Breast Whisperers and Milk Maids

Image from the Canadian Breastfeeding Foundation

I came across 2 recent (and 1 older) articles focusing on lactation consultants/breastfeeding counselors who help moms breastfeed.

First up was that of Zeny Feliciano, with an article from the Philippine Inquirer entitled "Milk Maid". Zeny is a breastfeeding coach who also conducts classes with Cher at Organics Asia. I personally have not met Zeny but I do read about her experiences working with new moms. (Update: I have received comments from several moms about negative experiences with Zeny. Please email me for details.)  I did meet her trainer, Lita Nery who is also a breastfeeding coach and does lactation massages.  (Edit: Per Ms. Lita Nery, she never trained Zeny.)

A few days later I read about the Breast Whisperer from New York, Freda Rosenfeld, a certified lactation consultant who has seen 2,000 moms (wow!). Like Zeny, she visits moms at home and helps them, coaches them and teaches the moms and their babies how to achieve that perfect latch. She also identifies other problems which may have led to the difficulty in breastfeeding. What I like about Ms. Rosenfeld is her credo: Rule 1, enjoy the baby. Rule 2, feed the baby.

Freda reminded me of Pat Shelley from Washington DC. Like Freda, Pat is an IBCLC counselor who was also the subject of a similar "breast whisperer" article in 2008. She runs the Breastfeeding Center for Greater Washington, a non-profit office which regularly conducts free breastfeeding classes and also does for-pay home or office one-on-one visits and consults. While pregnant with Naima, I signed up for and attended their free breastpump basics and free breastfeeding classes. The classes were about 1.5 hours and usually scheduled during lunch time. During the breast pump class, Pat Shelley even got one of the pumping moms to show how to hand-express milk!

Aside from classes, when you sign up for their emails, the Center also regularly sends helpful emails depending on your child's age e.g. meeting babies' needs for the 1st 6 months, starting solids, vitamin D and the breastfed baby, weaning. They also have photo fundraisers and maintain a shop with breastfeeding supplies at their office. They are currently working on referral book project which compiles recommendations for post partum support groups, breastfeeding friendly breast surgeons, oral-motor specialists, cranial-sacral therapists, and physicians and midwives who prescribe domperidone and oxytocin nasal spray and pharmacists that will offer them.

Locally, there are other breastfeeding support groups/resources that new moms can refer to, aside from Zeny. However, I don't think we have a group that offers comprehensive services and classes such as that of the Breastfeeding Center. It would be interesting to learn from the breast whisperers and develop similar programs and services for the Pinoy moms.

Medical Reasons for Breast Milk Substitutes

During the breastfeeding classes I've attended and conducted, it is always emphasized that from birth to six months, exclusive breastfeeding is best for babies, unless there medical reasons prescribing otherwise.

These “medical reasons” vary though from doctor to doctor, with some doctors even saying that moms who underwent caesarian births cannot breastfeed for x number of days!

In 2009, the World Health Organization and UNICEF released a 12-page publication entitled “Acceptable medical reasons for use of breast-milk substitutes”. According to WHO and the UNICEF, they first developed a list of medical reasons for supplementation in 1992, as an annex to the Baby-friendly Hospital Initiative tool package.

With new and emerging scientific evidence, WHO and UNICEF agreed to update the list with the participation of the departments of Child and Adolescent Health and Development and Nutrition for Health and Development. Other additional evidence sources used were (1) The Drugs and Lactation Database, a peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed, hosted by the United States National Library of Medicine; and (2) The National Clinical Guidelines for the management of drug use during pregnancy, birth and early development years of the newborn, review of which was done by the New South Wales Department of Health, Australia in 2006.

The WHO and UNICEF posit that only a small number of health conditions of the infant or the mother may justify temporary or permanent cessation of breastfeeding. Further, these conditions concern very few mothers and infants. In recommending the cessation of breastfeeding, the WHO and UNICEF mandates that the benefits of breastfeeding should be weighed against the risks posed by the presence of the listed conditions.

