Identify and network with an individual or organization with a mission that intersects with maternal child health. This shouldn’t be a challenge… “All roads lead to breastfeeding!” (A popular adage at Healthy Children Project.) Often, we find ourselves preaching to the choir, shouting in an echo chamber, whatever you want to call it. It’s time to reach beyond our normal audience.
Follow Dr. Magdelena Whoolery on social media to stay up to date on strategies that combat the multi-billion dollar artificial baby milk industry.
In an eerie parallel, WHO’s February 2022 report, How the marketing of formula milk influences our decisions on infant feeding, states that “Recommendations from health professionals are a key channel of formula milk marketing. Health professionals spoke of receiving commissions from sales, funding for research, promotional gifts, samples of infant and specialized formula milk products, or invitations to seminars, conferences and events.” (p. 7)
Last week, Nikki Lee, RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, RYT500 and I shared our reflection on the forces that shape physicians’ personal infant feeding experiences. In this second installment, we explore how physicians as professionals can support breastfeeding despite being targeted by the breastmilk substitute (BMS) industry and despite generally being woefully equipped with proper lactation education, training and counseling skills. These predicaments can lead physicians to “explicitly or inadvertently, introduce doubts around the ability of women to breastfeed and the value and quality of their breast milk.” (WHO, p. 12)
Pervasive industry influence for generations
Because “health professionals are among the most respected and trusted members of society…[their] advice…is highly influential for pregnant women and parents of infants and young children, including around infant feeding decisions.” Formula milk companies exploit this relationship of trust. (WHO, p. 12)
BMS representatives target physicians “with a range of incentives, including funding for research, commissions from sales, ambassadorial roles, merchandise, gifts and all expenses paid promotional trips.” (WHO, p.13)
The psychology behind gift-giving, both big and small is that “ it imposes…a sense of indebtedness…. The…rule of reciprocity imposes…an obligation to repay for favors, gifts and invitations…” (Katz 2003) Instead of supporting infant feeding purely through a health and wellness lens, physicians feel obliged to a company muddying their relationships with their patients.
Interestingly, most physicians feel immune to marketing’s influence, despite clear evidence to the contrary, Frederick S. Sierles, MD lays out in The Gift-Giving Influence.
Our culture fails to acknowledge the mother baby unit as a dyad, and this influences the way physicians can support breastfeeding too.
“We are never taught, in our fragmented system, that the mother and baby are a unit,” Lee reiterates. “OB/GYN/midwife sees mama; peds sees babies. There are even different places for them in the hospital: nursery, postpartum unit. What a struggle we had with the BFHI to keep mother and baby together.”
The Alliance for Innovation on Maternal Health’s (AIM) Patient Safety Bundles offer models for how health professionals can use task force approaches that break down silos of care and open channels of communication. The strategies used in these bundles aim to ultimately shift from fractured care to continuity of care where the dyad is protected.
We must also consider how physicians are compensated for their work. In the current U.S. healthcare system, physicians find themselves paid in Relative Value Units (RVUs), which bluntly put, is a pretty mechanical way to value providing care to other humans, as we mentioned in our first installment. In short, the more RVUs a physician racks up, the more they’re paid. Breastfeeding counseling takes time.
How are physicians to spend time with their patients, educating and supporting breastfeeding when they’ve had little to no breastfeeding education invested in them? Dr. Nigel Campbell Rollinspointed out in WHO’s How the marketing of formula milk influences our decisions on infant feeding webinar that faculty in medical schools themselves sometimes believe that formula products are inevitable or necessary.
Often, it is a physician’s own struggle to breastfeed that seems to spur advocacy and change. Our Milky Way’s repository includes a breadth of physicians’ stories of personal struggles that have inspired them to become breastfeeding champions for their patients and communities.
“There was no training about [breastfeeding] technique, no discussion about common problems before discharge, no training about clinical problems as far as in the first few months postpartum…when to introduce complementary food,” she continues.
We are honored to have been able to feature the work of the late Audrey Naylor in Commendable contributions to the field of lactation. With a lifetime interest in illness prevention, Naylor said she was quickly convinced of the power of breastfeeding after only attending a few hours of a breastfeeding seminar in 1976.
“Neither medical school nor pediatric residency taught me anything about breastfeeding,” Naylor said.
“It is easy to become frustrated with nurses and physicians who – often inadvertently sabotage breastfeeding mothers and babies, but I also sympathize,” she explains. “We are in a position where we are supposed to have answers, but no one has taught us the skills necessary to provide those answers.”
