Highlights from the 10th annual MAINN conference: Nutrition & Nurture in Infancy and Childhood: Bio-Cultural Perspectives

A small group of Healthy Children Project faculty were honored to attend and present at the University of Central Lancashire, Maternal and Infant Nutrition and Nurture Unit (MAINN) conference in lovely Grange-over-Sands, England last week. (For highlights of last year’s MAINN conference, visit this page). The MAINN conference has been held not only in the UK, Australia, and Sweden, but next year will be held in conjunction with Healthy Children’s International Conference in Deerfield Beach, Fla. from January 9 to 12, 2018.

This conference brings together researchers and experts in fields that support the establishment of the maternal-infant bond and related issues in nutrition and nurture. The remoteness of this seaside town in the Southern English Lake District created a container for further discussion and networking during and between sessions, as well as before and after the conference day. The schedule of the 3-day conference was prodigious, encompassing six plenaries, 72 breakout sessions, four workshops, and a poster session featuring the work of 17 research teams.

The HCP team offered to share insights with me from the conference, but struggled to do justice to all the learning insights and meaningful intellectual interactions that occurred. Therefore, they decided to blog about what they learned from one particular presentation.


One of the amazing presentations we attended was Renee Flacking’s report on the research that she had done with Fiona Dykes of the UK regarding the use of nipple shields in the neonatal intensive care unit (NICU.) We can’t think of any superlatives beyond “Wow!” to describe the level of excellence, passion, and insight contained in this presentation. In order to collect the data for the ethnographic study, Flacking spent more than 600 hours “living” in four NICUs in Sweden and England. Observations, field notes, and interviews were searched for themes related to parents’ and staff’s perceptions and experiences of using a nipple shield in transitioning a preterm infant to feeding at the breast.

As background, Flacking acknowledged the debate over nipple shield use and presented two influential nipple shield studies: one small study that indicated that transfer of breast milk was enhanced when mothers of premies used a nipple shield to breastfeed (Meier et al., 2000), and a large study that found that premies who were exposed to nipple shields were significantly less likely to continue breastfeeding and to breastfeed exclusively (Kronborg, Foverskov, Nilsson, & Maastrup, 2016.)

Dr. Fiona Dykes, conference coordinator

Flacking & Dykes found that parents and staff thought of nipple shields as a transitional tool to progress to feeding at the breast, but mothers had some mixed and negative feelings as well. Mothers felt that the need to use a shield indicated that their breasts weren’t good enough and expressed that the nipple shield became a barrier between them and their baby. The researchers found two organizing themes: 1) the need for the baby to learn quicker, in order to get to full breastfeeding faster, and thus the nipple shield could be a short-term bridge to this goal, and 2) the interference of the nipple shield in the relational aspect of breastfeeding; that the shield impacts the development of the relationship between the mother and the baby. Holding these two organizing themes “in balance may be the key to appropriate use of the nipple shield,” Flacking stated.

The mother and baby’s needs must be taken into account in determining strategies to facilitate breastfeeding in a person-centered and ongoing way.

As we thought about and discussed Flacking and Dykes work among ourselves and with others, we couldn’t help but agree that nipple shields are often presented as a quick means to an end (as we have heard mothers complain about “helpers” latching the baby mechanistically like screwing in a light bulb), without taking into consideration the potential negative ramifications of the meaning of the shield to the family. We would never want any mother to think that she was not enough for her baby, that her breast was somehow suspect or inadequate, or that a piece of silicon could come between her and her baby. Particularly when we are working with the potential of feelings of inadequacy or guilt coming from the incomplete pregnancy, we must assume that mothers need help decoding the meaning.

HCP Faculty and Colleagues

We also pondered the resonance between Flacking and Dykes’ findings and those of Kronborg and colleagues, who cited that while nipple shields may be help mothers in the early period, but are “not necessarily a supportive solution to the inexperienced mother who needs extra support in the early process of learning to breastfeed.”

Growing Green Families

On World Environment Day last week, The World Alliance for Breastfeeding Action (WABA) and Pesticide Action Network Asia and the Pacific (PAN AP) reminded us that The Earth is Our Mother, and caring for her is essential to our health.

It’s easy to feel defeated by the burden of environmental degradation we have created and carry though; To be aware is to be afraid.

“…How can we become aware, take action, and not let ourselves become so vigilant, so aware, so motivated, and so afraid that we forget to enjoy the beauty of the Earth around us, the sounds of our children and grandchildren laughing, the calm music softly playing, and living our best life?” Master Herbalist and Certified Aromatherapist Donna Walls, RN, BSN, IBCLC, ICCE, ANLC wonders.

Released earlier this year by Praeclarus Press, Walls’ Growing Green Families: A Guide for Natural Families and Healthy Homes offers families a concise, practical guide complete with simple recipes on how to reduce their exposure to environmental toxins. Walls’ casual tone is easy to digest and makes for a speedy read.

