January 2011: Informal sharing of milk

Check out the article in our January 2011 newsletter.

 January 2011: Media has been covering an article published in British Medical Journal “Six months of exclusive breast feeding: how good is the evidence? 

Found at: http://www.bmj.com/content/342/bmj.c5955.full

RESPONSES:

1. Randa Saadeh

World Health Organization

WHO's global public health recommendation is for infants to be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health. Thereafter, infants should be given nutritious complementary foods and continue breastfeeding up to the age of 2 years or beyond.

WHO closely follows new research findings in this area and has a process for periodically re-examining recommendations. Systematic reviews accompanied by an assessment of the quality of evidence are used to review guidelines in a process that is designed to ensure that the recommendations are based on the best available evidence and free from conflicts of interest. 

The paper in this week's BMJ is not the result of a systematic review. The latest systematic review on this issue available in the Cochrane Library was published in 2009 ("Optimal duration of exclusive breastfeeding (Review)", Kramer MS, Kakuma R.

The Cochrane Library 2009, Issue 4). It included studies in developed and developing countries and its findings are supportive of the current WHO recommendations. It found that the results of two controlled trials and 18 other studies suggest that exclusive breastfeeding (which means that the infant should have only breast milk, and no other foods or liquids) for 6 months has several advantages over exclusive breastfeeding for 3-4 months followed by mixed breastfeeding. These advantages include a lower risk of gastrointestinal infection for the baby, more rapid maternal weight loss after birth, and delayed return of menstrual periods. No reduced risks of other infections or of allergic diseases have been demonstrated. No adverse effects on growth have been documented with exclusive breastfeeding for 6 months, but a reduced level of iron has been observed in developing-country settings.

2. Comment by Adriano Cattaneo to the BMJ Rapid Response (Adriano Cattaneo is Consultant Epidemiologist and Co-ordinator of the Unit for Health Services Research and International Health, Institute of Child Health “IRCCS Burlo Garofolo”, Trieste, Italy, a WHO Collaborating Centre for Maternal and Child Health.)

The evidence provided by Fewtrell and collaborators to challenge the WHO 6-month recommendation is no better than the one provided by WHO. It is in fact slightly worse. The WHO recommendation is based on two RCTs and 16 observational studies. All the studies published after 2001 on infection, nutritional adequacy, allergy and coeliac disease, and outcomes in the longer term that Fewtrell and collaborators cite to question the 6-month policy are observational. The only two RCTs they cite are ongoing and can not be used to argue against the WHO 6-month policy. Until further evidence becomes available, I prefer to stand by the WHO recommendations (and hope the UK and Italian DoH will agree with me). Incidentally, the WHO recommendation has never been meant to apply to all infants. It is a public health recommendation to be used for national and professional policies and regulations (for example, on labelling of baby foods). Infants in fact do not wake up the day they reach six months and ask for solids!!! Readiness to eat the first solids is distributed as any other biological variable, a Bell shaped curve that in my opinion (because no research is available to know the real shape) has a mode at six months and is skewed to the right (i.e. more infants are ready after than before six months). Why don't we concentrate on physiology and neuromuscular development to advise mothers on when to start solids, instead of wandering in search of doubtful evidence? Finally, I am amazed by the rapid spread into the popular press and media of the questionable messages posted by Fewtrell and collaborators in their paper. Less than 24 hours after publication, newspapers in Italy (and I guess in UK and other countries; TV will follow suit) are already talking about a "new study" showing that exclusively breastfeeding infants to six months may be dangerous. Am I wrong if I ask the authors to make a quick public statement to transparently say that theirs is not a "new study" but just a respectable opinion based on shaky grounds?

3. From Francesco Branca - Head of Nutrition at WHO.

WHO's global public health recommendation is for infants to be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health. Thereafter, infants should be given nutritious complementary foods and continue breastfeeding up to the age of 2 years or beyond.

WHO closely follows new research findings in this area and has a process for periodically re-examining recommendations. Systematic reviews accompanied by an assessment of the quality of evidence are used to review guidelines in a process that is designed to ensure that the recommendations are based on the best available evidence and free from conflicts of interes

The paper in this week's BMJ is not the result of a systematic review. The latest systematic review on this issue available in the Cochrane Library was published in 2009 ("Optimal duration of exclusive breastfeeding (Review)", Kramer MS, Kakuma R.