Other stories and models for care
Lori Feldman-Winter’s, et al Residency curriculum improves breastfeeding care showed that “a targeted breastfeeding curriculum for residents in pediatrics, family medicine, and obstetrics and gynecology improves knowledge, practice patterns, and confidence in breastfeeding management in residents and increases exclusive breastfeeding in their patients. Implementation of this curriculum may similarly benefit other institutions.
As part of their work to build a cohort of breastfeeding-friendly pediatricians, the Georgia Chapter of the American Academy of Pediatrics and the Georgia Breastfeeding Coalition launched a “Breastfeeding-Friendly Pediatrician Interest Form.” Georgia pediatricians who are interested in becoming certified as a “Breastfeeding-Friendly Pediatrician” are invited to fill out the form.
“Even in the harshest of trade regimes, there is space for public interest laws to meet legitimate health objectives when they are founded on internationally adopted standards and recommendations such as the Code and subsequent relevant WHA resolutions.”– WHO, 2016
All three of my kids sport a similar look when they lie. As soon as the fabrication tumbles out, their cheeks suck in ever so slightly toward pursed lips. Once they’ve heard themselves, their eyes widen a smidge and their bottom jaw drops just a few degrees.
Most of us don’t like to be lied to, but usually the dishonesty we encounter can be considered trivial. “I didn’t do it!” when there’s crayon art on the kitchen walls. “Your hair looks great!” when you know it doesn’t. “Of course I remember you!” when you haven’t the slightest clue.
Just as humans tend to react physiologically when we lie, we have an ability to detect when someone is lying to us. Inundated by the lies told by marketing companies on behalf of major industries though, detecting truth and falsehoods can be majorly challenging. There’s no lip biting, no shifting eyes, no perspiring to give it away. Instead the tactics industries use are cunning, targeted, sometimes irresistible and truly brilliant in many ways. The lies they tell are perpetual, and their claims have completely saturated our culture, influencing just about every facet of our lives, all for commercial gain.
There’s a promotional video featured by a cooking show that showcases a chef professing his allegiance to gas stoves. The video was created by a utilities provider though, and having worked aggressively with state legislatures “to block legislation that would provide cleaner, electric-based building codes,” their marketing got us to believe that cooking on a gas stove is somehow the best while simultaneously waging “war on local electrification initiatives all over the country.” [https://www.thresholdpodcast.org/season-4-episode-6-transcript]
Here’s another example. Most of the seafood that we purchase and consume in the U.S. is mislabeled as something completely different. This “Seafood Fraud” is detailed in (Mis)labeled Fish.
Fossil fuel companies are greenwashing their efforts, helping to sow doubt about the fossil fuel industry’s role in the climate crisis.
As explained on How to Save a Planet: “They’ve… done it indirectly, by funding organizations who lobby congress, launching fake grassroots campaigns, and perhaps most importantly, through advertising. These ads, according to Martin Watters at the nonprofit firm ClientEarth, are greenwashing.”
Now consider the baby milk substitute (BMS) industry. A recent WHO report examines the scope, techniques and impact of digital marketing strategies for the promotion of breast-milk substitutes which reveals how the $ 55 billion baby formula industry “insidiously and persistently” targets parents online through “tools like apps, virtual support groups or ‘baby-clubs’, paid social media influencers, promotions and competitions and advice forums or services, formula milk companies can buy or collect personal information and send personalized promotions to new pregnant women and mothers.” [https://www.who.int/news/item/28-04-2022-who-reveals-shocking-extent-of-exploitative-formula-milk-marketing]
Their efforts have further adapted to target older children with their toddler milks and formulas. Lurie again calls out false claims like “Brain & eye development” and “Plant-based protein for toddlers.”
He writes: “The multibillion-dollar infant-formula industry is trying to convince parents that children older than 12 months need formula. They don’t. The beverages—made largely of fortified powdered soy or dairy milk, oil, and corn syrup solids or maltodextrin—typically supply added sugars. They certainly don’t beat a diet of healthy foods.”