She presents a collection of natural alternatives for personal care and housecleaning products, lawn and garden care, recycling strategies and a cleaner way to feed our families.

The recipes she shares come from years of experience as a lover of nature, all used by herself, friends and family or in classes she teaches.

When asked for her favorite recipe… “That’s like picking your favorite child– impossible, but the ones I use most are general cleaning and many of the aromatherapy recipes like the hand sanitizer,” she says.

Many of the recipes Walls suggests are concocted with easily accessible and relatively inexpensive ingredients like vinegar, plain yogurt, witch hazel, olive oil, baking soda, castile soap, to name a few. Still, some people have concerns about the perceived price of “going green,” like the cost of essential oils and organic food.  

“My usual response is that we all prioritize our budget, so it really is a matter of making healthy, clean living a priority for lifestyle and budget,” Walls begins.

“My snarky response: cancer co-pays are also very pricey,” she alludes to reports by the Environmental Working Group and the Environmental Protection Agency which estimate that many of the products we use are human carcinogens.

Walls’ granddaughter passes on the tradition of green cleaning.

Homemade product preparation has been criticized for being too time-consuming, too.

“Much as with money, we all have priorities,” Walls says. “We have time to do the things we value.”

She suggests combining activities, like preparing products while watching TV or prepping cleaning supplies while cooking. After all, “cleaning with a conscience” starts with vinegar, lemon juice and baking soda, all kitchen cupboard basics!

Of bigger concern is access to organic, clean food in food deserts. It is an opportunity for community and personal activism, Walls says.

She suggests supporting local community gardens, volunteering at local food pantries to help obtain healthy food, and establishing and contributing healthy options to street food cupboards.

Growing Green Families touches on concerns about toxins during pregnancy and nods to breastfeeding as “the best first food.” With fingers crossed, Walls says she hopes to publish her next book with a focus on childbearing years.

Potential consequences of invoking ‘natural’ in health promotion: Part 2 of 2

Source: United States Breastfeeding Committee.

When this conversation about breastfeeding being natural and its implications started, I thought a lot about how many families, including mine, get a good dose of parenting advice and health care information on the internet. Because I tend to distrust medical professionals, I almost always consult other resources (trusted individuals and the internet) for supplementary information when making choices that impact my children’s health.

But the internet is saturated with articles that claim this and that and the other thing, and there’s “evidence” to prove it all. Many parents, including myself, don’t have the expertise to recognize good research design or truly grasp the abstract nature of statistics. Other things happen when we seek out information on the internet and elsewhere: confirmation bias and the backfire effect. These terms are used by cognitive scientists and psychologists to describe the following reactions:

Confirmation bias is our drive to prefer information that appears to affirm our core beliefs.

On the other hand, when we are exposed to information that runs counter to our core beliefs, we may have one of the following responses:

  • Motivated skepticism: examining information with doubt that it is true, actively looking for flaws in the information
  • The backfire effect: rejecting information that challenges our strongly held beliefs; research indicates that being overwhelmed with a good deal of such information may actually strengthen the belief it is meant to challenge.

Turner-Maffei provides a few examples from the lactation world.

“The first news about Vitamin D deficiency in breastfed babies resulted in motivated skepticism on the part of breastfeeding advocates,” she begins. “Many dug into the research looking for problems and oversights, demonstrating motivated skepticism. The fact that we are motivated to attack information that seems to run counter to our beliefs (in this case, breast is best, why would babies need extra vitamin D?) shows how deeply held these beliefs are, close to our personal and group identity. We are less likely to be skeptical about findings that appear to confirm our core beliefs, such as studies showing a link between breastfeeding and positive health outcomes.”

On confirmation bias: When the World Health Organization’s guidance on safe preparation of infant formula was first added to the Baby-Friendly Hospital Initiative guidelines in 2009, many lactation professionals expressed a belief that instructing parents of newborns about how to safely prepare powdered infant formula to protect the infant might actually “scare” some new parents into breastfeeding to avoid Cronobacter, a potentially fatal infection. However, the current understanding of the backfire effect indicates that this viewpoint may be flawed. (Meanwhile this information triggers confirmation bias on the part of lactation activists, as it aligns with the strongly held belief that ‘breast is best.’)

A You Are Not So Smart podcast (about 28 minutes in) offers insight into these phenomenon covering research about the belief that vaccines can cause autism. It demonstrates how we are more heavily influenced by stories than by complex research.

It is easy to understand that parents might feel autism is a greater risk than the common diseases that childhood vaccination protects against: whooping cough, pertussis, measles, mumps, rubella, etc. The media is replete with stories of autism on the rise (up from one child in 150 in 2000 to one in 68 in 2012) while outbreaks of these diseases are reported sporadically in limited geographic locations.

