Let’s talk formula

Because someone needs to.  So here it is from me- someone who wanted to breastfeed and supports breastfeeding where reasonable, yet used and uses formula for medical reasons. Maybe that makes me a mostly neutral party. Maybe not.

First off- everything I learned about formula is self-taught or I learned from a Lactation Consultant. A good LC, on seeing that you want or need to use formula should be able to give you some pointers. Theoretically all formulas should be pretty much the same, brand name or budget. The WHO is supposed to regulate the ingredients and basic proportions. However-sometimes things are not so straightforward.

What you want out of a formula is to have it be whey based. Not casein based. You want the from birth formula. The follow-ons  marketed from age 6 months + are not as well regulated and unnecessary (though they are often cheaper…). If your child requires supplementation beyond 1 year, full fat cow milk can be given (or mixed with formula if you are concerned about diet or intake).

Cow milk is recommended because growing brains need fat. If your child does not like cow milk to drink (mine didn’t), just be sure to supplement with other high fat foods alone or in cooking. Food such as- avocado, cheese, coconut oil or cream, peanut or seed butters, butter, cream, lamb, olive oils, and so on. For extra calcium try various vegetables like kale, alfalfa, etc and fish like sardines, salmon etc.

Back to formulas. Whey or milk solids should be the first ingredient. Maltodextrin is a common additive and should be around the 3rd-5th ingredient. It is sometimes seen as the first ingredient- this is not necessary and may make your baby eat more- its a carbohydrate that is digested quickly.

If you are combination feeding you do not need any special formula. Any birth to 12 month one that suits you is fine.

This sort of thing

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Image credit

Is straight up predatory marketing. I was always ambivalent about formula companies being big and bad and preying on the breastfeeding mother, but yeah. Not after seeing that. I’m pretty sure people are eating it up too. I’d hate to be more cynical but I’d imagine that if the one on the left cost more people would be paying for that too.

Let me reiterate: You do not need anything special to combination feed. No formula is better than any other. In fact less is often more.

Some reading on safe formula use can be found here http://info.babymilkaction.org/infant_feeding/formulafeeding

Becoming a pariah: Breastfeeding’s underclass

I was a member, as previously mentioned, of a large parenting forum. I had a journal there which I started shortly after my baby was born. In that journal I documented our ups and downs with our breastfeeding issues. I’m considering how best to showcase those posts, often very raw and unhappy, on this blog. Anyhow, I titled my journal our journey with low supply as I thought that was our issue for 8-9 months. I keep digressing, but the main topic was about our struggle with low supply.

First off it made me hugely unpopular because the noisy breastfeeding advocates exclaimed that low supply was so rare and here someone was living with it, struggling with it, being public about those struggles and emotions, and apparently most aggravating, finding a way to keep breastfeeding despite it. Somehow being a successful combination feeder was a huge insult. I guess it’s easier if people fall into the breast feeder or formula feeder camps. It seems that once someone has fully gone over to not breastfeeding and they say that they did because of low supply it’s easier for those vocal people to tut and say that that wasn’t the issue. Far more difficult for them to do so to someone who has kept breastfeeding and has not managed to increase supply. Anyhow, as long as I didn’t argue the party line (all women can breastfeed; try harder!) too much I mostly got left alone; ignored even. But until I changed the title of my journal to something more general, at least three separate people came into my journal for the purpose of arguing with me about how I was wrong. I was told that if I’d been better educated, if I hadn’t doubted my abilities I would have seen that I was wrong about having low supply and I would have been a successful breast feeder. Now, at the time I tried to be nice and civil. After all they weren’t quite that blunt (ok, one person did tell me that if I’d believed I could breastfeed I would have been able to do it). People hardly talked to me in there as it was. I was trying to be sociable. But it got to me. I spent so much of that time plagued with extra doubt because of the things people were saying to me. By openly labeling myself a low supply mom, I publicly invited scorn from those breastfeeding advocates indoctrinated in the belief that 99% of women can breastfeed. One of the most hostile to me now has a blog herself (possibly one of the more hostile pro-breastfeeding blogs I’ve ever seen, not that I go looking) and is very much a ‘I did it why can’t you’ type.  I gave her latching advice and other support and she threw it in my face because after she ‘educated’ herself she decided my low supply wasn’t ‘real’.

