Why I am (surprisingly) in favor of banning the bags

Increasing numbers of American hospitals seem to be "banning the bags" these days--that is, abolishing their long-established habit of handing out free samples of formula to mothers on maternity wards. The "Ban the Bags" campaign has engendered a lot of debate, with most breastfeeding advocates strongly in favor, and many formula feeding advocates skeptical or somewhat offended. Not surprising, really: "Ban the Bags" very often comes hand-in-hand with measures which have upset many formula feeders, such as harassing or pressuring mothers who choose to bottle-feed. The Baby Friendly Hospital Initiative (BFHI) has been a case in point here. I have "issues" with several bits of the BFHI, as I'll be discussing in a future post. However--perhaps somewhat surprisingly--I'm still inclined to be in support of banning the bags. Here's why.

Paying for the label

The formula samples American families receive in hospitals and doctors' waiting rooms are invariably branded formulas, such as Gerber, Enfamil and Similac. You can buy these at the store, too, but big stores also sell "generics" (store brands) such as Walmart's Parent's Choice. British readers probably won't be familiar with generic formulas, but basically it's like when you're in Superdrug and you could buy either Calpol or Superdrug's own paracetamol suspension. It's just as good a product, but has a less prestigious label (and price tag) on it.

Generic vs brand formula is basically the same deal. All formulas in the States are required to meet strict, identical standards in terms of ingredients, processing requirements and so on. If you have a moment, go to the first link in the "Further reading" section below, and check out the lists of ingredients in generic formulas versus the fancy-pants ones: you'll find that each generic formula is basically identical to its brand equivalent. The various companies are also required to follow identical rules as to the quality and sourcing of each ingredient.

This is not to say, incidentally, that "all formulas are exactly the same"--they're not. There's cow's milk, goat's milk, soy, elemental, there are different levels of iron, there are different whey to casein ratios, there are things like DHA and probiotics which may or may not be added--but the thing is, whatever permutation you are looking for--say, "I want a soy-based formula with added DHA"--you can almost certainly find that option in either a brand or a generic form, and they're both equally good (I think there are fewer organic generic options, but some have appeared in recent years). There is no particular reason to purchase a brand formula unless you actually have found that your child does poorly on the generic option and seems to be better suited to the brand one when you try it out. Otherwise, it's as pure an example of "paying for the label" as you're likely to find. And the price differences are substantial; added up, we're talking anywhere between UD$400 and UD$700 a year. Double that if you have twins. This can be particularly hard on parents who fall into that unsweet spot of being poor yet not quite poor enough to qualify for income support programs or free formula supplies. Worryingly, parents who struggle to pay for formula sometimes try to "stretch" it through over-dilution or feeding leftovers from the last feed.

Where your money goes if you buy a brand formula
even though your baby does fine on generic.
 Yes, this is my kitchen. No, it isn't normally as clean as this. 

Can I trust my doctor?

The other casualty here is the credibility of healthcare professionals. Most of us think of doctors as authority figures, so when someone at a hospital or pediatrician's office gives you something, they are--whether this is intended or not--effectively endorsing the product with an unspoken message of "I, as a medical professional, believe that this product is the best thing for you, based on scientific evidence." When that kind of endorsement is being applied to a product whose high price tag is not justified by any superiority of quality, as a result of what is basically a commercial marketing tie-up with a corporation.... well, I find that tacky and also borderline unethical. And yes, I know this is far from the only case of this kind of thing happening--doctors also recommend brand-name drugs over generic versions to patients all the time (and I don't think they should do that either). But doing this stuff to new parents seems like a particularly low trick, given how vulnerable new parents are to marketing that appeals to fear.

Fear is probably the strongest emotion that most of us feel as we take our tiny, precious newborns home with us--that, and a desperate desire to do absolutely anything that might, possibly, help to keep them safe, whatever the cost. (This post comes to you from the woman who gave her baby her first bath at home in bottled water because I was convinced that radiation in the tapwater was going to give her cancer.... or something. Yes, really.) Doubly so for women who really wanted to breastfeed and are now writhing with guilt. Plus, once you have finally succeeded in getting your newborn to feed normally, poo normally and sleep at least fitfully on Brand A formula, you really, really, really don't want to start switching to Brand B. For all these reasons, parents who have been started on Enfamil or what-have-you at the hospital are highly likely to keep on using it.

When people shun vaccines and other conventional medicine recommended by the medical profession, one reason invariably cited for doing this is "You can't trust doctors, because they are shilling for pharmaceutical companies." The idea that the standard vaccine schedule is based on doctors' desire to get free mugs and ballpoint pens from Pfizer and AstraZeneca is bizarre, but when the medical profession falls into the habit of endorsing products based on a commercial rather than scientific rationale, it just doesn't look great. With so many voices out there encouraging parents to mistrust and shun conventional medicine, it's really important that doctors and other healthcare professionals ensure that all their recommendations are ethical and evidence-based.