The WHO report confirms these concerns: “Science is a dominant theme in the marketing of formula milk across all eight countries, including scientific imagery, language and pseudo-scientific claims. Formula milks are positioned as close to, equivalent and sometimes superior to breast milk, presenting incomplete scientific evidence and inferring unsupported health outcomes. Ingredients, such as human milk oligosaccharides (HMOs) and docosahexaenoic acid (DHA), are advertised as ‘informed’ or ‘derived’ from breast milk and linked to child developmental outcomes. Examination of the scientific evidence cited does not support the validity of these claims.” (p. 9)
The marketing of formula products is different from other commodities because it impacts the survival, health and development of children and mothers; disrupts truthful information– an essential human right as noted by the Convention on the Rights of the Child; disregards the International Code of Marketing of Breast-milk Substitutes; and exploits the aspirations, vulnerabilities and fears at the birth and early years of our children solely for commercial gain. (WHO/UNICEF, 2022, p. x)
Considering the current state of affairs– the industry’s guileful tactics, the permeation of their influence in every sphere of life, our nation’s lack of adoption of the International Code of Marketing of Breast-milk Substitutes/ subsequent WHA resolutions and any monitoring or enforcement systems– it’s easy to feel crushed as a maternal child health advocate, like the way forward is straight into the Apocalypse.
Fear not. Researcher Britt Wray has suggestions on how to keep ourselves within our windows of tolerance in order to continue to mobilize. While Wray’s work focuses on the climate crisis, her findings are easily applied to maternal child health advocacy. Learn about these techniques here.
There are also simple actions (and some bigger ones too) that we can employ to continue to move the needle.
Françoise Coudray of ADJ+ Allaitement Des Jumeaux et Plus offered this to health advocates attending the launch of WHO’s latest report : “The mosquito: small, small, but have one in your bedroom and you will have a very bad night; so do the mosquito, let us all do the mosquito.”
When marketed formula products on social media platforms, report them directly to the platform.
Make a presence at the Codex Committee on Contaminants in Foods Public Meetings. In April, individuals like Consumer Reports Senior Staff Scientist Mike Hansen, Ph.D, Environmental Defense Fund’s chemicals policy director Tom Neltner and Center for Science in the Public Interest’s Thomas Galligan, PhD made clear in brief comments that we need to rethink how toxin levels are approached at CCCF. Hansen pointed out that the current permitted levels are not sufficient to protect infants and young children. Echo these demands for safer products. [While we wait for more stringent requirements, consumers can check out the Clean Label Project to find information about food and products not available on their labels.]
Join forces with other advocacy groups to put pressure on the enforcement agencies responsible for food safety.
Get people fired up. Increase public interest participation using NACCHO’s flyer on advocacy and lobbying to drum up attention about how the Code benefits all babies, no matter their feeding method. This has been grossly overlooked and cannot be overstated as formula companies often attempt to pit breastfeeding advocates against those who do not breastfeed.
Encourage divestment. Check out Norwegian Secretary-General of Save the Children Tove Wang’s push for the Norwegian Government Petroleum Fund’s withdrawal from investments in companies aggressively pushing infant formula in developing countries. According to Save the Children’s Don’t Push It, “The largest global fund management firms have more than $110 billion invested in companies that market milk formula. As we have documented in this report, the profits these companies generate are fuelled in part by marketing practices that directly – and profoundly – harm children….Active investment funds have the power to wield huge influence over the boards of the companies they have a stake in.” (p44-45)
Originally from New Orleans, Erin Bannister, lab instructor and dietetic intern at Northern Illinois University, says that food is tied to her identity. Bannister was ten when she first learned to make a roux. Those early skills prepared her for her later work as a chef, which she describes as a kind of manual labor with long, hot hours.
Bannister shares with a laugh, that she started to wonder how she could work with food and continue to nourish people with weekends and holidays off. Eventually, she discovered the field of dietetics.
Currently in the thick of her Master’s thesis, Bannister is exploring the metabolic energy needs in adults and determining whether the default equations we use are accurate in the populations they’re used in.
For instance, it is widely accepted that an average allowance for a roughly 170 pound man is 2,300 kcal/day; for women, it is 1,900 kcal/day. We expect that pregnant and lactating people will have higher metabolic energy needs.
As Bannister spends a swath of her days compiling and extracting data, she says she’s discovering that some of the accepted equations need to be delineated.
“The real root of my thesis and the root of most of my studies and the goals that I have, is to use accurate evidence-based interventions in the populations that they are meant to be used in and to not remove ourselves from that evidence,” Bannister begins. “… Often times, things are taught and then they are believed because the person that taught it is an expert and the evidence gets lost on the way; don’t forget to review the evidence.”
As Bannister continues to pursue this idea that we can do better than sludging through the status quo, she sought out the Lactation Counselor Training Course (LCTC). Although Bannister has great interest in the complexities of nutrition and health from cradle to grave, she says that there is a solid argument that the health of a population is highly correlated with the health of its mothers.