The following are the conditions for infants not to receive breast milk or any other milk except specialized formula:
1. infants with classic galactosemia (a special galactose-free formula is needed) – a rare genetic metabolic disorder that affects an individual’s ability to metabolize the sugar galactose (one of the components of lactose) properly
2. infants with maple syrup urine disease (an inherited disorder in which the body is unable to process certain amino acids or protein building blocks properly. If untreated, this leads to severe brain damage and death) – special formula free of leucine, isoleucine and valine is needed
3. infants with phenylketonuria (a genetic disorder that is characterized by an inability of the body to utilize the essential amino acid, phenylalanine) - a special phenylalanine-free formula is needed – some breastfeeding is possible, under careful monitoring

For all other infants, breastfeeding is best although the following infants may need other food aside from breast milk for a limited period:

1. a. infants with very low birth weight – weighing less than 1500g
2. b. infants born too early – at less than 32 weeks of gestational age
3. c. newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand, if their blood sugar fails to respond to optimal breastfeeding or breast-milk feeding

• preterm
• small for gestational age
• have experienced significant intrapartum hypoxic/ischaemic stress
• those who are ill
• infants with diabetic mothers

Just because a baby is premature, it does not mean that s/he should be given formula or any other fortifier (like Cell Life a.k.a. spirulina). WHO/UNICEF listed above specific instances when fortifiers are necessary.

As for maternal conditions that may justify permanent avoidance of breastfeeding, only one is listed – HIV infection, only if replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS). WHO/UNICEF however recognizes that the most appropriate infant feeding option for an HIV-infected mother depends on individual circumstances – mother’s health status, health services available and most importantly whether there is replacement feeding AFASS.

Certain conditions justify the temporary avoidance of breastfeeding, such as severe illness that prevents a mother from caring of her infant (e.g. sepsis), herpes simplex virus-1, certain maternal medication (sedating psychotherapeutic drugs, anti-epileptic drugs, opioids, radioactive iodine-131, excessive use of topical iodine or iodophors (povodine-iodine), cytotoxic chemotherapy.

Meanwhile, the publication lists down certain conditions wherein breastfeeding can still continue, although health problems may be of a concern, namely: breast abscess, hepatitis B, hepatitis C, mastitis, tuberculosis, substance abuse. I highly recommend that you peruse the short publication to read the details on these conditions.

Clearly, there is a limited number of conditions for both infants and mothers to recommend the cessation of breastfeeding. I would definitely recommend that pregnant moms to read this WHO/UNICEF publication so they will be informed and know what questions to ask their pediatricians and ob-gynes. And if your doctor gets irritated when you ask questions, then I believe that it is time to look for a new medical provider.

Hierarchy of Infant Feeding Choices

Two days ago, I received a text message from R, a nursing mom I previously counselled. She was very worried with the amount of milk she stored for her baby. Apparently, her baby was drinking more milk that she could express at work. She was already down to about 12oz. which was less than what her baby drinks while she was at the office.

R's baby just recently turned 6 months but did not start solids yet. Her baby's pediatrician had already given the go-signal for them to start solids but she was still hesitant unsure what to feed her baby. I suggested that at 6 months, her baby could already start solids and referred her to my previous post. However, this does not mean that her baby's milk feedings will decrease. Until 1 year old, babies still need to get their primary nutrition from milk while solids are only for complementary feedings.

R did not want to give her baby formula so she asked if she could give water or dilute her breastmilk with water instead. I was reminded of the hierarchy of infant feeding choices which the World Health Organization established, in paragraphs 18-19 of the WHO's Global Strategy for Infant and Young Feeding:

The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother’s milk be considered unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances.

For infants who do not receive breast milk, feeding with a suitable breast-milk substitute – for example an infant formula prepared in accordance with applicable Codex Alimentarius standards, or a home-prepared formula with micronutrient supplements – should be demonstrated only by health workers, or other community workers if necessary, and only to the mothers and other family members who need to use it; and the information given should include adequate instructions for appropriate preparation and the health hazards of inappropriate preparation and use. Infants who are not breastfed, for whatever reason, should receive special attention from the health and social welfare system since they constitute a risk group.

As summarized by IBCLC Diane Wiessinger, the hierarchy is (1) breastfeeding; (2) mother's own milk expressed and given to her child in some other way; (3) milk of another human mother; and (4) artificial milk feed.

