The elegant and complex systems of flavor and nutritional programming

— This post is part of our “Where are they now?” series where we catch up with some of our very first Our Milky Way interviewees from over a decade ago! — 

“The societal and clinical impact of promoting sustainable food habits is significant, since what a child eats determines in part what the child becomes. (Mennella, et al, 2020, p. 291)

 

The pop of poppy seeds in aloo posto, cough-inducing spice in stir-fried lotus root with chili peppers, the meaty texture of a bowl of Cuban black beans. 

The dishes we crave tell stories. 

“Our food preferences have meaning,” Julie Mennella, PhD begins. “They’re more than just a source of calories. Food preferences provide families with identity.”

[Rough Translation’s Tasting at a Distance and Forgotten Foods of NYC’s Appetite for Home — Bitter-Sweet Memories of Learning to Cook & Eat in America both present beautiful audio embodying these connections.]

Elegant and complex learning systems 

The multidimensional interactions we have with food begin with our mothers. A fetus is passively exposed to the flavors of the biological mother’s diet through amniotic fluid, and the infant goes on to interact with these flavors through human milk. Mennella and her colleagues have called this “intimate bidirectional chemosensory communication.” (Mennella, et al, 2023)

In this complex communication, “diet and xenobiotic exposures of the lactating parent, due to lifestyle choices or necessitated by medical treatments, affect not only milk production and milk composition but also the infant’s biological responses, either beneficially or adversely,” the authors continue. “Developing alongside the chemosensory signaling is the seeding and maturation of the infant microbiome, which transfers and exchanges with that of the parent and of the milk, forming additional bidirectional linkages.” (Mennella, et al, 2023

Infant formulas, although available in many varieties, do not foster this elegant exchange and where developing food preferences are concerned, present a static flavor.

“That constant flavor doesn’t reflect the culture [a child] will grow up in,” Mennella comments.  

The same goes for infants fed jarred and pouched baby foods (what we’ve referred to as “the packet apocalypse” where the convenience of “ready-to-feed-super- glop” has largely replaced the art of dining and sharing meals.) The explosion of the baby food industry means parents often don’t feed their children what they themselves eat. Families can feed their babies canned peas, but never eat a pea themselves, Mennella points out. 

Mennella’s research has always been interested in flavor and nutritional programming in humans and the development of food preferences, but over the last decade, it has diversified to ask questions about the taste of pediatric medicines from a personalized medicine perspective, determinants of sweet and salt preferences during childhood, the development of psychophysical methods to study olfaction, taste and chemesthesis across the lifespan, biomarkers for dietary intake across the lifespan, and reproductive state effects on dietary intake and weight loss in women. [Retrieved from: Monell Center

Collective, family- focused approach

Mennella summarizes a few key points from her work. 

“Children live in different sensory worlds,” she says. ”They are really sensitive to the current food environment.” 

And like she and her colleagues have written, the food environment rich in added sugar and salt that caters to preferred human taste, provides challenges for all of us. 

“Fortunately, our biology is not necessarily our destiny. The plasticity of the chemical senses interacts with experience with foods to modify our preferences, producing an interface between our biology and our culture, our past and our present.” (Mennella, et al, 2020, p. 291

In order to influence our destiny, Mennella says that the strategy can never be for the child alone. She suggests there be more attention paid to the family as a whole in order for healthy behaviors to be sustainable. 

She nods to the success of peer counseling programs and recommends bolstering these opportunities for families to interact and learn from one another. She says she envisions primary care taking on a community approach to provide not only a forum for education but also opportunities for interaction between families.  

Where science and policy meet 

Mennella recognizes that ultra-processed, convenience foods are palatable and often inexpensive and deems this a “much bigger issue.” 

Her research has guided national and global health initiatives like the USDA and HHS Pregnancy and Birth to 24 Months (P/B-24) Project, the Breastmilk Ecology and the Genesis of Infant Nutrition (BEGIN) Project, and the World Health Organization’s (WHO) Commission on Ending Childhood Obesity. [WHO recently released its new guideline for complementary feeding of infants and young children 6-23 months of age. Read about it here.]  