“[I want] to be as helpful and effective as possible… to have the knowledge to be able to contribute meaningfully, and the certification adds credibility,” she explains. “The training was quite eye-opening, almost embarrassing to say how little I knew about breastfeeding.”
Bannister goes on that ultimately, she would like to work with nutrition intervention in low and middle income countries where the burden of improper nutrition is most severe. Currently, many countries worldwide face the double burden of malnutrition – characterized by the coexistence of undernutrition along with overweight, obesity or diet-related noncommunicable diseases (NCDs). In fact, nearly one in three people globally suffers from at least one form of malnutrition: wasting, stunting, vitamin and mineral deficiency, overweight or obesity and diet-related NCDs. (WHO 2017)
As Bannister buckles down at the end of the semester, she says, “I want to make sure I am utilizing all the forks I’ve got in the fire.”
Inform people about the links between breastfeeding and the environment/climate change
Anchor breastfeeding as a climate-smart decision
Engage people and organizations for greater impact
Galvanize action on improving the health of the planet and people through breastfeeding
Can breastfeeding really affect climate change and create a cleaner, healthier environment?
Our planet’s health is closely tied to human health, and so there is a growing interest in learning how to protect the health of the environment.
Among the many things humans can do to protect the environment, breastfeeding is one of the most important. Breastfeeding is the best example of a clean, eco-friendly action to protect and improve the health of planet Earth.
Breastfeeding is the ultimate natural, sustainable resource. It requires no raw materials needed for processing and no energy consumption in production or transportation. It does not produce any material waste or by-products, does not require any packaging materials, water resources or electricity, and creates no pollution of the air or water. Lactation is a perfect partner for environmental health and the ultimate example of “eating local”.
Parents who express their milk and feed from bottles or other methods also provide a more planet-friendly feeding method than artificial feeding. Formula manufacturing requires energy, material and transportation.
The carbon footprint of breastfeeding gives us another glimpse into the environmental impact of breastfeeding. Wikipedia defines carbon footprint as “the total greenhouse gas emissions caused by an individual, event, organization, service, or product, expressed as carbon dioxide equivalent.” In simple terms, it’s a measurement that shows us something’s impact on the health of the environment.
The carbon footprint of breastfeeding is based on the production and transportation of food for the mother based on the RDA of an additional 500 kcal/day recommended during breastfeeding. According to research from the United Kingdom, the carbon footprint of breastfeeding is estimated at 5.9 (this varies between countries).
In comparison, the carbon footprint of formula feeding— which is based on the use of resources, animal and factory production emissions and transportation of the formula as well as supplies, preparation and storage of formula at home— is estimated at 11.0 (again varying between countries). On average, feeding breast milk substitutes had a higher impact on the climate than breastfeeding in all countries studied. This certainly demonstrates the positive impact on the environment when the infant feeding choice is breastfeeding.(Bodkin, 2019 Meade, 2008)
The International Baby Food Action Network (IBFAN) supports optimal infant feeding practices and advocates for universal implementation of the International Code of Marketing of Breastmilk Substitutes, an international health strategy recommending restrictions on the marketing of all formulas and supplies intended to discourage breastfeeding. In 2015 IBFAN developed their statement on breastfeeding and the environment:
“Breastfeeding protects our health and our planet – right from the start, breastfeeding is the first step towards protecting human health, short- and long-term. It is also the first step towards protecting the health of our environment and conserving our planet’s scarce natural resources. We need to start at the beginning, with infants and young children. Our babies and children are in no way responsible for climate change and environmental degradation, but instead they suffer the disastrous consequences.” (IBFAN, 2015)
It’s clear that breastfeeding is the most climate-friendly option for infant feeding, but does the environment have an impact on breastfeeding? The answer is yes.
For decades scientists around the world have studied the impact of environmental contaminants on the mammary gland, and on mothering behaviors. For instance, a study from the Journal of Health Science demonstrated that rats exposed to dietary bisphenol A (BPA) in early pregnancy showed cellular injury to the mammary glands as well as lower prolactin levels. (Miyaura, 2004).
What’s more, Rochester Medical Center studies reported in Science Daily demonstrated damage to rat mammary glands to the extent that some mother rats were unable to nourish their pups after exposure to dioxins. Researchers noted that some rats were able to recover mammary function by late pregnancy. (Lawrence, 2009).
