><span lang="EN-US" style="font-family: Times; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">However, I concluded my suspicions may have been a little hasty after perusing <a href="http://www.nice.org.uk/nicemedia/live/11943/43890/43890.pdf" target="_blank"><b><i>Handling and storage of expressed breast milk</i></b></a>, a set of guidelines issued by the Microbiological Safety Division of the Food Standards Agency of the United Kingdom and used by the National Institute for Health and Care Excellence (NICE)—and as such, likely (I felt) to represent a more neutral and trustworthy viewpoint on the subject. Based on its review of the evidence in existence, the guidelines state: <i>"</i></span><i>Many studies have looked at the growth of bacteria in EBM under different storage conditions in both tropical and temperate climates… Many of the studies in this area are relatively small and are often difficult to compare directly due to design and methodology. However, collectively they provide a reasonable body of evidence in support of the bacteriostatic behavior of EBM during several hours under ambient conditions and several days at refrigeration temperatures."</i> Similar conclusions were reached by the <b><a href="http://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm" target="_blank">Center for Disease Control (CDC)</a> </b>and the <a href="http://www.bfmed.org/Media/Files/Protocols/Protocol%208%20-%20English%20revised%202010.pdf" target="_blank"><b>Academy of Breastfeeding Medicine (ABM)</b></a>. In other words, it looks as though Kellymom et al are basing their assertions on a handful of rather small studies because that really is pretty much all we have to go on right now, not because they are cherry picking. </span></div>
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<span class="Apple-style-span" style="font-family: inherit;"><span lang="EN-US" style="font-family: Times; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">Advice on how long one can leave breastmilk at room/refrigerator temperature varies quite a bit from source to source. </span>Around 3-8 hours at room temperature, and 3-8 days in the fridge are typical recommendations from sources such as LLL, Kellymom, Medela, Ameda and the CDC, but I have seen suggestions ranging from "up to two hours at room temperature, up to two days in the fridge," to Jack Newman's <b><a href="http://www.nbci.ca/index.php?option=com_content&id=16:expressing-breast-milk&Itemid=17" target="_blank">suggestions</a> </b>of up to 8-<span style="mso-bidi-font-style: normal;">12</span> hours at room temperature and 8-11 days in the fridge. </span></div>
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<span lang="EN-US" style="font-family: inherit; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">“Room temperature" can mean different things. Unsurprisingly, the higher the surrounding temperature the faster bacteria multiply (as the Igumbor study noted). The ABM protocol suggests EBM may be stored for up to <b>8 hours</b> at lower temperatures, but only up to <b>3-4 hours at 27-32 degrees C</b>, while the Hamosh study states that breast milk "should not be stored at 38 degrees C."</span></div>
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<span lang="EN-US" style="font-family: inherit; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">Surprisingly, fridge temperature can vary as much as room temperature. From the NICE guidelines: “The last comprehensive domestic refrigerator survey in the UK was carried out in 190. The mean temperature found ranged from -1 degree C to 11 degrees C over a 7-day period, and the overall mean temperature was 6.6 degrees C, with nearly 70% of fridges operating at more than 5 degrees C. Variation was found in performance between fridges and within each fridge over time. Different temperatures were also recorded in different parts of single fridges.” Other surveys cited by the guidelines tell a similar story. This matters, because assumptions that EBM is safe in the fridge for several days are based on studies that examined breast milk place in refrigerators that really had been set to the correct temperature.<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: inherit; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">As stressed by the ABM protocol, “Studies show that human milk containing fewer bacteria at the time of expression develops less bacterial growth during storage and has higher protein levels compared to milk that has an abundance of bacteria.” As shown above, the ABM suggests that the upper limit for storage (6-8 hours at coolish room temperatures) is only acceptable if the milk is "very clean." This is echoed by the NICE guidelines, which emphasize the need for "attention to hygienic preparation."<o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: inherit; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;"><b><span class="Apple-style-span" style="font-size: large;">Raw (breast) milk </span></b><o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: inherit;"><span lang="EN-US" style="font-family: Times; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">Breastmilk has a number of interesting compounds which either kill bacteria ("bactericidal") or stop them from multiplying ("bacteriostatic"), including secretory IgA, leukocytes, lactoferrin, lysozyme, lactoperoxide and lactobacillus bifidus growth factor. These appear to work to suppress the growth of bacteria in EBM; they don’t exist in formula, which is why a formula bottle can’t stay out of the fridge for</span> too long. The way breastmilk can kill bacteria or stop them in their tracks is fascinating but much too complex to cover here; see "Further reading" for more information. </span></div>