And it also doesn't help that a high percentage of pediatricians and doctors are also actually recommending branded formulas to families and steering them away from generics--based on precisely zero evidence--which makes me wonder whether the presence of all those attractively packaged samples and freebies is also having a kind of subtle subliminal effect on medical workers' thinking too. Doctors are only human, after all. It's often said (with some truth) that "doctors and pediatricians tend to be clueless about breastfeeding" but looking at articles like this one (check out the comments on generic formula by the vice-chair of Pediatrics who is quoted) makes me feel that some of them could do with a bit more education about bottle-feeding as well.

Formula = Breast pads

Perhaps one's feelings about "Ban the Bags" will depend on where one is coming from (literally). If you are American and have grown up with the idea of formula bag freebies, not having samples is likely to feel like having something taken away and also like an attack on one's choices. For people (like me) from the UK or Australia, where infant formula samples aren't handed out anyway, there is a sort of vague feeling of "Huh? Why would one expect freebies in the first place? This is just being neutral. Nobody's stopping you from buying your own formula if you want it." Nobody should ever be harassed for feeding choices, but I don't think "not giving a freebie" amounts to harassing women for formula feeding any more than my hospital's failure to provide me with free breast pads, nipple cream and nursing aprons could be considered disrespecting my choice to breastfeed. 

How about just handling formula in hospitals in the same kind of way we handle other maternity-related supplies, like breast pads? What that would mean in practice will depend, ultimately, on how your hospital/healthcare system/insurance coverage works. If a hospital is in the habit of providing products like breast pads, diapers and sanitary protection for free, there's no reason it can't provide formula as well--but it should be providing generic formulas that meet the requirements of food regulation authorities, not overpriced brand versions, and not as part of marketing or commercial tie-ups. If, on the other hand, a hospital expects mothers to provide their own sanitary protection, breast pads and so on (as did my hospital), it's perfectly reasonable to expect them to bring their own formula to the hospital as well, if they choose to formula feed. If a woman runs out of formula or if a breastfeeding mother needs formula or changes her mind, the hospital can provide her with generics, and add the cost to her hospital bill at the end--just like if you ran out of nipple creams or diapers. And yes, hospitals should be supplying low-priced generic breast pads and diapers too, as long as these do the job as well as the fancy brands.

By the way, there is definitely nothing wrong with formula companies posting free samples of Similac or whatever to families who email them with a request, but this should be based on an informed decision. It would be good if prenatal infant feeding education gave clear, science-based information on formula, including discussing the fact that generic formulas are not inferior to the brand versions. 

In summary, while there are reasons to be concerned about certain aspects of the BFHI, there is also a sound rationale for getting rid of the practice of having medical institutions pushing marked-up brand formulas at parents without any scientific basis for the inflated cost. Instead of handling formula like either an illicit substance or a money-spinner for companies, let's handle it like what it is--a babycare product--and in a manner that's neutral and science-based. Doing so will not only result in better support for both breastfeeding and formula feeding families, but can also help ensure that the medical profession maintains the respect and trust of parents.

Further reading

Supplement to Consultant for Pediatricians (February 2014): A Comprehensive Overview of Store Brand Infant Formula/Guiding Parents in Formula Selection: How Do Store Brands Compare to National Brands?  This easy-to-read supplement is worth a look. It also has a big, colorful table where you can look at the ingredient comparison for yourself.

White elephants in the freezer: The pros and cons of breastmilk stashes

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 ice cream 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.

The freezer culture
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.

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.

Beware of the scary freezer...

The dark side of the freezer (cue ominous music...)
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).

- Frozen breastmilk is significantly inferior to the fresh stuff 
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. (That said, frozen breastmilk still has more antioxidant activity than formula).

However, the evidence about decreases in vitamins is less positive. A 1983 study found that "Freezing and frozen storage did not significantly affect the levels of biotin, niacin, and folic acid." But in a 2004 meta-analysis (Ezz El Din et al), 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%, echoing a 2001 study (Buss et al) which found that Vitamin C decreased to 63% of the starting values after one month and 38% after two months of freezing; 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.

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.

- What are the benefits of avoiding all formula?
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.

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.

- Your stash might turn out to be unusable (I call these "White Elephant stashes")
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.

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 after 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.

- Your stash might be destroyed by a freezer breakdown, power cut or a freezer door accidentally left open
Hours and hours and hours of hard work literally down the drain. This happens All.The.Time.

