Wednesday, December 1, 2010

A Paradigm Shift is Afoot: from "combination feeding" with formula to informed milk donation

There has been a rather seismic movement afoot (pun intended) in the online breastfeeding community, as it were, over the last few weeks. If you're not in the loop, the gist of the situation is that a breastfeeding advocate named Emma Kwasnica has galvanized a Facebook-centered milksharing network online: Eats on Feets. Such a thing isn't 100% new, as a site called MilkShare has been working at the same for a while now, and those in the know might be able to find donors on boards like (I've unloaded my freezer to several strangers on MDC myself). But this is taking flight like nothing has before, and I think it has everything to do with harnessing the power of Facebook and social networking in general, and how integral it has become to many of our lives.

Other bloggers have done a great job detailing the phenomenon that is Eats on Feets, such as The Motherwear Breastfeeding Blog and One of Those Women. There's much to discuss, including the (over)reaction of the Canadian government - and I won't try to reinvent the wheel here; check out their posts! But this awesome recent development ties into something I've been struggling to write about recently anyway, which is the matter of supplementation, which, in our current Western society, is set by default to formula.

Some refer to the choice to supplement (often electively, but sometimes out of necessity) as "combination feeding" or "mix feeding". It sounds innocuous enough, right? I've heard it referred to as "the best of both worlds", and despite the crystal-clear recommendation from both the AAP and the WHO to breastfeed exclusively for a minimum* of six months, the number of women who breastfeed at all are combination feeders. By a huge majority.

Initiation rates have gone up in most areas (though there's still room for improvement), and this is a positive thing. But after even a few weeks, the number of women exclusively breastfeeding drops dramatically. Check out the CDC's latest report card: By 3 months, the number of women exclusively breastfeeding is only 33%, and by 6 months . . . 13.3%. The numbers for continued non-exclusive breastfeeding are a little bit better, if only by comparison to those exclusively breastfeeding: by that same 6 month mark, 43% are breastfeeding in combination with formula.

Let's look again from the flipside: by 6 months, 86.7% of all American babies are consuming formula.

There has been a lot of great material written about why our numbers for breastfeeding are so low. Many advocates and authors of such pieces focus on the fact that real world support is still so deeply lacking. Our initiation rates are high - should be higher, again, but still, 75% is better than it used to be - and this tells us that the message that Breast is Best has definitely gotten out there. And then, when challenges arise, it is pretty much luck of the draw whether or not the support you get will be enough to allow you to continue. Were I living in a different area, and didn't have access to the excellent IBCLC that I did, I myself would not have been able to breastfeed. It's no hyperbole. I would have been another casualty of this booby-trapped system.

But as I said, wonderful articles and posts abound on this topic. I want to think more about combination feeding and why, and how, it is so acceptable, commonplace, and even encouraged - including encouragement by professionals, despite the unmistakable consensus of their own organizations on exclusive breastfeeding.

Here's my loose hypothesis: the prevalence of combination feeding is yet another result of the well-intentioned but deeply flawed "Breast is Best!" message backfiring. How so? It's tricky, but think about statements like "Every little bit counts - it's liquid gold, after all!" and "Any breast milk is better than none!" Such sentiments abound. Are they true? Well . . . yes. But I think there's a perception out there that breast milk is so powerful that even one feeding a day is enough to confer its benefits. Breastmilk, an omnipotent panacea of mythical, even supernatural proportions - surely it will cut through all the well-documented risks of commercial, artificial infant milk. Right?

IS some breast milk better than none? Well, I'd be hard-pressed to say no. Yes, it is. But saying "yes" is so far from saying that some breastfeeding is even close to the same as exclusive breastfeeding. The immunological benefits of breastmilk are some of its most powerful, the introduction of formula actually negates these very benefits. Look at this recent study from BMJ, examining the protective effect of exclusive breastfeeding on infections in infancy. It concluded that "Partial breastfeeding was not related to protective effect."