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It's important to bear in mind that thawed frozen milk has less bacteria-inhibiting power depending on how long it was frozen, because some of these compounds are significantly affected by the freezing process. This is even truer for pasteurized milk.</div>
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<span lang="EN-US" style="font-family: inherit; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">Many of these compounds also exist in raw (=unpasteurized) cow’s milk—and I'll be frank, part of the reason why I was initially skeptical of the idea that it was okay to leave EBM hanging around for hours at room temperature was because I would never dream of doing the same thing with raw cow's milk, even if I did choose to drink such stuff. I am assuming that this difference has to do with the cleanliness of the collection conditions, something stressed by the NICE and ABM guidelines. Women have—quite rightly—fought for the right not to be sent to toilet cubicles to pump their milk, whereas if you’re a cow, the world <i>is</i> your toilet because cows crap everywhere (including during milking) and cow manure <i>splatters</i>. Even the cleanest milking barn isn’t an setting where I would feel comfortable pumping milk for my child. <o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: inherit; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;"><b><span class="Apple-style-span" style="font-size: large;">Bullshitometer verdict</span></b><o:p></o:p></span></div>
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<span lang="EN-US" style="font-family: inherit; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">Is it okay to leave breastmilk at room temperature for several hours (or in the fridge for several days)? My answer is that, thanks to a number of useful bacteriostatic and microbicidal compounds found in EBM, the correct answer is probably a cautious “yes.” Turns out I probably could have used that forgotten container that I poured down the sink. <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: inherit;"><span lang="EN-US" style="font-family: Times; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">Some caveats. Firstly, “a few hours” means just that—not 8-12 hours as a few sources like Jack Newman have claimed. Given that Newman gives no evidence basis for such generous time periods and none of the studies that I have seen support them, I am going to go ahead and discount them (along with Newman's other helpful suggestion that we should just avoid the need for expressing in the first place by bringing our babies with us absolutely everywhere, including the cinema.... erm, no thanks, Jack). The ABM’s suggestions of <b><span class="Apple-style-span" style="color: #990000;">“</span></b></span><span class="Apple-style-span" style="color: #990000;"><b>[*Room temperature] </b><b>3–4 hours optimal, 6–8 hours acceptable under very clean conditions; </b><b>[*Fridge] </b><b>72 hours optimal, 5–8 days under very clean conditions,”</b></span> seem more reasonable and accord with the (admittedly rather limited) studies that have been performed.</span></div>
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<span class="Apple-style-span" style="font-family: inherit;"><span lang="EN-US" style="font-family: Times; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">Secondly, "room temperature" really means something not much higher than 30 degrees C; if mothers are planning to be out and about all day in <i>hot</i> weather, </span>a cooler pack with ice sounds like a good plan.</span></div>
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<span class="Apple-style-span" style="font-family: inherit;">The "store in the fridge for several days" thing requires a little caution too, simply because in the real world people's fridges are frequently nowhere near as cold as they should be. If mothers want to leave EBM in the fridge for several days, they would be wise to think about the age of their equipment, maintain the fridge properly, use a fridge thermometer and store EBM at the back of the fridge, not in the door (which is significantly less cold).</span></div>