For premature babies, a publication entitled "Global health policies that support use of banked donor human milk: a human rights issue" authored by Lois DW Arnold presents a further classification within the hierarchy - between premature mother's milk vs. mother's milk and premature artificial milk feed vs. regular artificial milk feed, as can be seen from the author's diagram reproduced below:

Clearly, for both full-term and premature babies, water is not a safe option for feeding your baby. Water is included as an option only for infant feeding during emergencies.

The choice of donated breast milk is also a difficult subject. The American Academy of Pediatricians frowns upon using unpasteurized donated milk and recommends only using pasteurized milk from human milk banks.

In the Philippines, we are not too particular and although I know some pediatricians who would prefer to use pasteurized human milk, for some moms this is just not an option. I only know of 3 pasteurizers in our country and these pastuerizers do not run until the milk banks receive enough donated milk to operate the pasteurizers at full capacity. I myself have donated to moms and babies who come by my place to pick up my frozen unpasteurized milk.

When donated milk is not available, I believe that formula would be the remaining option. Some lactivists might disagree with me but I believe that formula is not at all evil. Diluting your breastmilk or giving your baby water is WORSE than giving your baby formula milk. If you are faced with this choice, call your pediatrician and ask what formula to give your baby. Then don't beat yourself up about it - stressing about the one bottle won't help you. Work extra hard to bring your supply back up so you can get rid of the artificial milk feeds.

Yay! I'm on someone's list

Just received an email from Amanda Quraishi, social media manager at UpSpring Baby, that this blog was included in their list of Top Ten Best Breastfeeding Blogs. Wow!! I'm flattered. This is the first time that I've been included in someone's list :)

UpSpring Baby is a US-company that distributes MilkScreen, Walking Wings and Shrinkx Hips. They also maintain a blog where they talk about various topics on parenting, child care and their products.

Other bloggers included in their list who I follow would be Melodie of Breastfeeding Moms Unite and Tanya of Motherwear Breastfeeding Blog.

I started this blog, intending it to be a space where I can store breastfeeding information that I can refer back to in the course of my breastfeeding career. It's becoming more useful now that my sister just started nursing and she can likewise read through the resources I've compiled. I'm also always happy and excited to read comments from my fellow moms who say that my blog has been helpful in their own breastfeeding journey.

Thanks to UpSpring Baby for the recognition :)

More Baby Blues

I really enjoy checking out Baby Blues - more so when they feature breastfeeding!

Wednesday, 10 February 2010

I previously posted a compilation of Baby Blues strips on breastfeeding in April 2009 and again in July 2009. Although this strip is mainly about homeschooling, if you look closely, you can see Wren nursing. I really don't think I can handle homeschooling Naima and I really admire parents with the patience and dedication to homeschool their kids! :)

Update 7/19/2010

Here's another Baby Blues Breastfeeding sighting.

Check out little Wren still nursing

World Breastfeeding Week 2010

Thanks to Claire for the heads-up! World Breastfeeding Week just released their theme for 2010: "Breastfeeding Just 10 Steps! The Baby Friendly Way". I checked their website but only the calendar is available for download.

In Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services (a joint WHO/UNICEF statement published by the World Health Organization), ten steps are identified for succesful breastfeeding, which each facility providing maternity services and care, ideally should adopt. These are:

• Have a written breastfeeding policy that is routinely communicated to all health care staff.
• Train all health care staff in skills necessary to implement this policy.
• Inform all pregnant women about the benefits and management of breastfeeding.
• Help mothers initiate breastfeeding within half an hour of birth.
• Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
• Give newborn infants no food or drink other than breast milk, unless medically indicated.
• Practise rooming-in - that is, allow mothers and infants to remain together - 24 hours a day.
• Encourage breastfeeding on demand.
• Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
• Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

The World Alliance for Breastfeeding Action (WABA) has seen it appropriate to revisit the ten steps issued by the WHO in 1989 due to reports of "lack of commitment, deteriorating hospital practices, and inadequate training of health workers to counsel mothers." Although more than 20,000 maternities, or about 28% of all maternities in the world, have fully implemented the Ten Steps and have been certified by the Baby-friendly Hospital Initiative (BFHI), reduced BFHI programming worldwide, inadequate training, and weakened compliance with the Ten Steps in accredited maternities are contributing to stagnant or declining exclusive breastfeeding rates in many settings.