And here's another piece on a larger study released earlier this year:

"Significantly, the study showed no health benefits for infants who received formula along with breast milk, even when partial breastfeeding extended a full six months . . . . None of the antibodies found in breast milk are able to be duplicated in manufactured formula, resulting in a significant lack of protection for formula-fed babies against infectious diseases. Formula is unable to match the complexity of breast milk, the consistency of which adapts over the first few months of a baby's life, changing to fit the baby's needs as he or she grows."
Allow me to repeat that - I apologize for belaboring the point, but I want to make sure it's not missed: "The study showed no health benefits for infants who received formula along with breast milk, even when partial breastfeeding extended a full six months."

Pretty far from "Every little bit of liquid gold counts!", isn't it? Why is this? If breast milk is so powerful - and it IS; believe me, I'm not saying it isn't the very definition of a vital substance - then how can the introduction of a little formula negate it? Much of this has to do with the effect it has on our intestinal, or 'gut' bacteria. This IS where our immune system is centered, and what takes place when foreign proteins are introduced is significant. If you have never read The Case for the Virgin Gut, I implore you to do so**. From the piece:
"When babies are born, they have sterile gastrointestinal tracts. If babies are exclusively breastfed, they develop a natural healthy gut flora. (When I speak of the gut, I mean Baby's insides where the food goes until it hits the diaper.) This means that the major flora in breastfed babies has reduced numbers of bad types of bacteria and increased numbers of good bacteria. Formula-fed babies have increased numbers of bad bacteria, leaving them at more risk for illness.

Having knowledge of the importance of what is normal for newborns inside may help some mothers in making a decision about whether or not to supplement their babies for convenience in the early weeks. Very few mothers know how totally different babies are on the inside when artificial food is added to their diets. Some mothers add the formula in the hopes that their babies will sleep longer at night. Knowing that only one bottle a day can totally change the protective environment of their baby's gastrointestinal tract may give them pause to reconsider before instituting this practice.

The case for the virgin gut is a valid one. There is much research to support avoiding supplementation if at all possible. A huge increase in diarrheal diseases occurs in babies who do not have optimal "intestinal fortitude," which is only possible with guts that have never been exposed to infant formula."
Yet again, something touted as the best of both worlds is revealed to not be the best of either, something I've blogged on before - it's practically a series.

Where does this leave us? Despite the overbearing harpy cliche, I'm coming to feel that breastfeeding advocates, including lactivists and educators as well as some medical professionals, ARE extremely sensitive about pressuring new moms, and want so badly to be reassuring and accepting and above all, non-judgmental . . . so much so that they/we end up understating the risks of formula feeding. Do what you can. Of course some breast milk is better than none. It's okay. You do what you can.

It's a conundrum. We DO need to be supportive. We DO need to be inclusive. We DO need to be non-judgmental. But we also need to make sure that mothers have all the relevant information, all the facts, in order to make empowered choices. Choice, yes, but informed choice. We need to not undermine parents right out of the gate by telling them that (as I witnessed from a professional firsthand) The breastfeeding bag they give you at the hospital has a bottle of formula in it, and that's there to tell you that hey! it's okay to do both! You don't have to choose!

As anyone reading this blog is likely aware, in addition to the risks for the infant, supplementation not done carefully leads to diminishing supply, and if the mother is not aware of how this works, mom's assumption is that something is wrong with her, that she "just couldn't make enough milk", and the slippery slope to total cessation of nursing has already begun. There has to be a way of being compassionate and inclusive without saying things like, as I have also heard with my very own ears from a pro, "If you want to nurse for 6 weeks and then start using formula, that's okay! Whatever works for you! If you want your husband to give a bottle of formula overnight so you can sleep, that's okay! Whatever works for you!"

But there ARE cases, as we know, where supplementation IS necessary. There is no denying that. We want to reduce these cases, but there absolutely are times when it is needed, such as moms with hypoplasia/IGT, or with some BFAR moms, for instance. And here's where the paradigm shift comes in.

It's time that donor milk becomes a real possibility for mothers.

