Julie - Thanks very much for sending in the links about diluting
formula and feeding inappropriate substitutes. One of them was a
blog where a friend of the family was asking if it would be
appropriate to report the mother who was doing this to CPS. The
consensus was that it was. So there is one answer. If mothers
trying to breastfeed can receive threats of removal of the baby by
Social Services for not feeding a baby formula (as certainly happens
here) then a similar scenario could be envisaged for a mother who has
elected to formula-feed also not feeding the baby formula. Not, I
hasten to say, do I think we should be necessarily penalizing
mothers. But we should be protecting babies. And I do think that
mothers who choose, against all professioal advice (AAP statement
refers), to not breastfeed, should be expected to pay for it
themselves. And - if the easy option of formula being available to
all was to be withdrawn - I think that it would help to focus
healthworkers and policy-makers on their responsibility to make sure
that all mothers receive up to date assistance to breastfeed. The
stories many are sending in about mothers not knowing that Kool-Ade,
or Pepsi being unsuitable, are just astonishing.
As to mothers' rights to choose their own preferred feeding method,
there's a very interesting section starting on page 18 of the current
WHO HIV and infant feeding guidelines,
at
<http://www.who.int/child_adolescent_health/documents/9789241599535/en/index.html>http://www.who.int/child_adolescent_health/documents/9789241599535/en/index.html
The background is that from 1998 until 2009 WHO was firmly behind the
concept of encouraging HIV+ mothers to choose their own infant
feeding method, or what has been described as "a neutral presentation
of options" (sound familiar?) What interested me was how strong
the parallels were between mothers in developed countries who were
encouraged to make that choice, and HIV+ mothers in developing
countries also being encouraged to make the same choice. Both
scenarios were stated to be underpinned by human rights
considerations, although I always wondered, whose? One of the
contributors to past guidance had suggested that promotion of infant
feeding choice is only possible in a balanced state of ignorance, but
perhaps it wasn't heard very clearly. What's interesting now is the
about-face that's been taken on the issue. The experts meeting in
Geneva in 2009 took a good close look at the concept, and they came
up with this reasoning:
"In considering the implications for principles and recommendations,
the group extensively discussed why and how a focus on individual
rights is important for public health activities. It was noted that:
* Focusing on individual rights enhances the efficacy of public
health activities;
* A focus on rights also reminds public health practitioners of
their reciprocal obligations;
* Human rights principles are not barriers to essential public
health activities, but they establish boundaries and parameters.
"The group concluded that a more directive approach to counselling
about infant feeding in which practitioners make a clear
recommendation for or against breastfeeding, rather than simply
presenting different options without expressing an opinion is fully
consistent with an individual rights framework. In reaching this
conclusion, it noted that there is no single approach to counselling
and consent that is appropriate in all situations. Rather, with all
medical interventions, there is a continuum of options that is
available, with the choice among options dependent on various
contextual factors ....The group considered "What does the
'reasonable patient' want to hear?" If there is a medical consensus
in favour of a particular option, the reasonable patient would prefer
a recommendation rather than simply a neutral presentation of
options.... The group considered that this did not represent a
conflict with the individual patient's interests, either the infant's
or the mother's."
[Me again] From this, it would seem that presenting a neutral
presentation of options for infant feeding (either in or outside the
context of HIV) is no longer seen to be acceptable, at least by
WHO. From the way this is written, it would seem that there are
some ethical concerns about endorsing formula-feeding just because a
mother chooses to use it, particularly if her choice is likely to
lead to compromised infant health. Health providers have a
responsibility to promote health. To take it a step further, we could
also ask if it is ethical to provide a mother with vouchers or tins
as an inducement to formula-feed, when the reasonable patient would
want to have a clear recommendation - and help - to breastfeed?
Pamela Morrison IBCLC
Rustington, England
------------------------------
Stories on parents diluting (or overconcentrating) formula:
http://www.scientificamerican.com/blog/post.cfm?id=warning-a-little-water-can-hurt--es-2008-12-04
http://answers.yahoo.com/question/index?qid=20080801184428AAolR9p
http://www.ismp.org/consumers/Formula.asp
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