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<span class="Apple-style-span" style="font-family: inherit;">Finally, as discussed in the ABM protocol, the storeability of breastmilk depends a lot on how cleanly it is expressed. Over the past few years there has been a big increase in computer and cellphone usage at work and leisure, with many mothers fitting pumping sessions in between typing sessions--and keyboards are notorious for being covered in germs. Very careful handwashing would appear to be called for if we want to store breastmilk as long as permitted by the studies that have been cited. And for a number of reasons, exclusively-pumping mothers are a lot commoner than they used to be. So we also need consider ways to ensure that women have safe and clean places to pump not just in workplaces but also in shopping centers, stations and so on.</span></div>
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<span class="Apple-style-span" style="font-family: inherit;"><span lang="EN-US" style="font-family: Times; font-size: 16.0pt; mso-bidi-font-family: Times; mso-font-kerning: 0pt;">Finally: just a plea for more and better research on EBM storage and microbial safety! These experiments are surely not particularly complicated to undertake, and with more mothers expressing milk than ever before, there is clearly a need for more information. Really good, evidence-based guidelines would improve safety, increase mothers' confidence and perhaps encourage the acceptability of EBM among daycare nurseries that are currently reluctant to handle the stuff. </span><span lang="EN-US"><o:p></o:p></span></span></div>
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<b><span class="Apple-style-span" style="font-size: large;">Further reading</span></b></div>
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<a href="http://www.nice.org.uk/nicemedia/live/11943/43890/43890.pdf" target="_blank"><b>Handling and storage of expressed breast milk (NICE)</b></a></div>
Good basic guidelines. It includes an interesting table allowing you to compare the time limits recommended for different storage conditions by all sorts of different sources, from UNICEF to the UK Association for Milk Banking.<br />
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<b><a href="http://www.bfmed.org/Media/Files/Protocols/Protocol%208%20-%20English%20revised%202010.pdf" target="_blank">ABM Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants (Original Protocol March 2004; Revision #1 March 2010)</a></b><br />
A more detailed guide, including discussion of appropriate container type and issues such as thawing and refreezing.<br />
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<b><a href="http://www.psmid.org.ph/vol18/vol18num2topic6.pdf" target="_blank">Antimicrobial Activity of Breastmilk Against Common Pediatric Pathogens</a></b><br />
<b>Esperanza F. Rivera, M.D. and Ricarchito B. Manera, M.D.</b><br />
A bit old, but this is a nice readable overview of EBM's bacteria-zapping properties.</div>
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<b><a href="http://www.livestocktrail.illinois.edu/dairynet/paperDisplay.cfm?ContentID=229" target="_blank">Antimicrobial Factors in Milk</a></b><br />
<b>Illini DairyNET (the Online Resource for the Dairy Industry)</b><br />
This one looks at cow's milk, and is an interesting comparison.<br />
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<b><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1545135/" target="_blank">Effect of storage and heat on antimicrobial proteins in human milk.</a></b><br />
<b>T J Evans, H C Ryley, L M Neale, J A Dodge, and V M Lewarne</b><br />
More detailed information on the extent to which freezing/heating EBM can alter its bactericidal/bacteriostatic powers.<br />
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<!--EndFragment-->BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com8tag:blogger.com,1999:blog-9064021843006104287.post-50666179140932875752013-05-14T05:58:00.002-07:002013-11-18T22:07:28.669-08:00Yes, we still need strollers<div class="separator" style="clear: both; text-align: center;">
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Stroller, prams, pushchairs, buggies--they're a part of childrearing, whether you love them or hate them. And an awful lot of people do seem to really hate them. Dislike of buggies is one of the top complaints among those people who have a hostile attitude towards parents and children in public spaces--whenever the <a href="http://www.washingtonpost.com/wp-dyn/content/article/2010/05/15/AR2010051503637.html" target="_blank">breeders vs. childfree-by-choice wars</a> break out online, you can guarantee that there'll be lots of moaning about stroller-users bashing people in the ankles or pushing them off the kerb.<br />
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Big ("SUV") strollers, expensive strollers and older kids in strollers come in for the most criticism. "These things get bigger every year!" "Just carry your kid already--and once they can walk, make them walk!" Sometimes--in one of those unholy alliances that only the Internet makes possible--the child-hating-by-choice people are joined by the attachment parenting brigade, who say things like "Oh, I agree! I don't know why people use strollers; we almost <i>never</i> used ours, just carried her everywhere in a sling! It's soooo much easier than a bulky buggy!"<br />
