Hi 
  
A code is always more than just guidance and therefore represents an 'ideal condition' and rightly so. To achieve the ideal means adhering to the code. In the less conducive environment; which is most often the case, even striving to achieve will not amount to non adherence or violation of code. We are just dealing with exceptions and alloing a bottle to be used in order to protect the nutritional aspect of breastfeeding. But to alter the code to include parameters which are many a times practical (like you have mentioned working with many mother who either did not want to breastfeed or could not breastfeed managing to feed their babies breast milk using bottles/teats) and more contemporary prevalence will run the risk of making is more lenient or less ideal in my perspective. Although, it may be true that using of bottles and teats may not be the actual deterrent and what goes into the bottle should be more important, aren’t we missing a BIG
 point here breastfeeding as a process can never be the same as breast milk feeding.
 
While the nutritional aspect of breast milk does get satisfied to large extend to mothers who plan to work and managing to a breast milk feed a baby I fear and wont be surprised when a time might come when breast milk might also be available off the shelf and being the BEST food for baby many might even become the ‘second’ formula in the world. The attitudinal change can be phenomenal. We will be comprising what BEST food means here - bonding, closeness, love, warmth and so many aspects of human relations which is what makes Breastfeeding much much more than just a means and mode of delivery of breast milk to a baby.
 
Besides, in a country like India, you may not be surprised to see a unsterilized, unclean bottle being filled with plain tap water mixed with some left over formula from garbage and stirred with unclean finger and this being fed to babies so therefore the risks of use of bottles/teats cannot be undermined especially when the control of use of such practices is a difficult undertaking.
 
All this with the present code, imagine the situation if the code has to include bottles and teats!!
 
Take Care
 
Effath Yasmin, LLLL 
Mumbai, India




________________________________
From: Pamela Morrison <[log in to unmask]>
To: [log in to unmask]
Sent: Sun, 22 November, 2009 16:06:44
Subject: WHO code again ...(long)

Hi Marianne

I love the way you're being so persistent in your attempts to maintain ethical principles within your local organizations!  And I note your efforts lately to clarify whether we need to support breastmilk, the product, or breastfeeding, the process, and how this question fits in with the Code.

I've been having some thoughts about this too, in the last few months.  As background, first let me say that I'm a big fan of the principles of the Code.  I was involved in formulation of a national Code in Zimbabwe and it was passed as law in parliament in 1998, and fully implemented in 2000.  It was fabulous to have such legislation to fall back on when hospital practices might undermine breastfeeding (rare) or when marketing of products falling under the scope of the Code hit you in the eye in shops and supermarkets, doctors surgeries etc (common).

However, the recent furore over marketing of certain breastpumps that include bottles and teats in their advertising makes me distinctly uncomfortable.  I worked in an environment where breastfeeding was aggressively protected and promoted, free formula was not available in hospitals for healthy babies, and bottles and teats were absolutely prohibited - if formula was medically indicated, it was fed via nasogastric tube, or by cup.  At the same time, in the early Nineties breastpumps were simply not available either, and I worked with many cases where lactation failed when engorgement had become so severe that hand-expression simply did not work, or didn't work fast enough.  As time went on, pumps started to be imported, and mothers who felt ambiguous about breastfeeding (without exception, all non-African mothers) would start off breastfeeding or breastmilk-feeding-by cup/spoon in the hospital because they had to, and then often switch to
 breastmilk-feeding by bottle after a week or so at home.  Some could later be persuaded to give breastfeeding a try, and I've worked with many babies who'd been almost exclusively breastmilk-fed-by-bottle for several weeks, who subsequently simply latched easily to the breast and went on to breastfeed without incident as if they'd never been exposed to a bottle-teat.  At first I wouldn't have believed it if I hadn't seen it, but after a while I realized that _bottles/teats are not the problem_!!  However, I also worked with many, many mothers who could never be persuaded to breastfeed direct, and seen their faces light up to realize that they could still give their babies the "best" milk, for as long as they wanted, by breastmilk-feeding-by-bottle - in those cases they were eager to know how it could be achieved, and many, many of them proudly exclusively "breastfed" their babies in this way for weeks, months and even years, and I helped them in the
 knowledge that the method of delivery might not have been ideal, but the alternative would have been formula.

Now that I live/work in UK where, clearly, bottle-feeding of formula is the norm, I begin to understand the paranoia about bottles and teats, even as I _can't_ reconcile myself to the easy-going acceptance of handouts of free formula in hospitals and the community to "poor" mothers who might otherwise (it is commonly believed) feed their babies any inappropriate liquid rather than breastfeed.  Where I come from, the poverty has to be seen to be believed, and it's a fact of life that mothers who can't afford to buy formula themselves (and fuel, bottles, sterilizing equipment) have to breastfeed or risk killing their babies, so a certain measure of responsibility is placed on mothers, rather than on governments, for keeping their babies alive and healthy - and this feels "right" to me.  In fact, I think that the necessity to actively support maternal choice about breastfeeding or formula-feeding places LCs in the really poor ethical position of having to
 endorse a baby-milk that is known to be harmful in a situation where it is rarely medically necessary.  We usually refer to this as the breast/bottle question, but really it's not - it's what goes _in_ the bottle that matters.  Could it be that it's the jargon used over the years, the so-called "breast/bottle controversy" which is muddying the waters?