As science evolves– where the picture gradually becomes more crisp and for every one question asked, fifty more arise– policies and practice must reflect and catch up to the robust body of evidence in order to best support child and family health.  

Read our 2012 coverage with Dr. Mennella here



Recent happenings linking maternal child health and planetary health

Late this autumn, I went for a hike with my family that moved me to tears. As I looked over the rolling foothills cascading in green, its beauty, while simultaneously reflecting on the horrors in this world, provoked a surge of emotion like the swell of ocean waves just over the mountain range we perched upon. 

I shared this experience with one of my dearest mentors and she replied: “I also find nature a powerful midwife and teacher about life. I remember being moved to tears by redwoods standing firm bearing deep gouges and gaping wounds from lightning strikes and subsequent fires… yet continuing to grow and foster another generation.” 

Photo by Tatiana Syrikova: https://www.pexels.com/photo/anonymous-little-kid-touching-tree-with-hand-3932861/

When I returned to my neglected inbox after this respite hiking and exploring new-to-me land, I came across the juxtaposed images of a human fingerprint and the dissection of a tree trunk suggesting that ‘we are nature’. 

With my mentor’s poetry in mind and the concept of “human nature,” I’d like to invite you to explore the following happenings, documents and projects as they all pertain to the inextricable connection between planetary and human health and the influence of infant and young child feeding practices on greater population health, a concept coined One Health

First up, the 46th Session of the Codex Alimentarius Commission (CAC46) came to a close this month. The CAC is a UN body established by the World Health Organization (WHO) and the Food and Agriculture Organization (FAO) in 1963 with a mission to protect consumer health and promote fair practices in food trade.

The International Baby Food Action Network (IBFAN) participated in the session, and as the organization reports:  “After more than a decade of challenging negotiations within the industry-dominant Nutrition Committee, the Revision of the 1987 Follow-up Formula Standard has been officially adopted this week – now renamed the Standard for Follow-up Formula for Older Infants and Product for Young Children.

Thanks to the relentless advocacy efforts of IBFAN, WHO, UNICEF, public interest NGOs, Brazil, Ecuador, Nigeria, and numerous [other] countries, the new standard now makes specific references to the International Code of Marketing of Breastmilk Substitutes and relevant WHA Resolutions in a Preamble. Despite sustained opposition from the USA, these safeguards were retained during CAC, although some of IBFAN’s warnings were removed from the CAC46 report.” 

You can find more detailed coverage at the Baby Milk Action blog here

Also this month, WHO hosted a webinar covering the release of the new WHO guideline for complementary feeding of infants and young children 6-23 months of age

Dr. Francesco Branca began by pointing out some hopeful news.

“The past decade we have seen important gains in improving maternal and child nutrition, including a one-third decline in the proportion of children suffering from stunting, and a tend point increase in exclusive breastfeeding on the way to reaching the 2025 World Health Assembly nutrition target of 50 percent of infants below six months exclusively breastfed. Yet multiple forms of malnutrition, poor growth, micronutrient deficiencies and overweight continue to jeopardize children’s ability to survive and thrive…” 

Dr. Larry Grummer-Strawn summarized that while some of what is in the report is repetitive, there are several key updates. 

For instance:

  • “Milks 6–11 months: for infants 6–11 months of age who are fed milks other than breast milk, either milk formula or animal milk can be fed… Milks 12–23 months: for young children 12–23 months of age who are fed milks other than breast milk, animal milk should be fed. Follow-up formulas are not recommended… (p. 15)
  • “Starchy staple foods should be minimized. They commonly comprise a large component of complementary feeding diets, particularly in low resource settings, and do not provide proteins of the same quality as those found in animal source foods and are not good sources of critical nutrients such as iron, zinc and Vitamin B12. Many also include anti-nutrients that reduce nutrient absorption. (p. 24) 
  • “Foods high in sugar, salt and trans fats should not be consumed… Sugar-sweetened beverages should not be consumed… Non-sugar sweeteners should not be consumed…Consumption of 100% fruit juice should be limited…” (p.32) 

There is also an emphasis on responsive feeding (pages 43 to 47). 