In 2013, a study in the Journal of Neurotoxicology and Teratology showed a decrease in maternal behaviors in Wistar rats (less grooming, protection and nuzzling), a concerning finding but not yet demonstrated in humans. (Boudalia, 2013}.
Studies like these are the basis for ongoing research looking into possible negative impacts on human lactation. The studies are also the basis of much education related to how to create a safer environment while protecting lactation.
An unpublished study from Wright State University looked at mothers with self-described low milk supply and the relationship between environmental contaminants. The 78 mothers in the study were four weeks to eight months postpartum and were all given education on reducing exposures to environmental estrogens (personal care products, food hormones and plasticizers).
Results were seen in one to five weeks and ranged from the mothers stating her “breasts were fuller,” the “babies seemed more satisfied,” and fewer needed supplementation. Some found a doubling of supply (noted with pumping during work hours). Seven had no noticeable increase in milk supply, and of those only two weaned from breastfeeding. The rest continued supplementation. (Walls, presented 2009).
In a Mexican study of young Yaqui tribe women, those who moved from native land to new chemical based agriculture, had less alveolar tissue compared to the young women who remained with the tribe and practiced traditional, non-chemical farming techniques.
Many of the agri-chemical exposed young women were found to have larger than normal breasts, but less glandular tissue (referred to as “empty breast” syndrome) and many were unable to breastfeed their infants which is viewed as an integral part of mothering in their culture. (Hansen, 2010).
On the surface, these studies can seem discouraging until we really weigh the risks and benefits of breastfeeding in a polluted world.
First, human milk contains properties that have been shown to mitigate some negative, environmental effects. (Williams, Florence, NYT)
For instance, human milk contains bio-active components which specifically control and resolve inflammation, promote a thick, healthy gut lining to support an optimum functioning immune system and provide the most nutritious food for optimum general health for infants and children.
Emeritus Director of the Carolina Global Breastfeeding Institute Miriam Labbok, MD, MPH, IBCLC stated “The fact that studies of child [health] outcomes in highly polluted areas are still better for the breastfed infant . . . would seem to indicate that certain factors in the production of human milk and in the milk itself, immunological and other, may mediate the potential harm of the ambient pollution.”
She went on to say, “… No environmental contaminant, except in situations of acute poisoning, has been found to cause more harm to infants than does lack of breast-feeding. I have seen no data that would argue against breastfeeding, even in the presence of today’s levels of environmental toxicants.”
Sandra Steingraber, biologist and author of Living Downstream and Having Faith: An Ecologist’s Journey to Motherhood agrees: ”We haven’t yet compromised breast milk to such an extent that it’s a worse food than infant formula…..”
The American Academy of Family Physicians (AAFP) has also published that certain components of human milk act to increase the infant’s elimination of some toxins and to protect the infant’s developing brain, central nervous system, and body as a whole.
WABA’s statement on breastfeeding and environmental contaminants echoes this sentiment and encourages breastfeeding as the safest feeding choice despite maternal exposure to contaminants.
Their statement reads: “Is the presence of these chemical residues in breastmilk a reason not to breastfeed? No. Exposure before and during pregnancy is a greater risk to the fetus. The existence of chemical residues in breastmilk is not a reason for limiting breastfeeding. In fact, it is a reason to breastfeed because breastmilk contains substances that help the child develop a stronger immune system and gives protection against environmental pollutants and pathogens. Breastfeeding can help limit the damage caused by fetal exposure.” (WABA, 2005.)
The World Health Organization’s (WHO) review on contaminants and human milk states definitively, “The benefits of breastfeeding far outweigh the toxicological disadvantages that are associated with certain POPs” (persistent organic pollutants).
To reiterate, considering the safety of human milk even when contaminants have been detected, neonatal intensive care researcher Fani Anatolitou (2012) states, “the detection of any environmental chemical in breast milk does not necessarily mean that there is a serious health risk for breastfed infants. No adverse effect has been clinically or epidemiologically demonstrated as being associated solely with consumption of human milk containing background levels of environmental chemicals”.
It is important to understand that many of the measurements of POPs in human milk are not clinically meaningful, hence are not a cause for alarm. Even more importantly, as mentioned earlier, a number of components of human milk act to counter potential risks of contaminant exposure (Anitolitou, 2012). The Centers for Disease Control and Prevention (CDC) points out that effects of exposure have only been detected in a breastfeeding infant when the mother was extremely ill.
As lactation care providers we are in a unique position to not only support the optimum health of infants and children, but also be a part of creating a healthier environment for the children to grow and thrive.
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