To ask what the Code intended is a Very Good Question, Marianne!    Should the Code that was drafted to meet the marketing strategies employed by industry in the 1970s still be endorsed nearly forty years on, in a world that has changed beyond what was ever envisaged at that time?  For instance, breast pumps available in 1981 were so inefficient as to be virtually useless, and - presumably not being seen as a threat to breastfeeding - were not included in the provisions of the Code.  Yet in 2009 pump manufacturers that include bottles and teats in their literature have been tarred with the same brush as formula manufacturers - to provoke an ethical dilemma keenly felt by IBCLCs today.  In 1981 the marketing of "bottles and teats" was seen as harmful, since bottles and teats were almost exclusively used to feed formula. But in 2009, IBCLCs use and sell and breast pumps, and the bottles and teats which are often sold with them, to aid
 breastmilk-feeding for babies who are compromised (prem/sick babies) or whose mothers choose to or are forced to be separated from them (eg millions of working mothers) - thus protecting, promoting and preserving the use of breastmilk itself over breastmilk substitutes.  Supplementing with milk (either EBM or ABM) is often temporarily medically necessary to protect the nutrition of babies whose mothers have suffered partial or total lactation failure (I agree that a miniscule percentage is inherently necessary, but in the industrialized countries we work daily with a damaged infant feeding culture).  Importantly, cup-feeding is not entirely benign, yet we have little research to support the WHO recommendation that all supplements and replacements for breastfeeding should be fed by cup, nor to show the consequences of lack of sucking opportunities for exclusively cup-fed babies, which are anecdotally reported to be profound.

So how is the existing Code being interpreted?  Even as we're enforcing adherence to the Code in the matter of bottles and teats to the extent that we're actually harming the provision of mother's milk as the normal food for infants, we're turning a blind eye to the irrational wholesale use of breastmilk substitutes by hospitals, governments, international aid agencies under the guise of fulfilment of human rights, inadvertently contributing to the profits generated by breastmilk substitute manufacturers.  Would it not make sense to look at the research undertaken since the Code was published, and to include that evidence base in current recommendations for breastfeeding promotion, protection and support in the new millenium?  Where is the evidence to show that the use bottles and teats to feed babies breastmilk really undermines breastfeeding?  Is it the use of bottles and teats per se, or is it the contents of the bottles that cause the major
 negative effects on the health and well-being of babies and the adults they will become?  I know we have Brian Palmer's and others' research about the process itself, but is cup-feeding of breastmilk ultimately "better" than bottle-feeding of breastmilk where breastfeeding itself is not possible or not chosen.  Do we need to re-examine whether a mother who can't/wont breastfeed should be helped to bottle-feed EBM without it being condemned as a Code violation?  Do we need to do more marketing of breastmilk, as a way to celebrate the product and increase number of mothers who might use it compared to those who currently opt for formula?  In order to do that, we'll need get over our current attitudes towards bottles.  We may need to re-visit the appropriate use and feeding of expressed breastmilk and take a close look at all the methods used to feed any milks to infants - what is rational, what is appropriate, what is the difference between use and
 abuse?

So I'd like to thank you, Marianne, for being so persistent in your quest for answers.  I've felt increasingly over the last few months that it might be time to revisit the ethical responsibility of IBCLCs to uphold our interpretation of the provisions of a Code that was conceived nearly 40 years ago for a world that was vastly different at the time it was developed - to place the dilemmas for IBCLCs in policy, practice, politics and research-based evidence (or lack of it) under closer scrutiny?  Let's all talk about this some more!

Pamela Morrison IBCLC
Rustington, England
------------------------------------------------
Date:    Sat, 21 Nov 2009 15:44:34 +0100
From:    Marianne Vanderveen-Kolkena <[log in to unmask]>
Subject: WHO-code, again...

Hi all,

Is there a way to conclude beyond reasonable doubt that the WHO-code meant to protect either *breastfeeding* or *breastmilk feeding* (= pumping and feeding otherwise)?
Or did the Code just not really think of breastmilk feeding, because it was not as common then as it is now? Or put in a different way: are bottles in the Code because they might cause suck confusion or because they undermine the process (as opposed to undermining the product) or for different reasons or for all reasons combined? Why are the bottles justifiably in the Code? (Don't convince me... I'm with you! ;-))
We are getting deeper and deeper into the discussion and I seem to be more and more on my own and regarded a rebel, when I state the Code first and foremost, even in 1981, meant to protect, promote and support the process and that integrally respecting the Code also means standing up for the process... Is there proof for that idea in the Code itself?
Any thoughts?

Warmly,

Marianne Vanderveen IBCLC, Netherlands

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