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Now, I like a good sling myself too. But strollers are a necessity for most of us at least some of the time. So, taking a hint from <a href="http://privilegedenyingdoula.tumblr.com/" target="_blank">Privilege Denying Doula</a> for a moment, I'll say why I think so.<br />
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<b>1. Not every baby will tolerate slings</b><br />
Some babies really, really don't like being worn--and it's not always a case of "Oh, but you just need to find the right sling!" Some babies just prefer the stroller. No, seriously. They do.<br />
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<b>2. Not every parent can use slings</b><br />
Some mothers have disabilities even before they get pregnant; others develop problems due to pregnancy and childbirth, which can do a number on your body. Mothers who have developed chronic back ache, who have symphysis pubis dysfunction, who are recovering from surgery or whose pelvic organs are falling out don't need to aggravate these issues by lugging the baby, baby gear and all their bags around for hours on end. Which leads me to...<br />
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<b>3. Prams carry stuff</b><br />
I love slings for short trips, but for whole days out or when doing errands on foot...? The problem is, you don't just have your child; you've also got a diaper bag, change of clothes, toys, maybe snacks or drink. PLUS groceries and shopping... or maybe bags of dry cleaning and recycling... or maybe a bag of library books and the boots you're taking to the menders... perhaps raingear and umbrellas... or a picnic lunch... I have actually tried doing trips like this with a sling rather than a pram, and discovered that the hassle of occasionally having to search for an elevator is actually a lot less miserable than staggering round like a packhorse for hours and hours.<br />
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<b>4. Prams let you catch a break</b><br />
A child falling asleep in the pram is your cue to slip into a cafe or restaurant for a quiet lunch with your friend or partner, or even just a nice half-hour to have a coffee and knit/read by yourself. You really cannot enjoy this kind of moment with a baby glued to your front; you can't eat in comfort because you have tyrannosaurus-rex arms (= you struggle to get your hands near your face), and you can't drink anything hot for fear of dropping it on their head. If they're on your back, you can't sit back in your chair and relax. Ugh!<br />
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<b>5. Kids who can walk sometimes need strollers too</b><br />
A lot of people <a href="http://thebadmomsclub.com/2011/05/do-not-poke-the-mama-bear-or-her-stroller.html" target="_blank">love complaining</a> about walking-age children in strollers. "Let them walk! They need exercise!" Yes, but. The four-year-old you briefly spied in a stroller yesterday was almost certainly <i>not</i> there all day long. Most likely they walked for ages, and then took a little rest in the buggy when their legs started to give way. A stroller makes it possible to cover substantial distances without driving; nobody moans about a four-year-old being driven from A to B in a car, even though said child is getting no more exercise than a child in a stroller (less, actually, since the strollered child probably did much of that journey on foot); Show me a person who says "Well, <i>my</i> little one was out of the buggy by 21 months! I believe in making children walk!" and I will show you someone who <a href="http://www.mumsnet.com/Talk/_chat/a1735444-I-have-just-been-judged-for-using-a-pushchair-with-my-2yo" target="_blank">flippin' <i>drives</i> everywhere</a>. Which brings me on to...<br />
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<b>6. If you don't have a car, your stroller IS your car</b><br />
The whole notion of "babywear only, skip the stroller and then make them walk once they're toddlers" is actually quite doable for most people who drive most places. You can dump all your stuff in the car, drive from place to place, and when you get out, bring just those few things you need right now; a baby can fall asleep in the carseat and you unsnap the bucket and carry it into the restaurant; an older child can take a nap in the car on the way home. If you don't drive it's a different story. It is often not possible to carry a baby, diaper bag and errand stuff/shopping round for hours on end while covering considerable distances on foot; nor is it practical to do everything at a small child's pace. And your toddler will have nowhere to rest or nap. I think, to be honest, this is what's at the crux of all those furious online arguments about strollers in public places. The demographic which is most hostile to having children in their midst tends to be concentrated in densely populated urban areas... however, it is precisely those areas where parents tend to need their strollers the most.<br />
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<b>7. Not all strollers are created equal</b><br />