I continued to offer advice and support to women who were also experiencing similar issues. During this time I noticed an upsetting trend. I am a member of other open breastfeeding support and information sites and networks and I saw it there as well. It was acceptable to treat women with breastfeeding issues as second class breast feeders. Talking about what problems looked like was ‘not ok’, ‘scaring women’ and the like. Those who had issues were dismissed as uneducated and failed by the system, those who succeeded were hailed with a ‘job well done’. This further glossed over what symptoms of breastfeeding issues look like. Who needs breastfeeding information and advice most? Those with issues, yet these areas are frequently dominated by passionate women with breastfeeding as their cause. Those who had issues, with pertinent advice to give, are most often relegated to the back seat while those who have overcome, or did it without too much fuss, become the first line of offense for those looking for help. The feelgood message is all very well and good, but it’s not appropriate for anyone with an issue beyond ignorance. So yes, know what a normal newborn feeding pattern is like, but also know when things are verging on abnormal and do not apply the protocols for ‘normal’ to that.

I know this is overflow from the dispelling breastfeeding myths movement. Dispelling myths is all well and good since our cultures need to relearn what normal breastfeeding looks like, but preventing knowledge of what problems look like to keep from ‘scaring’ someone hurts us all. No wonder when breastfeeding fails women feel so lost. They don’t know why or how things went wrong. There’s rarely any closure. On top of  not being able to access adequate help that is able to competently discuss the issues and come to a satisfactory resolution, you have these freaking mommy wars pushing that it was all about toughing it out. Advocates pushing that it’s all about the mother’s ability to stick with it and it becomes a spiral of what-if and if-only long after the fact.

I spent a long time feeling really bitter about how I couldn’t get any meaningful advice. Then I realized, those who had it to give had long since distanced themselves from those who only had platitudes because the self proclaimed bearers of breastfeeding wisdom feel continually justified and vindicated in what they are telling people (most of which is more or less true and nonetheless helpful and reassuring to those who are simply ignorant of what normal newborn behavior looks like), while those who have advice to give on problematic matters get shot down, belittled, accused of scaring or misleading women and other negative things. So they, though they may crave the providing of proper information and support, slowly withdraw because frankly it’s a demoralizing atmosphere. Like me. So now I’m part of the problem. At least I’m preserving my sanity.

Regret for information not had, and tears shed for the wrong reasons, are most bitter indeed.

Being better at baby friendly.

When I was pregnant I was pleased to learn that every hospital and maternity centre within reach was baby friendly. By that I mean BFHI accredited. I was pretty set on breastfeeding and I’d heard too many tales from acquaintances in the US and elsewhere who had had to fend off staff with bottles of formula, or who’d had bottles given to their babies as a matter of course. The way New Zealand implemented the BFHI has been of some interest. The number of BFHI hospitals here is much higher than in similar OECD countries. New Zealand has 72 as of 2010, or over 90% of it’s maternity hospitals, where the US has 119 , which is less than 5%, and the UK has around 52, or less than 20% of it’s hospitals.  Small country advantage, clearly.

Here’s what the BFHI is:

  1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
  2. Train all health care staff in skills necessary to implement this policy.
  3. Inform all pregnant women about the benefits and management of breastfeeding.
  4. Help mothers initiate breastfeeding within one half-hour of birth.
  5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants.
  6. Give newborn infants no food or drink other than breast milk, not even sips of water, unless medically indicated. (this is for staff)
  7. Practice rooming in – that is, allow mothers and infants to remain together 24 hours a day.
  8. Encourage breastfeeding on demand.
  9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. (this is for staff)
  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

The program also restricts use by the hospital of free formula or other infant care aides provided by formula companies. (Definition shamelessly stolen from wikipedia)

That’s all really. Now, of those 10 steps I can say I personally experienced 6,7,8 and 9. I probably would have seen 4 as well if I hadn’t been groggily recovering from my (non general anaesthesia) emergency c-section. When I was aware I wasn’t in the operating theatre and able to ask for my baby she was handed to me and I was helped.  I was also summarily helped most (but not all) of the other times I asked for help during my stay. So halvsies on number 5 then because no one ever showed me how to pump. I was also given a cartload of flyers so I guess that’s the effort for number 10 there as well. So 4 fully out of 10, with an additional 2 tacked on the end and one which probably would have been done had circumstances permitted.  The other 3, 2 really aren’t about me, they are about staff, and the third wasn’t an issue as I was already intending to breastfeed.