- Going mad with the pump can jeapordize your current breastfeeding
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.

- Stashing costs time, effort and emotional energy
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."

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)?

- Freezer stashing can become competitive, obsessive and compulsive
With modern, super-efficient double electric pumps, some women put very large amounts of milk into the freezer.

"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."

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 scary situation that actually places your baby in peril.

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:

"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." 

"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."

Obviously these are extreme cases, but it's common for freezer stashing mothers to express ambiguous attitudes towards their stashes. (See this discussion at Mothers in Medicine, 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 this mother) 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.

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.

Keeping the White Elephants at bay!
I would recommend that anyone thinking of creating a massive stash rule out potential issues first, before they start to pump, to avoid the frustration of a "White Elephant stash."
- If your baby seems to have digestive issues/colic, hold off on stash building until you have ruled out

Just say no to White Elephant stashes!

the possibility of allergens in your milk.
- Check whether you have lipase issues; if you do you will need to scald all your milk (see here and here).
- Maintain your freezer by using a freezer thermometer and not overstocking (I now blush to think how clueless I have been in this respect).
- Have a backup plan in case the freezer fails. And stick a SHUT THE DOOR note on the door!
-Find whether you actually meet the requirements to donate milk.
-Get your baby used to the flavor of frozen milk early on.

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.

Relishing the experience or shouldering a burden?
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 not stashing (and minimal stashing) too, and the benefits and conveniences that that can bring.

Creating a stash is an option, not something breastfeeding mothers have to do. No, even if they are employed full-time.... 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.

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.  

Freezing milk
Tips for refrigerator freezers
ABM Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants

Lipase issues
The lipase mini-saga from The Adequate Mother

Frozen milk vs fresh
Effect of storage on breast milk antioxidant activity Hanna et al, Archives of Disease in Childhood. Fetal and Neonatal Edition, 2004
Effect of storage time and temperature on folacin and vitamin C levels in term and preterm human milk Bank et al, The American Journal of Clinical Nutrition, 1985
Is stored expressed breast milk an alternative for working Egyptian mothers?   Ezz Al Din et al, Eastern Mediterranean Health Journal, 2004
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 Friend et al, Pediatric Research 1983

Inadvertent Booby Traps from Nursing Freedom: Some interesting discussion about the necessity of freezer stashes

In closing
Trying and Failing to Control Everything and How it Led to Happiness: I love this story!

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

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

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

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

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

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

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

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

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

A modest proposal

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

Parent and Baby Room

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

What feeding rooms need to have:

• “Essential”

- Chairs where both breastfeeders and bottle feeders can sit in comfort and feed their babies

- Small curtained-off booth/area with a chair, exclusively for breastfeeding/expressing mothers who prefer privacy

- Table (where bottles can be mixed and prepped)

- Handwashing facilities

- Electrical outlet (for electric breastpumps)

• Not essential, but “nice to have”

- Tap dispensing hot water heated to 70 degrees C

- Vending machine with drinks, snacks and baby supplies—baby wipes, ready-to-feed (RTF) formula cartons, disposable diapers and hand sanitizer

- Magazines, pleasant décor and a bit of general nice ambience

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

A couple more things: Whoever is in charge of designing baby rooms… please, please consider separating the baby changing facilities from the feeding areas. If they really have to be in the same room, for God’s sake make sure the bin is regularly emptied and the room is a decent size and well ventilated. No parent should have to feed their child in a stinking room next to a (usually overflowing) nappy bin, or express milk in an environment with feces hanging around (contrary to popular belief, baby poo contains similar bacterial concentrations levels to adult feces and can carry pathogens that spread disease). As I discussed previously, there is good evidence that breastmilk expressed in cleaner conditions stays safer for longer. Oh, and while you’re at it, please install chairs without arms; I don’t know what idiot decided that it’s easier to feed a baby in an armchair, but they clearly haven’t based this decision on experience. And could the sign on the door include a picture of a bottle and the International Breastfeeding Symbol, or something neutral, like a picture of a baby? 

 

I’m aware that all this may sound a little demanding. Still, installing a vending machine with bottled drinks and baby supplies might help cover some of the cost. Also, in the brave new world of online shopping that we now live in, brick-and-mortar retail is having to undergo a certain amount of reorganization; less focus on boring and functional provisioning, more emphasis on the fun and leisure aspects of shopping. Making sure that shopping is not a ghastly experience for parents is one obvious thing that malls and department stores can do to encourage parents to shop in their stores; shoppers these days expect nicer treatment as a reward for turning up. Supporting parents of all feeding styles and genders would be a win-win for everyone concerned.