I'm not sure where this whole "Strollers keep getting bigger all the time!" idea has come from--haven't the people who say this ever seen a tank-like <a href="http://www.babble.com/mom/the-evolution-of-the-stroller-a-photographic-history/#the-1920s" target="_blank">1950s pram</a>? Now those really <i>are</i> strollers you could haul a week's worth of coal home in (and of course that's just what people did). Teeny umbrella strollers are great for older kids, but tiny babies need to lie flat. And if you're a city parent who uses your stroller a lot, it is perfectly reasonable to spend $$$ getting an good one; cheap strollers will steer awkwardly, rattle your child around when they're trying to nap, and rapidly wear out and need to be replaced. False economy. I'm not sure why it's considered so morally abhorrent to spend some money on something which one is going to use <i>hard</i> every day and be seen with for hours at a time. Nobody bitches at the person who invests in a decent winter coat rather than the cheapest anorak they can lay their hands on. (Just one thing: if I'm brutally honest, I do think that some of the strollers used by some parents are bigger than they need to be. I think the best urban stroller is mid-size: big enough to carry your gear, small enough to be reasonably agile.)<br />
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<b>Closing thoughts</b><br />
Much as I love my Beco--it's practical, fun and sometimes life-saving--I'd be disappointed if the existence of slings started to become yet another excuse for stroller bans, hostility towards pram-users in public spaces, or failing to make accommodations for strollers such as ensuring elevator provision. Hating on parents with strollers won't make us and our offspring disappear--it will just drive us into cars, which won't help anyone. Of course it is <i>possible</i> to "manage" without either prams or cars--in remote villages in Nepal and Sierra Leone and so on, women trudge around with babies, firewood, water and farm produce strapped all over them. I wouldn't want to live that way, and women in Nepalese villages probably wouldn't live that way either if they had any choice in the matter. At least Nepalese village women have the option of leaving toddlers in the care of extended family members or older kids (who do most of the childcare in traditional societies). In developed countries, we have little choice other than to drag toddlers around with us on errands. Strollers are an important tool in making sure parents, especially mothers, can occupy public spaces easily and get their stuff done.BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com10tag:blogger.com,1999:blog-9064021843006104287.post-16695909290052625522013-04-05T05:21:00.000-07:002013-11-18T22:06:35.686-08:00Homemade formula and the Weston A. Price bust-up<div class="separator" style="clear: both; text-align: center;">
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It's always kind of interesting when crunchy people fall out with each other (you know, like elimination communication fans vs. let-your-child-sit-in-diapers-till-they're five-if-they-want-to people... that kind of thing). The latest bust-up--if you'll pardon the pun--concerns the Weston A. Price Foundation (WAPF) vs. breastfeeding advocates.<br />
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WAPF is a kind of nutritionist movement that's been around for decades, and which advocates for "traditional foods"--organic everything, lots of animal products and lots of fermented/home-processed foods, from konbucha to bone broth to a yohurt-like product called kefir. It also advocates making homemade formula. Some breastfeeding advocates have become suspicious of WAPF in recent times, claiming that WAPF proponents are too quick to push homemade formula recipes on struggling mothers, rather than getting to grips with their latch issues, tongue ties, lack of support and so on. In the most extreme form, some WAPF advocates have stated that WAPF homemade formula can be <i>better</i> than breastmilk... if the mother eats an imperfect diet, and especially if she's vegan. WAPF doesn't actually sell its formula, obviously (this formula has to be made freshly), but it does encourage followers to purchase ingredients from a sponsor company called Radiant Life, which sells $170-$400 <a href="http://www.radiantlifecatalog.com/product/nourishing-traditions-kit-homemade-baby-formula/baby-child-care" target="_blank"><b>kits</b></a> containing one to six months' worth of the supplements and powders needed to make the formula at home.<br />
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I don't always agree with Best For Babes but I think <a href="http://www.bestforbabes.org/from-karo-syrup-to-goat-milk-the-formulas-may-change-but-the-booby-traps-remain-the-same" target="_blank"><b>their piece</b></a> on the WAPF thing got it more or less right. Full-on malnutrition <i>can</i> affect breastmilk quantity and quality, but this is rare in developed countries. In spite of its hippy image, woo/crunchy stuff/pseudoscience is often big business, and WAPF may well be subtly encouraging homemade formula use because it's in its business interests to do so, no different to Similac or Cow & Gate. Women who want to breastfeed would therefore be advised to be wary. Incidentally, this is not really about whether we think formula is wonderful, evil or something in between; it's because it behoves us to maintain a proper degree of skepticism concerning the advice given by <b><i>anyone</i></b> who is trying to sell us stuff. I mean, I use disposable diapers and wouldn't want to live in a world where they didn't exist; however, I have no intention of getting my toilet-training advice from a Pampers helpline. After all, businesses are businesses, not charities; it ought to be possible for us all to take advantage of their products appropriately<i> and</i> take what they say with a good pinch of salt.<br />