While there are rare side effects to vaccinations, high level research has not found a causative link between vaccination and autism (IOM, CDC, WHO). Some have suspected that mercury found in the preservative, thimerosal may be linked to autism; not only does research deny this linkage, but the originator of this theory was found to have engaged in ethical misconduct.  Nonetheless, the U.S. government recommended removing this preservative from vaccinations in 1999 (although it is still used in some multi-dose vials of flu vaccine.)

When expert opinion regarding lack of linkage between vaccination and autism is shared with concerned parents, research indicates that the backfire effect may cause those who are most against vaccination to accept the lack of evidence, but also to strengthen their commitment to avoid vaccinating their children, as shown in Effective Messages in Vaccine Promotion.

As a side note, the low incidence of things like hemorrhagic disease as described in Dekker’s article means that most parents have not seen or heard of a family member or friend with this outcome . The likelihood of a child contracting a vaccine-preventable disease in the U.S. is relatively low too, in this case thanks to herd immunity or community immunity.

Turner-Maffei points out that the CDC reported that 667 people in the U.S. had measles in 2014, and the last death in the U.S. from measles occurred in 2015 for instance.

“With 4 million children born annually, the risk of contracting measles whether one vaccinates or not is incredibly low,” she explains which might explain a false-sense of security against disease among those who choose not to vaccinate. “But the more people who decide not to vaccinate, thinking they’re safe from this risk, the greater the potential spread of the disease in the unimmunized pockets of the community, thus the greater the risk to children as the trend grows. The safety of not vaccinating decreases with the herd immunity.”

Today, health officials are dealing with the largest outbreak of measles in Minnesota in almost 30 years after a population “fell under the sway of anti-vaccination activists.”

The same type of risk/benefit ratio pertains to the risk of a newborn contracting a Cronobacter infection from contaminated infant formula, Turner-Maffei reports. Again, the occurrence of these infections is low. (CDC reports that it learns of four to six cases per 4 million infants annually, although they note that many cases are likely not reported.)

Expectant parents who are made aware of the potential contamination of infant formula may also be falsely reassured by the rarity of this infection, she suggests.

Is it possible all humans are prone to believe we’re protected from rare negative outcomes associated with our core values?

The release of WHO recommendations on infant feeding by HIV-positive mothers, based on new evidence, suggests that HIV-positive mothers or their infants take antiretroviral drugs throughout the period of breastfeeding. This means that the child can benefit from breastfeeding with very little risk of becoming infected with HIV, Breast is always best, even for HIV-positive mothers reads.

Over 1,000 words earlier I quoted, “The term natural has a lot of values packed into it.” And here we are about 1,000 words later still with much to consider. When we engage in activities designed to convince people something is best, or the natural choice, we are entering into complex endeavors that may trigger sophisticated cognitive responses, including the backfire effect, in some individuals.

So what can we do to propagate evidence-based thinking, we wonder. In response to a question from You Are Not So Smart’s Dave McRaney, Jonas Kaplan states that currently science can’t tell us how to make others accept the facts we consider unassailable (around 37:00 minutes), Turner-Maffei reiterates. Rather, Kaplan proposes that we strive to be more flexible when encountering information that runs counter to our beliefs, to be aware of the tendency toward motivated skepticism, and to learn to distinguish our beliefs from our identity as individuals.

Turner-Maffei suggests, “Perhaps in this way we can model cognitive flexibility while becoming more open to the beliefs of others, less centered in our own worldview, and hopefully less likely to contradict the beliefs of others since contradicting core values may trigger the backfire effect.”

Research which suggests a delay in breastfeeding at the time of the oral rotavirus vaccine to “overcome [breastfeeding’s] negative effect” on the potency of the vaccine has been met with outrage by some breastfeeding advocates.  As an exercise in cognitive flexibility, we invite you to read the publication and take note of your feelings and cognitive process.

Also for your consideration, a list of common misconceptions that corrects erroneous, widely-held beliefs.

Potential consequences of invoking ‘natural’ in health promotion: Part 1 of 2

Ever since a Pediatrics article and an Evidence Based Birth publication showed up at her desk on the same day, Healthy Children Project’s Cindy Turner-Maffei, MA, ALC, IBCLC has been pondering the relationship between them, and the impact of lessons on how we communicate about biologic functions such as breastfeeding, and also about risk surrounding biology.

The Pediatrics Perspectives article reports on the unintended consequences of claiming breastfeeding is natural. The Evidence Based Birth article describes a rise of exclusively breastfed babies with life-threatening hemorrhagic disease due to avoidance of Vitamin K shots in Tennessee.

“The term natural has a lot of values packed into it,” Turner-Maffei begins. “Also, risk:benefit ratio is a difficult concept to convey in a practical sense.”