Around 38 minutes into the recording of the webinar, Grummer-Strawn recognizes the reality of consumption of unhealthy food and beverages, the convenience of UPFs and calls on the need for broad policy actions to protect child health. 

Finally, Conference of Parties (COP) 28 wrapped up this month. At COP27, Healthy Children Project’s (HCP) Karin Cadwell presented research on the environmental impact of powdered baby formula milks in North America and HCP’s Kajsa Brimdyr on skin-to-skin contact (SSC) in the first hour after birth as a simple and easy, inexpensive, appropriate for all dyads with countless benefits intervention. (Read more coverage here.) 

Notable from this year’s session, among other important endeavors, includes work by the London School of Hygiene and Tropical Medicine (LSHTM) like the Children, Cities and Climate Action Lab and a partnership to understand how floods and heat driven by climate change affect the delivery of maternal and child health care in Brazil and Zambia

For further reading on climate action, check out Hidden Brain’s newsletter blurb:

“Psychologists have studied how to raise awareness about climate change and get people to take action on the issue. The answer can vary depending on a range of factors, like culture, age, gender, political ideology — the list goes on. An international team of scientists behind a recent paper has created a tool that shows which messages and interventions are most effective with different demographics. ‘To maximize their impact, policymakers and advocates can assess which messaging is most promising for their publics,’ said study co-author Kimberly Doell, who also helped lead the project. Check out the tool for yourself here.

Opportunity to join research project documenting Code violations

Surveying the Landscape of Breastmilk Substitute (BMS) Marketing Practices in Four Countries is well underway!

Launched this summer, the purpose of the research project is to document violations of the World Health Organization’s International Code on Marketing of Breast-milk Substitutes and subsequent WHA resolutions (the Code) in the U.S., Canada, the UK and Australia. 

On behalf of those conducting the study, Ellie Mulpeter, MPH, CLC Director, Academy of Lactation Policy and Practice (ALPP) says that they are excited about the level of engagement.

“It seems that participants are seeing and monitoring code violations across all four countries, perhaps even more than they expected!” she exclaims. “This is such a fun and engaging project – both active and practical – and is telling us so much already about what is happening throughout these four countries.” 

So far, the most prevalent violations have been reported on online social media platforms, influencers and online advertising and sales platforms. Read Scope and impact of digital marketing strategies for promoting breastmilk substitutes to understand why this finding is unsurprising. 

Mulpeter says of the research that “raising awareness is the first goal, particularly in countries that do not currently monitor or enforce the Code.” 

According to this 2022 WHO status report, “as of March 2022, a total of 144 (74%) of the 194 WHO Members States (countries) have adopted legal measures to implement at least some of the provisions in the Code. Of these, 32 countries have measures in place that are substantially aligned with the Code. This is seven more countries than reported in the 2020 report.” The U.S. and Canada have no legal measures. 

Mulpeter comments, “Policy makers in the U.S. are behind the ball when it comes to protecting breastfeeding individuals and their babies. That is nothing new. For many, I believe that seeing the sheer number of violations that the average individual can identify when walking along the aisles of their grocery store(s) will be eye-opening. Additionally, it’s great to have a study where those who care about maternal and child health can get out there and help with this project. If we are fortunate to find one or more advocates in the legislature that are passionate about this legislation, I think we can find a way to bring the U.S., Australia, the UK and Canada up to speed with other countries that effectively monitor and enforce The Code and its subsequent WHA resolutions.” 

Examples of countries with legal measures include Brazil, India and Bangladesh though compliance and enforcement is not always substantial. 

“It is inspiring to see the successes that other countries have had in protecting breastfeeding parents and their babies from the harmful practices of the infant formula and other breastmilk substitute industry,” Mulpeter continues. 

In the U.S., the Federal Trade Commission (FTC) provides an avenue to monitor false advertising and hold companies accountable for making claims that are not evidence-based. Mulpeter reports that INFACT USA has submitted several different reports of false advertising on infant formula cans and other commercial milk formulas in the U.S.