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However, amid all this talk, there's actually been very little discussion of the homemade formulas themselves. So I thought I 'd talk about that.<br />
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<b>How to make formula (quick explanation)</b><br />
Bit of background: You can't give straight cow's milk to young babies as a main drink because it's pretty different from human milk. Too much protein, for a start. Also, there are two types of protein in all animal milks: casein and whey protein. Human milk is about 30:70 casein-to-whey, while cow's milk is more like 80:20. All that casein's hard for a baby's belly to digest. The resultant stress on the intestines causes microscopic bleeding, which can add up to quite a lot of blood loss. Now, there's hardly any iron in cow's milk, which tends to cause anemia, and that gradually accumulating blood loss makes things even worse. Cow's milk also has too much sodium, and not enough carbohydrates. (It's a similar story for goat's milk, by the way, despite the urban legends about how it's supposedly similar to mother's milk)<br />
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Formula companies therefore process cow's milk and add things and take things away to make it more similar to breastmilk. Not <i>the same</i>, mind you; many nutrients are better absorbed and more useable ("bioavailable") in breastmilk than they are in formula, and the storage and preparation of formula may cause loss of some nutrients. So in order for the formula-fed baby to get the same amount of, say, calcium as the breastfed baby, you may actually have to create a formula with more calcium in it than breastmilk.<br />
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Now, the WAPF formulas purport to do the same thing--just on a homegrown scale. <a href="http://www.westonaprice.org/childrens-health/recipes-for-homemade-baby-formula" target="_blank"><b>The website lists three types of formula</b></a>--cow's milk-based, goat's milk-based, and liver-based--and explains the ingredients and preparation method for each. There is also a nutritional chart comparing what's in them (maddeningly, however, it uses <i>ounces</i> which makes it difficult to compare with scientific data on formula composition).<br />
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<b>Protein</b><br />
Now, the WAPF cow's milk and goat's milk formulas are certainly better than the crude recipes your grandma might have used--the sort where you just watered down evaporated milk and then bunged in a bit of sugar. Like commercial formula, the WAPF recipes get you to "rebalance" the casein-whey ratio, by making a separate batch of curds-and-whey (remember Little Miss Muffet?) and then adding some of that whey into your formula mixture. The actual amounts of protein also turned out to be comparable with commercial formulas, when I checked. So far, so good.<br />
<b>UPDATE: </b>I've had a chance to read through some of the materials linked to me by Becky (the commenter below) on cow's milk in the first year. Cow's milk protein in the first year irritates the intestines and causes occult enteric blood loss in babies, meaning that their stools contain unusually large amounts of blood when examined. This over time can add up to substantial blood loss, greatly increasing the risk of iron deficiency anemia, which is strongly linked with mild cognitive problems later on in life. In commercial formulas, these milk proteins are heat-treated, making them easier to digest and minimizing blood loss. As I discuss below, the WAPF milk-based formulas are already low in iron; the fact that they contain elements which could cause the baby to loose what little iron they have must be considered a further strike against using such concoctions. And I think this also ties in with what I talk about in the final section--that when it comes to infant formula, processing is generally a <i>good</i> thing.<br />
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<b>Raw milk</b><br />
It is concerning, however, to see that WAPF is advocating raw (unpasteurized) milk for babies. When a person consumes raw milk, there is a small but real risk of infection which can have very serious consequences including organ failure, as the Real Raw Milk Facts website explains--no matter how clean the milking barn is. And most adults who drink raw milk are only having the odd glass. A baby is getting many bottles of milk a day--the chances of coming across a bad batch sooner or later are going to add up fast.<br />
