In the June, 1995 ILCA Globe, Judy Knopf asks me to explain what I meant in
a letter asking ILCA to try to keep the public health separate from the
clinical levels in its thinking. It isn't easy to give a short answer,
suggesting my thinking is not complete either, but here come some examples
and ideas anyway.

When doctors realized that a few cases of childhood diarrhea got worse if
the patient kept on eating, they began advising that food be withdrawn from
all children with diarrhea. Years later, researchers showed that for the
majority this meant only a longer period of sickness and worse nutritional
status. So now the World Health Organization recommends continued feeding
throughout diarrhea. The public health approach says not to harm the many
in order to provide special care for a few cases. (Actually it is the
weighing of cost and benefit that counts. In many countries it is
considered in the public interest to provide iron fortification to avoid
anemia in the many, although the few with genetic hemochromatosis may be
hurt by it.)

In the March 18, 1995 issue of Lancet, my wife Stina Almroth writes that it
was a mistake to push oral rehydration salts for home management of
diarrhea. Many women make it too concentrated and actually speed up the
progression toward dehydration. Most fluids and foods already present in
the home would work fine to prevent dehydration in the early stages of
diarrhea, and no one makes them too salty. In Lesotho in Africa, she found
that ORS fit into the existing traditional category for drugs (like herbal
teas) that are given for long periods of time, so young babies get water
with a bit of salt and sugar for weeks or months at a time, not just when
they are suffering from diarrhea, further reducing how much exclusive
breastfeeding is practiced. Thus a seemingly useful public health approach
is probably on the whole doing harm compared to a simpler approach based on
respect for what people already do and already know.

In my editorial on breastfeeding and maternal employment in JHL 9(4):214-5,
1993, I write that the "flexisy-going' side of
breastfeeding gets far too little attention." Virginia Phillips of
Australia wrote to me and said "amen," that this is what she believes
explains cases when grandmothers and others are able to relactate and
breast feed orphaned relatives. Often such women were not even intending to
"get milk." It just "came on its own."

I am myself no expert on (here I have to brace myself to get my fingers to
type the words) "lactation management." But I wonder if we know how
important and how easily lost this easygoing aspect of breastfeeding is.
Some osomething one has to get educated about?

Here in Sweden, those who work with breastfeeding, both in woman to woman
support groups and in hospital settings, tell me they do not feel the need
to intervene, to touch a woman's breasts, to show her what toy have not noticed any cases like the ones
spread throughout the US mass media, though rare ones might well exist.
Here most breastfeeding experts seem to feel there might be something
subtle but important lost if breastfeeding has to join the many aspects of
Swedish life that are guided, informed and boxed in with rules.

On an individual basis, anything goes. I'm sure there are rare cases in
which, all things considered, no breastfeeding at all is the best option
for mother and baby. But I'm sure we'd all agree not to advertise what
those conditions might be so thy identify the 1994 surge of rule-making as the blow that
once again brought down breastfeeding rates in the US (or slowed the
progress made by the "real" BFHI, ILCA, etc.).

Ted Greiner, PhD
Senior Lecturer in International Nutrition
Unit for International Child Health, Entrance 11
Uppsala University
751 85 Uppsala
Sweden

phone +46 - 18 515198
fax   +46 - 18 515380

home phone +46 - 8 191397 (can be used as fax also)