“Unfortunately, the FTC does not actively investigate those submissions, but does keep a database of those submitted,” she explains. “After submitting those cases, a message is relayed to the submitter notifying them that they will not receive a response from the FTC, but that the report will be logged in their database.” 

Though the U.S. has not adopted the Code, this research may eventually feed into the NetCode Protocol which supports the development of a monitoring framework, protocols and training materials for monitoring of the International Code and relevant WHA resolutions, and the formulation, monitoring and enforcement of national Code legislation. 

The study will be capped at 1,000 participants. Once enrollment closes, new submissions of violations will be accepted for approximately six months. You can join here

Further exploration on the topic

Changing the culture of mother baby separation in one Northeastern hospital

“I got to touch him once and they took him right away from me,” Northern Light Eastern Maine Medical Center labor and delivery nurse Jennifer Wickett says, remembering the birth of her first child 19 years ago.

Wickett desired non-medicated births, but her three children ended up being born via cesarean sections for various reasons. Wickett’s personal birth experiences coincided with her early professional life, working at a hospital in Massachusetts as a labor and delivery nurse.

At the time, she explains, the process was this: the baby was born,  taken to the warmer, vitals and weight were recorded. The baby was wrapped in a blanket and held next to mom’s face for five to ten minutes and then taken to the newborn nursery.

Skin-to-skin in the OR, Healthy Children Project

“I hated that for my patients and I hated that for me,” Wickett says.

So Wickett singularly started changing that culture of mother baby separation.
Now, at Northern Light Eastern Maine Medical Center, Wickett attends about 95 percent of the c-sections, and she says she was able to “take control.”

“[Initially] I wasn’t tucking baby in skin-to-skin, but I was putting baby on top of mom with the support person helping hold the baby,” Wickett explains.
She deemed it the Wickett hold: baby placed chest down on mom with knees tucked under the left breast and baby’s head on the right breast.

Attending a Kangaroo Mother Care Conference in Cleveland galvanized her efforts: the evidence clearly supported skin-to-skin contact immediately after birth and beyond.  Fellow nurses, anesthesiologists and other team members were resistant, but Wickett and a few other fellow nurses who created the Kangaroo Care Committee kept at it, always leading with kindness and communication. Rather than approaching the process with an “I have to do this” agenda, Wickett involves and acknowledges all of the participants in the room.

For instance, to the mother, she asks permission while also explaining the importance of skin-to-skin contact.

“They’re in hook line and sinker when I explain that their body regulates their baby’s temperature,” Wickett explains. “They don’t want to give that baby up; they are not letting that baby go.”

To the anesthesiologist, she facilitates open communication. Wickett lets them know that she assumes responsibility for the baby. “Are you good?” she often checks in with the anesthesiologist, while minding their space to work safely and efficiently.

Wickett  makes certain to involve the partner in their baby’s care, asking them to keep a watchful eye over mom and baby.

Photo by Jonathan Borba

Just about half of the babies she sees begin breastfeeding in the OR, she reports. From the OR, babies are kept on their mothers’ chests as they’re transferred to the recovery room, continuing the opportunity to breastfeed. All in all, Wickett says that babies born by c-section at her hospital spend more time skin-to-skin than those who are born vaginally.

After a vaginal birth, eager nurses often disturb skin-to-skin contact to complete their screenings and documentation. Excited partners wanting to hold their baby tend to do the same.

In the OR though, Wickett says there are at least 30 minutes without these disruptions.  Once mother and baby are transferred to the PACU, mothers report decreased pain when skin-to-skin is practiced.

What’s more, Wickett reports hearing often “This baby is such a good breastfeeder!” because the babies have an opportunity to initiate breastfeeding within the first two hours of life.

The World Health Organization (WHO) recommends that immediate, continuous, uninterrupted skin-to-skin contact should be the standard of care for all mothers and all babies (from 1000 grams with experienced staff if assistance is needed), after all modes of birth. The recent Skin-to-skin contact after birth: Developing a research and practice guideline synthesizes the evidence. [Read more here.]