Despite formula companies spending millions to convince you that their product is the "next best thing" to human milk, the WHO designates formula as fourth best - dead last, in other words. The first choice is simply mother breastfeeding her own child, and then pumped milk from the same mother to her own child. Then, third best, is donor milk from another mother, not formula. Yet when supplementation proves to be necessary (either temporarily or long-term), the default in our society is to go directly to formula. Then begins a cycle of figuring out which formula is less difficult for the baby's system. Do we try the "gentle" variety? What if milk is the problem - do we do soy? If that's not working, on to the hydrolyzed and painfully expensive kinds. What if donor milk was a viable option? What if it wasn't just a vague possibility - difficult to pull off in the short term and even harder to do over any substantial length of time - what if donor milk was, instead, the default?

Now, milk banking has been around for a while, and while I think it's basically a good thing (as in HMBANA), to say that it's prohibitively expensive for most families is an understatement, and can be difficult to impossible to get unless your child is ill. Doctors can prescribe it and SOME insurance companies are starting to cover it - but we're a long ways from this being the standard. There's always talk of making banked milk more plentiful and accessible (as the Canadian government stated in response to the growth of Eats on Feets), but that time has definitely not yet arrived.

Doesn't milk sharing and direct donor milk (as opposed to the pasteurized kind one can gets from banks) carry some risk, though? Yes it does. There are diseases that are communicable via breastmilk, and it's absolutely wise to vet the donor in whatever way both parties feel comfortable, wether there's a formal or an informal process in place. I've given milk directly to moms who knew me and trusted me, and have done a little bit of wet nursing, but to one mother who found me via MDC, I submitted a medical record of my most recent blood workup, which I thought was totally fair and the other mom seemed satisfied by this. It still involves some trust, but the risks taken in accepting donor milk must be weight against the risks of infant formula. PhD in Parenting has already done a bang-up job of doing just that (though of course every parent has to make this comparison on their own, as she illustrates).

As someone who participated in a nursing support group where milksharing was common, and donated literally gallons of my own milk to several babies, I am so pleased that since mothers are frustrated with the admirable but glacial progress of milk bank accessibility, they are making their own informed choices, taking this into their own hands - and feets.

*This is something that gets lost in translation, telephone game style. I have heard and read more than one mother claiming that the recommendation is to breastfeed for six months, period. They literally interpret the recommendation -whether second or third or fourthhand through peers, or not explained well enough by professionals, or misread in a book - as endorsing breast feeding for six months
and no longer.

** Another helpful link on the subject: Just One Bottle Won't Hurt - Or Will It?


  1. I think this is a big part of the issue with the "formula is normal" mindset. Breastmilk is normal; formula alters the gut in unhelpful ways. I wish I had a better way to communicate this with families where I work; we are trying to have better info to give them on the actual risks of formula feeding if they choose to supplement, because like you said - heck yes it's a choice but right now it's not informed.

  2. The fact is that there are plenty of kids who walk around seeming to be "just fine" who were either completely formula fed or had only a few token weeks of breastfeeding before whatever factors undermined it. Those same kids grow up to be "just fine" know, except for the few hundred dollars in prescription drugs that are pretty normal these days. I guess if formula fed children are in fact just fine, then it means that our standards aren't high enough.

    I'm proud to say that I was given 6 months of exclusive breastmilk by my mother, and a few months after that as well, and at the age of 30 have no health problems and take no medication and have an excellent medical track record...may I be so blessed for that to continue.

  3. QUOTE Allow me to repeat that - I apologize for belaboring the point, but I want to make sure it's not missed: "The study showed no health benefits for infants who received formula along with breast milk, even when partial breastfeeding extended a full six months."

    I think this is a bit of a misleading statement to be honest. The study only examined upper and lower respiratory tract infections and gastrointestinal infections - and makes the statement Partial breastfeeding, even for 6 months, did not result in significantly lower risks of THESE infections.

    To extrapolate that to the message some breastmilk has absolutely no benefits simply isn't accurate. We know that all of the above are reduced due to SiGA coating the gut which is destroyed by any formula - thus "mix feeding" with formula will not protect.

    However - breastmilk is about a LOT more than just SIG A protection? hormones, HAMLET, stem cells and all the antibodies that work by entering the bloodstream rather than gut coating protection.

    I never underestimate the risks of formula, I've blogged a lot about them - but for mums that for whatever reason cannot achieve that, I think personally we also need to recognise some is still massively valuable. Even taking all the health reasons out of the equation - the psychological/emotional aspect for baby is significant no?

