LACTNET Archives

Lactation Information and Discussion

LACTNET@COMMUNITY.LSOFT.COM

Options: Use Forum View

Use Monospaced Font
Show Text Part by Default
Show All Mail Headers

Message: [<< First] [< Prev] [Next >] [Last >>]
Topic: [<< First] [< Prev] [Next >] [Last >>]
Author: [<< First] [< Prev] [Next >] [Last >>]

Print Reply
Subject:
From:
Pamela Morrison <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Sun, 22 Nov 2009 10:36:44 +0000
Content-Type:
text/plain
Parts/Attachments:
text/plain (184 lines)
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

              ***********************************************

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome

ATOM RSS1 RSS2