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<b>Sodium</b><br />
One reason you shouldn't feed straight cow's/goat's milk in lieu of formula/breastmilk is their high sodium levels--about 430mg per 36oz (compared to breastmilk's 180mg). Commercial formulas, when I did the calculations, ranged from 180-360mg per 36oz. So the sodium levels in WAPF's milk-based formulas--308-320mg--seem to be fine.<br />
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<b>Iron</b><br />
Breastmilk iron is unusually bioavailable--there doesn't need to be a lot of it. Formulas need more iron in order for baby to get enough. Commercial ones usually have around 3.5mg per 36oz in the case of low-iron formulas, and up to 14.5 mg in the high-iron types. WAPF's cow's milk and goat's milk formulas, however, contain only 1.4mg and 2.2mg per 36oz, respectively, which looks rather low to me. The WAPF does emphasize that parents should start egg yolk feeding at 4mo, which will certainly help, but I wonder how the baby is supposed to manage till then--or what happens if your baby just can't take a spoon at 4mo.<br />
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<b>Vitamin A</b><br />
Perhaps mindful of the low iron levels in its other formulas, WAPF have come up with a third formula--"Liver based." You make this one by grating raw liver into meat broth, plus vegetable oils and other things. This formula has more iron in it (and it's haem iron, which is well absorbed).<br />
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Unfortunately, the liver means it has potentially toxic levels of Vitamin A as well. 20,000iu of Vitamin A per 682 calories means <b>2,933iu per 100kcal</b>; meanwhile, <b><a href="http://jn.nutrition.org/content/119/12_Suppl/1820.full.pdf" target="_blank">"Toxic manifestations have been reported in infants when the daily intake was 2,100 iu/100 kcal or higher."</a> </b>I can't really imagine that very many people are actually going to bring themselves to feed their baby a pureed liver concoction all day long, but I do think it's a bit scary to think that if you followed WAPF s instructions to the letter, you could risk poisoning your child. Of course, a few decades ago, mega vitamin doses were very much the thing; I remember my mum's Adelle Davis books recommending that readers take some truly scary amounts of Vitamin This and That. Since then, the pendulum has swung very much towards recommending low doses of vitamins only; high doses of Vitamin A in particular have come out very badly in recent times, including concerns about teratogenicity (birth defects) in pregnant women; that's why pregnant women are supposed to take prenatals (with special low Vitamin A) rather than normal vitamins.<br />
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<b>Other nutrients</b><br />
Most of the micronutrients in the formula seemed to be higher than comparable amounts in commercial formula, when I did a comparison. One or two--like Vitamin E--were lower. Other than the scary liver-Vitamin A thing, I can't see anything here that would cause acute toxicity. Still, from a long-term perspective, I think I'd rather feed my baby something where the levels of all these nutrients have been balanced reliably and consistently to just the right levels, based on research by dietitians.<br />
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The advantage of manufacturing formula using artificial vitamin and mineral drops and powders is that if you want to add exactly such-and-such amount of, say, manganese, you can go ahead and do just that. When you use natural materials, anything you add tends to come packaged with other nutrients, which then throws the mixture's balance off. Like... okay, one can boost the iron content of a formula by adding liver. But that iron comes bundled up with way too much Vitamin A. Or, perhaps we could bump up the rather low vitamin E level by adding more vegetable oil? But then the mixture might face composition/texture problems such as excessive oil separation. We could add something else to deal with the separation issue... but then you're inadvertently adding other nutrients. And so on. And the more steps and ingredients you have, the more opportunities for errors. I just think it's going to be really, really difficult to produce a well-balanced and foolproof formula on a home-kitchen scale.<br />
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<b>Margin for error</b><br />