Skin-to-skin, Healthy Children Project

Wickett and seven other colleagues had the opportunity to complete the Lactation Counselor Training Course (LCTC) last year.
While she says she would have loved to have been able to take the course in-person, Wickett still found the material and resources “fabulous.”

For the past four years, there’s been a vacancy in the perinatal coordinator position at her hospital, so Wickett hopes that her new credentials will allow her to fill the need.  In the meantime, Northern Light Eastern Maine Medical Center offers outpatient lactation visits. The center’s breastfeeding support groups halted during the height of COVID and have yet to resume; Wickett reports that they are trying to bring those back virtually.

Additionally, Maine residents have access to the CradleME Program which
offers home-based services to anyone pregnant up to one year postpartum.
In partnership with the Mothers’ Milk Bank Northeast , Northern Light Eastern Maine Medical Center became the first milk depot in the Bangor area.

You can read more Our Milky Way coverage on skin-to-skin after cesarean birth in  Skin-to-skin in the operating room after cesarean birth , The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth , and Skin to skin in the OR.

Also check out Skin to Skin in the First Hour After Birth; Practical Advice for Staff after Vaginal and Cesarean Birth Skin to Skin.

Find some beautiful KMC imagery here.

Respectful maternity care: the problem and suggested solutions

Guest  post by Donna Walls, RN, BSN, CLC, ANLC with intro by jess fedenia, clc

 

Donna Walls’s, RN, BSN, ICCE, IBCLC, ANLC unmedicated births were sort of a fluke.

“I remember being horribly afraid of someone sticking a needle in my back,” she recalls.

The “glorious” feelings of confidence and joy were unexpected consequences, but thinking back, Donna says, “Boy, I am sure glad I [gave birth that way.]”

In all other aspects of parenting, Walls credits growing up in the 1960s for becoming a self-described Granola Mom.

“When everything went ‘back to nature’, that was a big influencer for me,” she says.

As a nurse, Walls was always drawn to maternity care and supporting breastfeeding as the natural progression after giving birth.

It felt thorny to her when babies were taken to the transition nursery immediately after birth and later given back to their mothers.

This ritual sent the message that “We (as in the staff) can take better care of your baby than you (as in the mother) can.” That never sat right with Walls.

Then, one pivotal moment in particular, Walls on duty in the transition nursery, walked by a baby only a couple of hours old.

“He was frightened,” Walls begins. “His lip was quivering and he was splayed out underneath the warmer. He was so frightened. It just affected me.”

After that, Walls galvanized to change the culture in this hospital. She worked very hard alongside a physician colleague to open a birth center within the hospital. In 1995, Family Beginnings at Miami Valley Hospital in Dayton, Ohio was unveiled, offering families an option where birth wasn’t pathologized and where mothers and babies were honored as dyads. (Birthing at Family Beginnings remains an option for those in the Dayton area today.)

The center was designed to look like a home. There was no nursery for babies to be separated from their parents. When mothers came in to labor, the staff would pop in bread to bake, a special touch of aromatherapy.

Freshly baked bread, though enticing, wasn’t the number one reason families signed up to birth here. Instead, they chose Family Beginnings because they didn’t want their babies taken away from them, Walls reports.

Walls has since retired from her work in the hospital, but respectful maternity care remains forward in her mind and in her advocacy.

She graces us with reflections on respectful maternity care in her guest post this week on Our Milky Way. Read on!

******

As a nurse in maternity for over 40 years, I have too often witnessed what I refer to as the “empty vessel theory”. Women are regarded as merely a container for the fetus and care providers merely the technician to remove it, usually as quickly as possible. I have often been saddened when the emotions and spirituality of birthing are disregarded or even mocked. This miraculous process is a rite of passage with all the inherent pain, joy, lessons and connections needed to begin the journey into parenting. My hope is that through discussions and activism, we can reach a point where the birthing family is honored and all newborns are brought into the world with love and respect.

Photo by João Paulo de Souza Oliveira: https://www.pexels.com/photo/gray-scale-photo-of-a-pregnant-woman-3737150/

Respect is “showing regard for the feelings, wishes, rights or traditions of others”. Concerningly, there is an abundance of anecdotes from patients and caregivers that demonstrate how maternity care practices are often disrespectful, sometimes even abusive.