Why I think the BFHI is a good thing:

Those first days are important to teaching the baby how to suck from the breast appropriately. Giving bottles or soother devices when not medically indicated can cause issues like flow preference and nipple confusion which can be a challenge to overcome. I think if women do want to breastfeed they shouldn’t have to worry about what the staff are getting up to in terms of accidental sabotage.

In addition, the first few hours are regarded as critical for longer term breastfeeding success.

It does increase breastfeeding longer term rates. No question, there are many countries with success stories. If you don’t want to breastfeed you are able to bring your own feeding materials, and if you change your mind you are often not in hospital for very long. Our usual stay here is 48 hours for normal vaginal deliveries and 96 for caesarean. Complications like excess blood loss or surgical vaginal deliveries merit additional time. If you don’t want to breastfeed or suspect potential complications I’d urge anyone to get a copy of the hospital’s written infant feeding policy. Actually, probably it should be required reading for anyone giving birth, but that’s probably above and beyond what most people are interested in doing in terms of informing themselves. After all if they are BFHI they have to have one that they give to staff.

Where I think the BFHI needs work:

  • The quota system: Part of the BFHI is that to maintain the BFHI designation (and often the extra funding that goes along with it) BFH institutions must have at least a 75% breastfeeding initiation (discharge?) rate. This effectively turns front line staff into sales people selling breastfeeding to mothers to keep their institution’s funding. Can sales and support really be the same thing? I’d kind of think if you implemented the rest of the guidelines sensibly that the increased breastfeeding rates would follow without any uncompromising push from staff. Many people do actually want to breast feed. Really. But if they don’t, it’s less energy all around to just leave it. Give more flexible limits (apply the ‘quotas’ to only healthy singleton term infants, or have different quotas for mothers and infants at risk of lactation failure) to hospitals dealing in more complex cases.
  • Points 1 and 2. The staff training, which is where the implementation of the BFHI can go awry, needs better minimums or at least better standards. What goes into that staff training exactly? Is the training the same kind of overzealous lactivism that is used on women to push breastfeeding or is it something more along these lines? I find some of these scripts useful and some of them pretty objectionable.  Right now the minimum staff training for BFHI accreditation for nurses and midwives is 18 hours (I’m not clear if this is yearly or once ever), and for non nursing staff, so obstetricians, pediatricians and similar, is 3 hours (this is per year). The article referred to above (here it is again) outlines a lot of the issues with getting and keeping everyone trained. No wonder then that the result of the training seems to often turn front line care providers into walking breast is best posters. Which, you know, I’ve never seen? I did see a lot of breastfeeding posters at my various stays, but they were about gauging infant hunger cues, appropriate bodily output for the breastfed infant, signs of dehydration, and latching technique. So, more helpful things instead of useless platitudes.

I think this is the most telling quote from the article:

…specific resources and training may need to be provided for birthing centres that deal with complex cases where exclusive breastfeeding may be less likely to be achieved.

  • Point 3.  Misinterpretation of the guidelines. This is such a recognized issue I found a PubMed article about it. Being baby friendly does not disallow use of formula or information about formula. There are two main goals, one of which is to stop the free and low cost formula from being marketed to hospitals. The other is to protect breastfeeding by following the 10 steps for accreditation.  Because of the tie to certain numbers of breast feeding rates that I outlined in my first objection the guidelines are often exploited by staff.
I guess what I’m asking is if the education of front line staff  is adequate to have women’s experiences be more positive. I don’t think it is.  More interestingly, what goes on in those 3-18 hours of staff training? Is is a seminar with dire warnings about breast being best or is it something more informative, like infant stomach size marbles and spotting potential issues?
I’d imagine the 15 hour training time difference for primary support staff does have some more practical help with latching and positioning. But what about informing mothers they are at risk of lactation issues? Those with high blood losses, C-sections and similar? Gosh, what about tongue tie or IGT screening while we’re wishing? I think they must have some leanings toward that here as I had a lactation log card I was given to be filled out for feeding times and durations. I saw the writing on mine and though I dutifully filled it out my milk status was written on there for various days without having consulted me at all (colostrum, filling and full when full didn’t ever really happen). So even in fully compliant institutions there is some data fudging to get people out the door.
So, what should front line staff be taught?

