In response to:
<<Showing a movie about bottle-feeding is one form of promotion,>>

Nikki said:
<<I wonder about this. I teach all the healthcare providers I work with
about paced bottle-feeding, in my breastfeeding training. All the healthcare
providers I offer my classes to with [will?] have clients that feed their
babies via bottles.
 
<<What's the difference between education and promotion? Lactation
professionals frequently have clients using bottles as a step in
breastfeeding  recovery; it is important for the parenting relationship and
the infant's ease of feeding if folks understand how to bottle-feed well. I
am not identifying any particular brand or style, nor endorsing nor
promoting.>>

Here's my comment:
I support Nikki in teaching paced bottle feeding to classes of healthcare
professionals.

I think Linda Smith's distinction between "normalized bottle feeding" and
"therapeutic bottle feeding" is one key point in this discussion. 

Another key distinction is the target audience of the teaching, whether it
is health care professionals or parents, and whether it is parents
individually, whose baby-for whatever reason-is unable to obtain good
nutrition through breastfeeding, or parents in groups who may be planning to
use bottles for reasons that we don't approve (convenience, casual
mother-baby separation, so dad or grandma can bond with the baby, etc.).
(For this last group, see the "poser" at the end of this message.)

The International Code itself was a hard-fought compromise document. Formula
companies were part of the discussion, and back in 1979-1981, pumping as a
substitute for breastfeeding by a healthy mother and baby was rare. Thus the
Code does not give us clear guidance in 2007 on the subject of our
responsibility regarding bottle feeding of human milk. However, if we
interpret the Code broadly, I think we can find some guidance.

Remember, though, that commercial infant feeding interests might prefer to
interpret the Code narrowly.

I've trolled through the dozen subsequent resolutions by WHA without seeing
that feeding bottles and teats were specifically addressed in most of them.
The main focus of the Code and the subsequent resolutions is on what's IN
the bottle, not on how using bottles and teats themselves can interfere with
breastfeeding, either directly, by affecting mother's lactation and/or
baby's suckling skills, or indirectly, by changing perceptions and attitudes
of the mother and/or of caregivers, family members, and the community-in
short, by "normalizing" bottle feeding.

* The Code clearly states in Article 1 that it concerns "the provision of
safe and adequate nutrition for infants...by ensuring the proper use of
breastmilk substitutes, when these are necessary, on the basis of adequate
information..." 

To me, "proper use" would include feeding techniques along with correct
measuring and mixing of formula and hygienic concerns about safe water,
sterilization, hand-washing, etc. "Safe and adequate nutrition for infants"
means ALL babies, even babies whose mothers do not breastfeed them. 

* Article 2 lists feeding bottles and teats among the items that are covered
by the Code, and says that it applies to "marketing, and practices related
thereto, [and]... also applies to their quality and availability, and to
information concerning their use."

To me, "quality" refers to design as well as to manufacturing standards. Are
the bottle and teat design based on the physiology of baby's
suck-swallow-breathe? Is the teat design based on the interaction of baby's
mouth and tongue with mother's breast? I have long suspected that feeding
bottles and teats are NOT designed to preserve breastfeeding skills, but I
would be happy to be proved wrong!

This is one area where I wish that "scientific and factual" materials were
provided to health workers, so we would know what bottles and teats (if any)
really ARE best for therapeutic feeding of babies.

"Information concerning their use" surely includes paced bottle feeding and
other topics, such as protecting baby's airway during bottle feeding, and
avoiding over-feeding or under-feeding.

* Article 4.2 is about "informational and educational materials" for
mothers, "whether written, audio, or visual..." These must include
information on "the negative effect on breastfeeding of introducing partial
bottle feeding," and, "where needed, the proper use of infant formula,
whether manufactured industrially or home prepared." Also, if formula is
discussed, there must be information on "the health hazards of inappropriate
foods or feeding methods..."

Finally, Article 6.5 says, that "feeding with infant formula, whether
manufactured or home prepared, should be demonstrated only by health
workers, or other community workers if necessary; and only to the mothers or
family members who need to use it; and the information given should include
a clear explanation of the hazards of improper use."

I think we've all seen bottle feeding techniques that we would describe as
"inappropriate feeding methods." Were the original drafters of the Code
thinking of lonely babies with propped bottles? hands-off feeding devices? a
baby in a car seat sucking a bottle held by a distracted parent with no eye
contact? growing premies force-fed with scheduled bottles and quantities so
they can reach discharge weight sooner? the hospital nurses' bottle
technique someone has described as the "Deep Throat, gag and vomit school of
feeding"? There is lots of need for someone to teach better methods of
bottle feeding. The question is, who should teach them, and to whom?

What I conclude, after this morning's look at the Code, is that teaching a
group of health professionals about safe bottle feeding is OK, and teaching
individual parents "therapeutic bottle feeding" as part of a transition to
breastfeeding, when their baby has a feeding problem, is OK. But I am left
wondering what, if anything, the lactation community should be teaching
ordinary parents about bottle feeding. 

I am reminded of the sex education controversy in the USA, where some people
support teaching young people "abstinence only" and others support teaching
them about contraceptives, saying that not everyone will abstain from sex
until marriage, and those who do not should know how to protect themselves
from pregnancy and STDs (sexually transmitted diseases). 

So.here is a "poser" for you. Exclusive breastfeeding is the gold standard,
but for a variety of reasons, not all mothers will meet that standard.
Should we refrain from teaching them about the safest possible alternatives
to exclusive breastfeeding? or should we leave women to learn from their
peers and their parents, from trial-and-error with commercial products, and
from marketing materials produced by non-Code-compliant companies? 

What do you think?

Chris Mulford

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