Disrespectful care encompasses racial inequity, lack of confidentiality, physical and/or emotional abuse, denial of care or provision of substandard care, lack of informed consent or coercion or condescending communications. This type of care occurs in all countries around the world, to all demographics of women and their families. Fortunately, disrespectful care has drawn the attention of many health organizations, including the World Health Organization, and steps are being taken to stop disrespectful, abusive care practices.

Examining the intersection of maternity care and human rights has been a recent topic in many maternal and infant care advocacy groups as well. We cannot assume that hospital admission for an appendectomy is equal to admission for the birth of a baby. This is because  the scope of the process of birthing impacts a person, a family, a community and a nation which is not so of a surgical procedure.

Most women and families expect they will receive safe, inclusive, compassionate care and trust their caregivers to provide prenatal, intrapartum and postnatal care with honest communication and respect for their needs and choices. Provision of safe care should look beyond the basics of preventing maternal, fetal or neonatal morbidity or mortality and consider how to support the family’s human rights– rights inherent to all people, without discrimination, regardless of age, nationality, place of residence, sex, national or ethnic origin, color, religion, language or any other status. (White Ribbon Alliance, 2020)

Photo by Dipu Shahin DS: https://www.pexels.com/photo/baby-in-pink-and-white-blanket-4050647/

The first stated right is to be free from harm and mistreatment, yet we find continuing cases of physically and emotionally abusive treatment of pregnant and birthing women. Secondly is the right to competent, culturally sensitive care for both mother and newborn.  Next is  the right to companionship and support, and lastly the right to meet the basic life-sustaining needs of the dyad, including breastfeeding support for the newborn.

The first step toward respectful care is choosing  healthcare providers who value open, honest communication and who will discuss options and listen to the family’s needs and concerns. WHO defines respectful communication as communication which  “aims to put women at the centre of care, enhancing their experience of pregnancy and ensuring that babies have the best possible start in life.” (WHO, 2018)

Other components of respectful communication include the use of positive body language, active listening, the use of non-judgmental language, assuring patient privacy and honoring physical and emotional needs.  Respectful communication can begin with simply referring to the person by the name they prefer. If it is not documented, ask.

Another important step is selecting the birthing place. (Niles, 2023) Most care providers practice at one to two hospitals or birth centers. Choosing the birthing environment is an important decision in creating a birth experience which is in line with the family’s expectations and goals. Research and discussions with childbirth educators, lactation care providers and other families can give insights into common or routine practices at that institution. Will the family’s requests be honored? Will questions be answered with open and honest informed consent? Will the birthing and breastfeeding practices support their goals? These are all questions that need to be answered before a birthing place decision is made.

Creating an environment of respectful care in the birthing place is foundational. It is care that assures women and their families will be regarded as capable of making decisions. Making decisions which respect the values and unique needs of the birthing woman can only be made when patient autonomy– the right of patients to make decisions about their medical care without their health care provider trying to influence the decision–  is recognized.

Photo by Rebekah Vos on Unsplash

Individuals often comment on birthing in the hospital as a time when you lose all modesty; however, it is possible to follow protocols that set a standard for assuring privacy and modesty which can positively impact the birth experience. Simple steps like not discussing patient history or current conditions in front of others (without the patient’s permission), being mindful of covering intimate body parts (or culturally sensitive covering) whenever possible, asking permission before touching or knocking (and waiting for a response) before entering the room are a huge part of maintaining patient dignity. It cannot be overstated that any cultural requirements for modesty must be respected at all times.

More on respect in health care on Our Milky Way here, here and here.

Other recommended resources 

The International MotherBaby Childbirth Initiative (IMBCI) A Human Rights Approach to Optimal Maternity Care

Inclusive, supportive and dignified maternity care (SDMC)-Development and feasibility assessment of an intervention package for public health systems: A study protocol.

The Giving Voice to Mothers study: inequity and mistreatment during pregnancy and childbirth in the United States.

Exploring Evidence for Disrespect and Abuse in Facility‐based Childbirth: Report of a Landscape Analysis