Honestly, though, in a way the recipes themselves are less scary than the comments below. People saying stuff like "We have been using the cows milk formula and have replaced the yeast with vitamin b and maple syrup..." "My bottle of yeast flakes was crushed entirely in my check-in luggage; is yeast flakes absolutely required for this recipe or can I do without it for 3 weeks?" "I have been feeding our adopted newborn the goat milk formula since he was 3 weeks old. I did not realize that I was supposed to wait on giving him the cod liver oil until he was 3 months old. Have I done something dangerous to his health?" "I increased the cream by a tablespoon because he is a big boy..." "How about coconut nectar from the company called coconut secret? Just ideas....." "I noticed that it had curdled almost, more like became gelatinous...is this suppose[d] to happen?" Seriously, people, why are you even <i>asking</i> these questions? This is your baby's lifeblood we are talking about, not a fun baking experiment. The newborn period is a time when most of us feel like we deserve a round of applause just for getting a simple meal cooked. Creating formula using all these elaborate rules when you are sleep deprived seems like an invitation to disaster (especially when one considers how many parents make errors even with commercial infant formula preparation).<br />
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The food that breaks the rules</b><br />
Formula breaks all the rules of normal food. We all know these rules: "Cook food at home," "Use real produce," "Eat fresh food," "Try to eat foods with as short an ingredients list as possible" and so on. But formula is a food with a unique job to do: it's got to mimic a natural food (breastmilk) as closely as possible. So the processing that commercial formula undergoes and the long list of ingredients on the package are <i>good</i> things; they make the formula more like breastmilk and less like cow's milk. A simple homemade formula using fresh materials is likely to behave less like breastmilk, and is therefore less suitable for a baby.<br />
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To be fair, the WAPF's milk-based formulas (as opposed to the scary liver puree thing) don't look to me like they could induce toxicity in an infant, which fits in with the fact that many people do use these formulas and their babies seem perfectly alright...although to be honest, the impression I get from the comments on the WAPF page is that the greater part of parents using homemade formula are doing so as a supplement for a predominantly breastfed infant rather than as a full-time thing, which would greatly reduce the risks. In a situation where commercial formula and donor milk weren't available (and yes, this can happen: after the earthquake in Japan around the time I gave birth, formula started disappearing from the shops due to distribution problems and panic-buying) I have no doubt that something like the WAPF cow's milk formula, with pasteurized milk, would keep baby ticking over OK until supplies resumed. However, I'd really question the utility of using homemade formula by choice in peacetime conditions.<br />
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The optimal milk drink for a baby is breastmilk, but if a mother can't nurse or prefers not to, I think the next best thing is a commercial infant formula correctly made up. Buy a tin and follow the instructions on the label. Done. This is one of those pleasantly hedonistic moments in childrearing where the easiest approach is actually the best and safest too. Making your own formula falls into that interesting category known as "Putting a lot of effort into actually making your parenting worse." It's complicated, there's no evidence it's any better, and there's at least some indications that it may be less well balanced and riskier.<br />
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<b>Further reading</b><br />
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<b>*</b>Best For Babes's take on the WAPF bust-up<br />
<a href="http://www.bestforbabes.org/from-karo-syrup-to-goat-milk-the-formulas-may-change-but-the-booby-traps-remain-the-same"><b>http://www.bestforbabes.org/from-karo-syrup-to-goat-milk-the-formulas-may-change-but-the-booby-traps-remain-the-same</b></a><br />
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*More discussion at Unlatched<br />
<a href="http://unlatched.wordpress.com/2013/04/02/the-weston-a-price-foundations-dangerous-breastfeeding-advice-should-not-be-ignored/"><b>http://unlatched.wordpress.com/2013/04/02/the-weston-a-price-foundations-dangerous-breastfeeding-advice-should-not-be-ignored/</b></a><br />
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*Vitamin A toxicity<br />
<a href="http://www.medceu.com/index/index.php?page=get_course&courseID=3903&nocheck"><b>http://www.medceu.com/index/index.php?page=get_course&courseID=3903&nocheck</b></a><br />
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*Commercial formula composition<br />
<a href="http://www.espghan.med.up.pt/position_papers/con_23.pdf"><b>http://www.espghan.med.up.pt/position_papers/con_23.pdf</b></a><br />
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*Real Raw Milk Facts website<br />
<a href="http://www.realrawmilkfacts.com/raw-milk-hot-topics"><b>http://www.realrawmilkfacts.com/raw-milk-hot-topics</b></a><br />
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*Cow's milk induced intestinal bleeding in infancy<br />
<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1029246/pdf/archdisch00547-0084.pdf">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1029246/pdf/archdisch00547-0084.pdf</a>BFwithoutBShttp://www.blogger.com/profile/14311113448295882286noreply@blogger.com18