World Breastfeeding Week 2010 also commemorates the 20th anniversary of the Innocenti Declaration that called for implementation of the Ten Steps in all maternity facilities. The Innocenti Delcaration was produced and adopted during the WHO/UNICEF policymakers' meeting on "Breastfeeding in the 1990s: a Global Initiative" held in Italy in 1990.

Among the objectives of this year's World Breastfeeding Week which I find particularly important would be: To ensure that health workers who care for mothers and babies are adequately trained to counsel and support them in optimal infant feeding. My recent experience with a Metro Manila hospital on breastfeeding wasn't too good.

Another objective which I think is also particularly important is "to inform people everywhere that protection, promotion and support of breastfeeding is a mother’s right, a child’s right, and a human right." We often take several weeks of childbirth preparation classes and spend an equal amount of (if not more) time shopping for baby's clothes, gear etc. However, reading or preparing for breastfeeding is relegated to a half day or even less.

For World Breastfeeding Week 2010, the WABA calls advocates to reassess and consider what needs to be done to revitalize and expand the Baby-Friendly Initiative. Some of the things they suggest that can be done would be:

1. Help your friends, colleagues and community to find the path.
2. Find out what the status of the Ten Steps and BFHI is in your country and advocate for changes in hospitals
3. Create change at the national level. Advocate for changes in hospitals, maternities adn in the wider health care system - health centers, primary care and communities.
4. Improve our world for mothers and children and for our future.

For World Breastfeeding Week 2009, we had a Breastfeeding Festival at my workplace and also started a Lactation Policy Program. However, the program has not yet been completed although a breastfeeding room has been estblished. This year, hopefully, we will finally be able to establish a permanent lactation program and execute it in time for Breastfeeding Week. I also hope that L.A.T.C.H. or Children for Breastfeeding or other breastfeeding organizations in the Philippines will be able to focus on hospitals and reestablish or reiterate the need to promote, support and protect breastfeeding especially to new moms!

Milk of Sorrow

One of the nominees for the Academy Award's (a.k.a OSCARS) Foreign Language Film Category is a Peruvian film "La Teta Asustada" or Milk of Sorrow. This film previously won the Golden Bear Award at the Berlin film festival. The film revolves around Fausta who is suffering from the "frightened breast" which she got from her mother (who was raped) through breastfeeding. Read Variety's review and the Wiki entry.

I'm happy that a film featuring breastfeeding was given an Oscars nod. But I'm not too happy about the "frightened breast" theory. I would love to watch this film to see how breastfeeding during the war is depicted - whether positively or negatively.

Interestingly, a report released mid-January by Simon Fraser University in Vancouver, Canada found that breastfeeding during war helped lower infant mortality.

Exclusive breastfeeding can decrease the risk of two of the deadliest war-related health threats children face, a recent study shows. Breastfeeding's greatest impact on declining wartime deaths has been in sub-Saharan Africa, though more work is needed.

As with calamities, war victims normally do not have access to clean water or facilities, and subsequently, use of breastmilk substitutes often result to higher infant mortality.

My internet research do no show any detailed synopsis about "Milk of Sorrow". I do hope it wins the Oscars for Best Foreign Film as this will increase its chances of being shown locally, allowing me to watch and decide if this film is good for the breastfeeding advocacy.

New growth charts for babies - now out!

When I posted about growth charts based on breastfed babies in May last year, Kate (a fellow nursing mom who works at the National Nutrition Council) shared that the the NNC was working on the adoption of the 2006 WHO charts to the Philippine setting. About 2 weeks ago, I got an email from Kate telling me that the chart was now ready and they are now trying to disseminate it among health professionals. You can check out the National Nutrition Council's growth chart here.

From what I understand, the NNC's growth charts are more forgiving especially if your baby is not quite that big. For instance, in the NNC charts, at 3 months, normal weight for a baby girl would be 4.5-7.5kg. However, if you check the CDC chart, at 4.5kg, your baby will be between the 5th and 10th percentile and I'm sure your pediatrician will be saying that you are not feeding your baby enough and will direct you to supplement. How's that for a confidence buster?

On the other side, if your baby is about 7kg, she would still be considered within the normal range under the NNC charts but be overweight in the CDC charts as she will be above the 95 percentile.