Similarly, the authors of the Pediatrics article entitled Unintended Consequences of Invoking the “Natural” in Breastfeeding Promotion write that “‘natural’… lacks a clear definition.”

Perhaps this is why, when I spoke with Turner-Maffei, our conversation took several directions. In part one of two posts, she’s contributed great insight on several abstract ideas that warrant ongoing investigation.

Turner-Maffei reiterates the Pediatrics publication authors’ concern about breastfeeding promotion that praises breastfeeding as the natural way to feed infants because the “messaging plays into a powerful perspective that ‘natural’ approaches to health are better.” The authors claim this promotion may actually be “ethically problematic… and… may ultimately challenge public health’s aims in other contexts, particularly childhood vaccination.”

Manifesting the authors’ concern, Rebecca Dekker’s, PhD, RN, APRN notes that when parents were asked why they had declined Vitamin K, their reasons included: concern about an increased risk for leukemia, a belief that the injection was unnecessary and “unnatural,” and a fear that their infant would be exposed to toxins in the shot.

Surely, our bodies and our planet can benefit from lifestyles with less harmful toxins; still, just because something is “natural” doesn’t make it intrinsically good for you.

“Rattlesnakes are natural, but you don’t want to step on one,” Turner-Maffei points out.  “I’d rather step on a plastic bottle than a rattlesnake any day.”

When it comes to maternal child health advocacy it’s sometimes easier to be a purist, touting a Breast is Best message.

“But it’s not that kind of world,” Turner-Maffei says.

She admits that she’s “done the purist thing,” once believing that moms who choose not to breastfeed weren’t doing what’s best for their children. She’s since changed her viewpoint.

“It’s too rigid, too unfair, not a justifiable position,” she explains. “Parents make infant feeding decisions based on their own unique situations; it’s no one’s right to judge them on the basis of infant feeding choice.”

Instead, we need to “look at our own mythology around lactation,” Turner-Maffei advises.

Not long ago, many in the lactation community fought back against Vitamin D recommendations for the exclusively breastfed infant, for instance.

“We tend to resist news that implies that breastmilk doesn’t have everything a baby needs,” she comments. “Most of the time [breastmilk] is great, but it can’t help with Vitamin K and most of the time, not Vitamin D.”

Interestingly, Dekker poses this question: “If all infants are born with low Vitamin K levels, is it really a deficiency or is this the natural design of human beings?” She includes three theories including a survival of the fittest scenario, the potential that an infant’s clotting system needs time to mature, and the potential that there is an unknown reason that leads to low Vitamin K transmission from mom to baby.

Dekker adds, “You could also make the argument that it doesn’t really matter why babies are born with low levels. The point is that they are born with low levels of Vitamin K, and that some babies will die from Vitamin K deficiency bleeding if they do not receive supplemental Vitamin K at the beginning of life. Most will not bleed. But some will, and some will experience brain injury or death. And these injuries and deaths are 100% preventable.”

Stay tuned next week for discussion on cognitive processes and flexibility. In the meantime we wonder, what other “natural” things can you think of that might not necessarily be healthy or beneficial?

Miracle Milk™ campaign shares power of human milk through storytelling

It’s Miracle Milk™ May! This year, Best for Babes’ (BfB) Miracle Milk™ campaign is bringing it back to the basics with a grassroots effort to share the power of Miracle Milk™ through storytelling. Throughout the month, Best for Babes encourages us to talk about the power of human milk and breastfeeding in our communities as well as digitally through social media.

In years past, Best for Babes hosted the Miracle Milk® Stroll, the only national consumer-driven nonprofit for the human milk cause. In the midst of a transition searching for an Executive Director, the organization has modified its campaign format.

Best for Babes’ media specialist Kelly Doherty and manager of the 2017 campaign points out that some very committed Stroll organizers from years past are still hosting Strolls in their communities.

Dover, Delaware 2016 Miracle Milk Stroll
Credit: Katie Phillips Photography [https://www.facebook.com/KatieTPhillipsPhotography/]
As part of the digital campaign, you’ll find memes on Best for Babes’ Facebook page posing specific questions about breastfeeding like “What is the best piece of advice you have for a nursing mom?” and “What don’t you know about donating human milk?”

Doherty says that reaching out to potential milk donors is just as important as getting Miracle Milk™ to babies in need.

“If you’re a person who had great milk production and an easy nursing relationship, you don’t even realize what you could be providing to babies in need,” she says.

Prompting conversations about human milk is the first step in an effort to make donor human milk and the Human Milk Banking Association of North America (HMBANA) as mainstream as formula companies. Best for Babes co-hosted Public Citizen’s 2017 Day of Action to Protect Parents and Babies in an effort to promote commercial-free infant feeding information.

Best for Babes is an organization dedicated to diverse family experiences and supports safe infant feeding methods. Join the cause. Join the conversation!