On 10/05/2012 18:10, Nikki Lee wrote:
> Dear Lactnet Friends:
>
> "Because the reality is that many babies, for whatever reason, are going to
> be fed either completely or partially on formula ...."
>
> If we who are the world's breastfeeding guides and therapists, espouse the
> belief that formula is ubiquitous, breastfeeding can not advance.
Aiming for a better future as soon as we can bring it about doesn't
exclude recognising the reality of the present and of the imminent
future. Formula *is* ubiquitous. Of course we want to change that, and
of course we *plan* to change it, but it would be rather ostrich-like to
refuse to recognise that that isn't going to happen at any time in the
immediately foreseeable future. So, yes, I stand by my statement -
there is, currently and for the foreseeable future, an important role
for specialists in infant nutrition to oversee the quality of that
product, and it is therefore quite ethical and appropriate behaviour for
such a specialist to choose to take up such a role. (To answer another
post on the subject from yesterday, I entirely agree that this should
not slip over into a promotional role.)
As for milk sharing... OK, here is where I recognise my viewpoint is
going to get controversial. I think there are two important problems
with milk sharing to bear in mind.
Firstly, human milk that has been pasteurised, frozen, stored,
defrosted, stored for a few hours further, and then fed from a bottle is
likely to be fairly different from human milk fresh from the source in
terms of outcomes for infants. Some of the immune factors will have been
destroyed by the pasteurisation and freezing process, and any storage
outside the body will allow at least some chance for bacterial
multiplication, so the differences in infection rates between donor
milk-fed babies and FF babies will likely be less than the differences
between directly breastfed babies and formula-fed babies. Without the
sucking action at the breast itself, we won't get the benefits in terms
of improved dentition and possibly otitis media reduction. And, as yet,
we don't really seem to have anything much in the way of research on
outcomes of donor milk feeding outside relatively uncommon situations
such as premature NICU babies. So, as far as I can see, we don't
actually know how donor milk and formula would compare in terms of
outcomes on a more population-wide basis. Although I would expect that
donor milk will probably still turn out to have advantages over formula,
I would expect those advantages to be rather smaller than those shown in
studies comparing breastfeeding with formula.
Secondly, the need for screening, processing, and refrigeration of human
milk mean that it's currently orders of magnitude more expensive than
formula and presents practical difficulties in distribution to boot.
I've no doubt there's scope to improve things considerably on that
score, but I doubt it would be possible to remove those difficulties
entirely. (And, again for practical reasons, I think the direct 'wet
nurse' option is never going to be that common a solution.)
The combination of both those problems means that, before rolling out
the kind of widespread milk donation programme you describe, we really
ought to know a great deal more than we currently do about how the
benefits and costs of donor milk actually stack up in practice on a
population-wide basis. The question isn't just whether donor milk is
still going to turn out to be better than formula feeding - we also run
up against an issue that I believe is known as 'opportunity cost',
namely, the fact that there are always going to be a number of possible
beneficial ways that the resources under consideration (in both money
and time) could be spent, and that we need to consider whether this is
actually going to be the most beneficial possible use. I just don't
think we can or should assume that that will be the case.
Finally, even given a best-case scenario with milk donation - that we do
eventually discover ways of making the processing and storage much
cheaper without sacrificing safety, that we also find that the benefits
of donor milk are close enough to those of breast milk to make it worth
rolling out a much more universal milk donation programme, and we have
enough willing mothers without health contraindications to supply those
who can't or don't wish to breastfeed - there are still going to be rare
scenarios such as babies with severe multiple food allergies where donor
milk would only be possible in situations where the parents can find
accessible donors on the appropriate exclusion diet, or babies with
metabolic problems such as galactosaemia. Or, for that matter, much
more prosaic situations that you wouldn't necessarily think of when
thinking of all the reasons why a baby might end up getting some formula
- such as my own daughter, who became very distressed on giving EBM when
I was at work and was much happier getting formula (we theorised that
the EBM might just have been too tantalising a reminder of the important
person in her life who wasn't there right then). No matter how
widespread the milk donation programme eventually becomes, I don't think
it will ever totally get rid of the requirement for formula in some
situations. So, I stand by my initial statement - I want to know that,
when that formula is used, it's as good-quality a product as is
possible, and, for that reason, I think it entirely ethically
appropriate for HCPs with specialist knowledge of infant nutritional
needs to work in the quality control area of formula production.
Best wishes,
Dr Sarah Vaughan
MBChB MRCGP
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