    Anyway here's my take on things :)

  4. This is why it bothers me so much that we only talk about the 'benefits of breastfeeding' and not the 'risks of formula'. It gives the impression that formula is the norm to which breastfeeding is compared and it relegates breastfeeding to the category of extra credit. If we simply change the language and always describe formula as a risky and abnormal practice then we can never forget that the risks are there ANY time formula is given, regardless of the amount.

  5. Armdillo, it's fitting that you posted here - I read that very post of yours when it was very recently shared by Dispelling Breastfeeding Myths on Facebook. It was one of several pieces that got my wheels spinning on this issue.

    I do state several times that yes, it IS true that some is indeed better than none. The benefits of partial breastfeeding are still worthwhile. I fceel really strongly, though, that parents are very often not geting the full picture of how much the benefits are diminished by introducing formula. "Every little bit counts", while true, slips and slides all too easily into "a litte bit is all you need". (And if continued without measures to maintain supply, a little bit will be all that is produced.)

    I do see that I should clarify the part you quoted to make it clear that "no benefits" was specifically in regard to the infections being studied - I didn't intend to omit info, but I can see how it needs rewording. It's still a very significant diminishment of the potential protective components of human milk, and more people need to be aware of it.

    I do appreciate your thoughts, as always - thanks for posting!

  6. I wish I knew then what I know now! Is becoming my mantra when it comes to breastfeeding. When my first child was born he spent 32 days in the NICU and I pumped so he'd have breastmilk, when we got home I laboriously transfered him from bottle/pumped milk to breastfed. And we successfully breastfed for 13 1/2 months. But I had constant supply issues. I drank lactation tea every day, 32 oz that had sat overnight with 4 teabags in it. I drank 100oz of water or more, I kept my calorie intake up, I took fenugrek (sp?) Supplements. Still, my babe nursed every hour 24 hours a day and by about 3am I was dry, he was hungry, and he got a bottle of formula. If I knew then what I know now I would rather have gotten up and walked and bounced a hungry, fussy baby for an hour every night until I had some milk than give him that bottle. But I didn't know, and I don't blame myself, but I am angry at the medical establishment that made me believe formula was inferior to breastmilk but still a 'healthy' alternative. I bet I could have found someone to donate a bottle of breastmilk a day for a hungry NICU survivor!

  7. BTW your post sparked my thoughts about who should be offered donor milk...curious to hear your opinion!

  8. To me the biggest problems affecting breastfeeding are structural - that is to say, a lot of the problems women encounter with breastfeeding are created, rather than "natural" - by created I mean by practices that sabotage BF (you know the list - lack of skin on skin, immediate supplementation, failing to nurse on demand, etc). There's a disconnect right now between the accessibility of the "Breast is best!" motto and the real, substantial opportunities and information about BF offered to women (or lack thereof). Hospitals are full of booby traps. And then when women supplement, others stand around going "Why do these women choose to supplement?" I think it's important to think of it this way - choosing not to bf exclusively is a "choice" rather than a real choice in many cases, because of there are so many structural difficulties. I believe strongly if there was better education and support and hospital practices in place, the BF numbers would rise without women feeling judged or pressured. I think a lot of the hostility from formula feeding mothers to BF advocates comes from a place of frustration - many of them tried, really hard, and couldn't make it work. Lack of access to donor milk is just structural problem. (And of course in the States many people are grossed out by milk sharing because of the larger social fears of human milk and women's bodies.)

    I'm so excited about Eats on Feets! As soon as I read my first post about it, I rushed over and checked my area - and viola there's a woman in my region who needs milk. And I have it! Our babies are exactly the same age! We're in touch and I may be beginning my first informal donation. I'm also a Milk Bank donor, so I have full medical screening, etc. I like the Milk Bank because much of the milk gets to NICU babies, and they were the reason I wanted to donate in the first place. So I will always be a strong advocate for Milk Banks first - if properly funded, they would provide centralized support, awareness, and access. But grass-roots women helping women! Awesome!

  9. Nice article. very interesting, thanks for sharing.