The Cochrane Library 2009, Issue 4). It included studies in developed and developing countries and its findings are supportive of the current WHO recommendations. It found that the results of two controlled trials and 18 other studies suggest that exclusive breastfeeding (which means that the infant should have only breast milk, and no other foods or liquids) for 6 months has several advantages over exclusive breastfeeding for 3-4 months followed by mixed breastfeeding. These advantages include a lower risk of gastrointestinal infection for the baby, more rapid maternal weight loss after birth, and delayed return of menstrual periods. No reduced risks of other infections or of allergic diseases have been demonstrated. No adverse effects on growth have been documented with exclusive breastfeeding for 6 months, but a reduced level of iron has been observed in developing-country settings.

4. From Elisabeth Sterken, INFACT Canada

Introduction of solids is in actual fact a learing and discovery of the tastes, textures, colour and feel of food and should do little breastmilk replacement at 6 months. If infants are started on the rice starch with iron fillings and a few B vitamins the replacement of valuable breastmilk is of concern.

-5 From Patti Rundall, Baby Milk Action UK.

Bear in mind the following:

·         Three of the authors receive funding from the baby food industry (Mary Fewtrell, Alan Lucas and David Wilson)

·         This is not a report on new data.

·         The argument to introduce solids at 4 months to prevent coeliac disease and allergies was summarised by ESPGHAN in late 2009 and were considered by many to be flawed. see our press release: http://www.babymilkaction.org/press/press23dec09.html .  At present it is observational only and there are RCTs in progress; pre-empting the results of these seems foolish.

·         The UK Scientific Committee on Nutrition (SACN) and the Committee on Toxicity ( COT) are reviewing the evidence on solid foods and coeliac disease. The draft opinion is NOT FINAL BUT Is on the SACN website with the Agenda papers for next week's SMCN meeting. See paper SMCN/11/01 downloadable from http://www.sacn.gov.uk/meetings/sub_groups/maternal_child_nutrition/19012011.html

·         SACN use international growth charts to describe the optimal pattern of infant growth in the UK (UK-WHO charts). The mean age at introduction of solids to this cohort of breastfed infants was 5.4 months (or "..about 6-months").

·         The UK policy is to introduce at around 6-months and progress responsively, in line with individual babies' progress and acceptance. Not all babies need solids at the same time: in every aspect of infant development there is a wide range of normal. Very importantly the introduction of the new policy in 2003 was associated with a marked reduction in the numbers of mothers giving solids very early (i.e. before 4-months). Since almost everyone agrees that very early introduction carries greater risk (particularly of coeliac disease) the UK policy could be considered from this perspective a success.

With thanks to Betty Sterken of Infact Canada for comments 2-5..

Basically - the recommendation is exclusive breastfeeding until about 6  months. And like any guideline this was meant to be a GUIDE. There is nothing new at this point to suggest a change in this guideline.

Bisphenol (BPA) is a plastics product found in polycarbonate and is an endocrine disrutor. Polycarbonate is a clear hard plastic that is used in a multitude of products including baby bottles, breast pump equipment and the linings of food cans including formula cans. In April 2008, Health Canada announced that they were taking a number of actions to reduce exposure to BPA focusing on infants and young children.
To read more about BPA check out the Environmental Working group website and their timeline on BPA found at http://www.ewg.org/reports/bpatimeline as well as http://www.toxicnation.ca/bpaga

Keep in mind that there is alot of conflicting information available on the net - much of it from industry organizations. Check out sites for who are the members or sources of the information!

Health Canada advises...... re informal sharing or buying of human milk
Health Canada has posted a warning about the risks of acquiring human milk through the internet or other casual means. As it is not possible to screen the donor or the milk there are many unknowns which may place the recipient at risk for illness and disease.

Health Canada advises:
There is a potential risk that the milk may be contaminated with viruses such as HIV or bacteria such as Staphylococcus aureus, which can cause food poisoning. In addition, traces of substances such as prescription and non-prescription drugs can be transmitted through human milk. Improper hygiene when extracting the milk, as well as improper storage and handling, could also cause these products to spoil or be contaminated with bacteria and/or viruses that may cause illness.

Health Canada also advices consumers to check with "their health care professional should they have questions about breastfeeding or if they are considering acquiring human milk from another source."