Lactivism vs Feminism

I wandered into a discussion the other day about whether or not lactivists want to ban formula completely. I actually wrote this post last week, but have been putting finishing touches on it and autoscheduled it for later.

Anyhow, some of the anti-formula commenters involved in the discussion (I don’t consider being pro breastfeeding the only requirement for being a lactivist) said that no, they didn’t want to ban it completely, but they wanted it to be prescription only. I backed away before I started picking fights because I’m being a coward. But that just made me feel sick. (Not the prescription only bit, that’s old news, the banning it bit. Also, you may have had to be there.) How has lactivism come to supersede feminism? First off, some of the problems with that are that it punishes women for needing to formula feed without adding anything to help women. It assumes that formula being available causes formula feeding. Long before we had commercial infant formulas people would feed babies anything white in lieu of breast milk, so chalk dust and water for instance. Oh and then there was pap. Bread, water and flour. I’ve even seen reference to pap containing ground walnut shells. I am not kidding. Not that long ago condensed milk was given to babies. Even now there are people who dilute formula or give infants skim milk to save money. I don’t think formula is that great, but it’s pretty darn good compared to what used to be available. Sure it would be grand if there were milk banks for everyone and it was free, or cheap, and screened, but there aren’t.  So stop holding up the what if and focus on the what is.

I wish everyone wanted to and was able to breastfeed, but, fact is they don’t or can’t. Punishing formula is not the answer. Besides the fact that it’s inanimate and you can’t hurt it, limiting it hurts women. Limiting formula availability does not guarantee more available care for breastfeeding. More available care for breastfeeding does limit formula use though. Sure, they have a connection, but there are many other factors at play, foremost the education of health care providers. You know what? I fully support the Baby Friendly Hospital Initiative for promotion of breastfeeding. When properly applied. Properly applied it doesn’t limit it, it just makes it not free. Having it not be freely available in the hospital setting does more to protect women’s breastfeeding goals from poorly trained health care providers, than it limits any choices. If you know you want to formula feed, you bring it in. If you have serious issues while you are there they do provide it for you. If you don’t know before you go, then you aren’t actually in the hospital that long. I both gave birth and did my post birth recovery in BFHI centres (two separate places), and they provided water and washing supplies for formula preparation and bottle cleaning, they just didn’t provide the formula. I realize there can be issues with BFHI staff, but I’m just going to have to come down on the side of women who want to breastfeed on personal principle. I guess I’d rather have untrained health care providers being snotty than sabotaging biology.

Popular voices of the lactivist movement have little regard for the feminist movement. Erroneous lactivism wants women to have jobs that are suitable for breastfeeding, if they have jobs at all. So what about women who travel, who work unpredictable schedules on call or similar, and women who work in the field, away from spaces and facilities to pump? Are these jobs no longer suitable as women’s work? Because of breastfeeding is there again such a thing as women’s work? Is that what lactivism is currently telling us? Even women who just don’t pump well get the short end of this stick, being lesser in lactivist eyes for simply working outside the home.

I don’t like to consider myself a feminist because I don’t like associating with other self described feminists. Oddly enough those were the people that gave me the most flack when I became my households primary earner in a male dominated field. I’m certainly a postmodern feminist. I enjoy the benefits I would not have had historically, but find little issue with my modern life. I don’t like to think of myself as a lactivist either, because of the company that I’d be keeping. I certainly do have issues with breastfeeding support and education as well as access to services. I just can’t get on that bandwagon with many of those that consider themselves lactivists. In both cases, for me, its about walking the walk without talking the talk.

The ideas behind, and in truth, real lactivism is no more ‘breastfeed or else’ any more than real feminism is about the superiority of women and putting y’s in words. With both there are hangers-on to the cause that miss the point and push a different agenda. Lactivism is about breaking down barriers to women breastfeeding. Feminism is about women being equal people. The image of lactivism is now tainted by unyielding group-think much the way the image of feminism has been tainted by bra burners.

I guess that’s my new comeback for the anti-formula crowd (I’m making an effort to use the word lactivist properly, for those trying to inform and break down social barriers). Oh, so you aren’t a feminist then?