In Naima's case, she is almost 26 months and currently weighs about 28lbs. or 12.7kg. Using the NNC chart, the normal range for her age would be 9.4-15.4kg. In the CDC chart, it's at 10.25kg (3 percentile) to 15.5kg (97 percentile). I realize that the difference in the charts would really matter if your baby is on the borderline of underweight and overweight. And usually, it would mothers with borderline babies who would be more vulnerable to supplementation or eventual cessation of breastfeeding.

You can download the CDC growth charts here and download this for the girls height/weight charts for birth-36 months.

Breast Milk for Haiti

Since the Haiti earthquake, I've been reading a lot of blogs and news about the call for breastmilk donations for children. Then came the news articles and more blogs on the "controversial call".

On 21 January 2010, the UNICEF issued a statement discouraging breast milk donations:

Human milk donations while safe when processed and pasteurized in a human milk bank also require fully functioning cold chains. Such conditions are not currently met in Haiti and human milk donations cannot be used at present. All queries and any donations that do appear should be directed to UNICEF, the designated nutrition coordinating agency in Haiti.

Then came the International Breast Milk Project and Human Milk Banking Association's calls for breast milk donations. About 500 ounces of milk was couriered on 28 January 2010 to the US Navy's ship called Comfort which was stationed near Haiti. However, this donated milk remains unused to date. Plus, the U.S. Navy spokesman has been promoting the use of infant formula rather than this donated milk!

But the staff on the U.S. Navy ship said they haven't used the milk out of concerns raised by OFDA and other agencies. Mothers aboard the Comfort are urged to nurse their own babies and there’s infant formula available to children whose mothers cannot or will not breast-feed, said Lt. David Shark, a U.S. Navy spokesman.

Comfort has been identified as the world's only nautical milk bank but apparently it is ill-equiped to handle the flood of breast milk donations.

Eager to do something to alleviate the suffering of the smallest, many lactating women are wishing the Comfort had more storage space to handle donated milk. At least one Navy staffer, who had to leave her 10-week-old baby behind when she deployed, was "pumping and dumping" — nursing slang for pumping then discarding milk. Now that there's a use for her milk, she's ferrying it to the ship daily from the mainland, where she is currently working. Beard Irvine has a name for that milk: "Comfort food."

It is just sad that instead of addressing the upgrade on the facilities or promoting relactation or cross nursing, Dr. Nune Mangasaryan, senior adviser on infant nutrition for UNICEF, instead promoted the use of ready to drink formula and this is despite the joint statement issued by WHO, UNICEF and WFP discouraging the donation and use of breastmilk substitutes or formula.

Dr. Mangasaryan: At this point what we recommend for them is ready-to-use infant formula, that's already in a liquid form, meaning no risk of contamination by mixing powdered formula with water, for example. It's already ready-to-use, and there are certain numbers already available in the country.

The Philippines faced a similar disaster (Ondoy and Parma) in October 2009. We were also involved in breastfeeding missions and brought donated, pasteurized breast milk in coolers to evacuation sites. But as I previously shared, out of the 15 liters (about 507 fl. oz.) of milk we brought, only 1.5 liters (50.72 fl. oz.) were used up. We wanted to leave the unused milk there but the health workers told us that they had no facility to keep the milk cool and prevent spoilage. So we ended up lugging it back to the milk bank.

I learned that in times of calamaties such as this, what is more important or useful would not be breast milk donations but rather breastfeeding information - relactating, switch nursing, protection of milk supply, encouragement. As fellow LATCHer Mec also shared, sharing of strategies, loot bags and the use of wet nurses were also particularly useful.

I'm not saying that moms with extra milk should stop donating milk. Even without calamities, milk banks are continuously asking for donations. In fact, every time I call up the PGH Milk Bank, they always excitedly ask me if I have extra milk to give. Moms should continue to donate milk but just have an expectation that their milk may not be directed towards Haiti but to other needy babies within their locality. I'm not sure if it is feasible in evacuation centers in Haiti but instead on focusing on calls for milk donations or promoting ready-to-drink formula, maybe international organizations can instead focus in information drive with strategies, tips and tricks on relactating and the promotion of direct breastfeeding.