Too bad they didn't refer people to the HMBANA website ( www.hmbana.org) for a safe option for acquiring pasteurized donor milk. HMBANA banks like BC Women's have been handling, processing, screening and distributing donor milk collectively for over 200 hundred years. There has never been a child who became seriously ill from milk received from a HMBANA banks. This is not a claim that artificial baby milk companies can make. Spread the word about the safe sources of donor milk!! We need to ensure health care professionals have the correct information.
Health Canada link 

Oh bouncing baby boy, here comes the next round in the never-ending slugfest over the health benefits of breastfeeding:

The lives of nearly 900 babies would be saved each year, along with billions of dollars, if 90 percent of U.S. women breast-fed their babies for the first six months of life, a cost analysis says. ….The findings suggest that there are hundreds of deaths and many more costly illnesses each year from health problems that breast-feeding may help prevent. These include stomach viruses, ear infections, asthma, juvenile diabetes, Sudden Infant Death Syndrome and even childhood leukemia.

That's according to an AP article, covering a new study just released by the journal Pediatrics.

I bet a lot of bottle-feeding mothers are going to read that paragraph, sigh, and think: “Great. Now I’m being blamed for billions of dollars in health care costs and 900 dead babies.”

The AP writer must have anticipated such a reaction, because she goes on to quote not one but two doctors saying we “shouldn’t be blaming mothers for this.” Then she puts the blame elsewhere: “jobs and other demands” that prevent women from breastfeeding, and “many hospitals [where] newborns are offered formula even when their mothers intend to breast-feed.” CNN’s take on the study is even more explicit in pointing its finger at an apparently unsupportive medical-industrial complex:

Bartick says moms shouldn’t be blamed, because they receive mixed messages and often lack support from the moment their babies are born. Bartick says many hospitals delay immediate urgent skin-to-skin contact between mom and baby, which can make things harder for the newborn to act on its natural instincts to suckle. Moms also need to be better educated about the importance of breastfeeding and they need adequate support after they leave the hospital in case they run into problems because the newborn isn’t properly latching on and therefore not getting enough food.

This may sound progressive, but it’s not new. It’s the standard line from breastfeeding advocates, lactation consultants, et al: Breastfeeding is a medical miracle, but we shouldn’t blame mothers who don’t manage to do it long-term, because they surely would if the corporate patriarchy weren’t preventing them from doing so.

There’s some truth in this argument. Yes, breastfeeding does have health benefits (although we could argue all day about the magnitude of those benefits, especially given how complex and multifactorial the diseases listed in this article are – breastfeeding prevents leukemia?). Yes, many hospitals do send new mothers home with formula samples, and many workplaces make it difficult or impossible to pump breast milk during the day. Yes, mothers need “adequate support” (and that doesn’t just mean a visit from the local La Leche League rep) immediately after bringing a newborn home.

But it is simply silly to argue that all women would breastfeed for six months (or a year, or even two years, as the World Health Organization recommends) if only The Man weren’t keeping them down. Some women find breastfeeding immensely painful – they get infections; they get bitten; they wind up with babies who just can’t latch properly even after multiple consults with a lactation expert. Other women want desperately to breastfeed and have all the “support” in the world that should enable them to do so, but their breasts just won’t cooperate.

I was one of these. My hospital nurses knew all about “skin-to-skin.” My baby latched perfectly. My family and friends made sure I had all the support I needed throughout my luxuriously long maternity leave. My “supply,” to use the preferred euphemism, was at first so bountiful that my hospital’s maternity support group recruited me to demonstrate breastfeeding for other new moms. I threw out the doctor-provided formula samples like so many soiled diapers.

And then, at four months, the milk dried up. My daughter’s weight fell from the 25th percentile to the seventh. She was so hungry she couldn’t sleep at night. Still, I fought putting her on formula. I spent whole days in bed, futilely trying to nurse, until our pediatrician gently told me that this wasn’t my fault, and I should stop crying, because what my baby really needed wasn’t my milk: it was me.

We gave my daughter a bottle of formula that evening – I made my husband do it, because I couldn’t – and for the first time in weeks, she slept through the night. She is 13 months old now. She has never had a stomach virus or an ear infection. If someday she develops asthma or diabetes or, God forbid, leukemia, I will of course be sad. But I won’t feel guilty, and neither should anyone else in the same situation.

I know there’s no way to convey the emotional complexity of breastfeeding in an AP article. But it would be a good start if, when writing about why some women don’t breastfeed, the standard line went something like this: Breastfeeding has some health benefits, but we shouldn’t blame mothers who don’t manage to do it long-term, because not everyone can. Sometimes that is the fault of hospitals and corporate workplaces and formula makers. And sometimes -- it may be unsatisfying to say it, but it's true -- there really is no one to blame.