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Thursday, February 18, 2010

Hierarchy of Infant Feeding Choices

Two days ago, I received a text message from R, a nursing mom I previously counselled. She was very worried with the amount of milk she stored for her baby. Apparently, her baby was drinking more milk that she could express at work. She was already down to about 12oz. which was less than what her baby drinks while she was at the office.
R's baby just recently turned 6 months but did not start solids yet. Her baby's pediatrician had already given the go-signal for them to start solids but she was still hesitant unsure what to feed her baby. I suggested that at 6 months, her baby could already start solids and referred her to my previous post. However, this does not mean that her baby's milk feedings will decrease. Until 1 year old, babies still need to get their primary nutrition from milk while solids are only for complementary feedings.
R did not want to give her baby formula so she asked if she could give water or dilute her breastmilk with water instead. I was reminded of the hierarchy of infant feeding choices which the World Health Organization established, in paragraphs 18-19 of the WHO's Global Strategy for Infant and Young Feeding:
The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother’s milk be considered unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances.
For infants who do not receive breast milk, feeding with a suitable breast-milk substitute – for example an infant formula prepared in accordance with applicable Codex Alimentarius standards, or a home-prepared formula with micronutrient supplements – should be demonstrated only by health workers, or other community workers if necessary, and only to the mothers and other family members who need to use it; and the information given should include adequate instructions for appropriate preparation and the health hazards of inappropriate preparation and use. Infants who are not breastfed, for whatever reason, should receive special attention from the health and social welfare system since they constitute a risk group.
As summarized by IBCLC Diane Wiessinger, the hierarchy is (1) breastfeeding; (2) mother's own milk expressed and given to her child in some other way; (3) milk of another human mother; and (4) artificial milk feed.

For premature babies, a publication entitled "Global health policies that support use of banked donor human milk: a human rights issue" authored by Lois DW Arnold presents a further classification within the hierarchy - between premature mother's milk vs. mother's milk and premature artificial milk feed vs. regular artificial milk feed, as can be seen from the author's diagram reproduced below:
Clearly, for both full-term and premature babies, water is not a safe option for feeding your baby. Water is included as an option only for infant feeding during emergencies.
The choice of donated breast milk is also a difficult subject. The American Academy of Pediatricians frowns upon using unpasteurized donated milk and recommends only using pasteurized milk from human milk banks.
In the Philippines, we are not too particular and although I know some pediatricians who would prefer to use pasteurized human milk, for some moms this is just not an option. I only know of 3 pasteurizers in our country and these pastuerizers do not run until the milk banks receive enough donated milk to operate the pasteurizers at full capacity. I myself have donated to moms and babies who come by my place to pick up my frozen unpasteurized milk.
When donated milk is not available, I believe that formula would be the remaining option. Some lactivists might disagree with me but I believe that formula is not at all evil. Diluting your breastmilk or giving your baby water is WORSE than giving your baby formula milk. If you are faced with this choice, call your pediatrician and ask what formula to give your baby. Then don't beat yourself up about it - stressing about the one bottle won't help you. Work extra hard to bring your supply back up so you can get rid of the artificial milk feeds.


Dr Sarah said...

In this situation, I'd ask why not just go for the formula supplements and not sweat about it? She's no longer in a situation of trying to keep the baby exclusively breastfed, and, really, do you know of any evidence that formula supplements have any disadvantages once a baby is old enough to be on solids anyway? Why would it be different from offering a baby cheese to eat? (The exception, of course, would be a baby at high risk of food allergies in whom the mother might want to avoid all exposure to cow's milk at this age.)

Jenny said...

Hi Sarah! Thanks for dropping by. Actually, the mom did NOT want to give formula. So I presented her with the hierarchy and told her that giving formula would actually be better than giving water or diluting breastmilk. As for formula supplements past 6 months, you can check out these links:

Dr Sarah said...

Fair enough, though probably still worth discussing with her the lack of evidence for any harm from giving formula at this stage. I'm guessing she'd probably been reading the kind of lactivist websites that give a very generalised 'formula bad, avoid formula' message without really addressing the fact that, actually, giving formula supplements to an older baby is an entirely different matter physiologically from giving them to a younger baby.

Thanks for the links, but they're about duration of breastfeeding, not about whether formula is also given in the older-baby stage. By the way, the studies Kellymom references are actually very mis-cited - most of them look at breastfeeding in babies, not toddlers, and some of them don't say what she claims at all. I'm not fond of her as a resource for that reason.

Jenny said...

Also would like to share a comment by Dr. Z about the perils of formula feeding babies in a 3rd world country:
Also keep in mind that formula feeding someone over 6 months and less than 1 still puts an infant at greater risk for disease and malnutrition because we are a third world country with poor hygiene (think unclean water and unclean bottles; and while food may be given in unclean implements at least breastfed infants have a constant source of Immunoglobulin A to fight diarrheal disease) and where most people still live below the poverty line - this means they are less able to sustain the expense of properly-prepared formula for the recommended duration (until age 1). As such, they are more likely to be fed diluted formula or other alternatives such as regular powdered milk, coffee creamer, rice water, or even plain water.

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