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Friday, May 31, 2013

Reconciling Milk Storage Guidelines - Philippine Setting

I haven't posted anything for more than 1 week!! I started working on this post about 2 weeks ago and really agonized how to make it all come together.  Finally, here it is and I hope this will be helpful and not confusing to breastfeeding moms.

Back in my 2009 post about milk storage guidelines, I referred to guidelines culled from Western countries.  I'm happy to share that there are now guidelines specifically created for the Philippine climate. However, if you notice the charts, the suggested storage guidelines are not the same.  One guidelines were developed by MDs while the other was developed by internationally recognized expert breastfeeding counselors.   

Guidelines from Arugaan
Guidelines from the Philippine National
Committee on Human Milk Banking
The first set of guidelines were developed by Arugaan.  According to Ines Avellana-Fernandez, the ranges specified in the Arugaan guidelines is dependent on usage.  Nanay Ines engaged with Dr. Ruth Elena Arango of Guatemala Ministry of Health in developing these guidelines.  The Philippines and Guatemala share similar traditional practices.  For instance, the "refrigeration system" used is by digging the soil and placing earthen jars to cool and preserve food.

Since the 1980's, Nanay Ines adopted and taught a similar method applied by Filipino breastfeeding mothers in urban poor communities - placing expressed breastmilk in containers (usually recycled bottles) inside a container with water to avoid ants and keep the milk cool despite of the heat.

To overcome brownouts, the mothers put small bottles of expressed breastmilk inside a plastic bag with water then freeze everything - double bagging.  The bag of water will be defrosted first, keeping the expressed breastmilk in a frozen state.  This will allow the frozen expressed milk to last longer - until the brownout ends.

Meanwhile, Dr. Lei Alfonso has also discussed storage guidelines for Pinay moms in her blog here.  One thing that really bothered me about the MD guidelines was that the storage period was much shorter.  I asked one of the drafters, Dr. Jessa Sareno why they drafted it as such.  She shares that since most Filipino households that have refrigerators usually have a lot of household members using the same ref (e.g. opening and closing the ref often), the Committee opted to recommend the margin of safety that can ensure the optimal quality of stored milk.  If the refrigerator is dedicated for breastmilk (which is rare and usually cannot be afforded by an average low-income Filipino), then more than 48 hours may still be safe.

If you noticed, the MD guidelines referred to 24-48 hours in the refrigerator while the Arugaan guidelines referred to 3-5 days.  Fortunately, my favorite resource Dr. Z reminded me of two things.  First, if in law we have different levels of quantum of proof (substantial evidence, prepoderance of evidence, proof beyond reasonable doubt), in medicine they follow a similar levels of evidence when they offer clinical advice.

When the Committee on Milk Banking drafted their recommendations, they used the highest level of evidence - where recommendations are based on pooling of current available scientific data. (Edit:  Dr. Z clarified: "When drafting recommendations, we ideally use the highest level of scientific evidence available at the time - so if there are multiple studies then we pool that data together, and if there are none, then we will end up using Expert Opinion")

Meanwhile,  Nanay Ines' recommendations are considered "Expert Opinion" - based on her background research, experiences and learnings.  Dr. Z shares that often times, it is expert opinion that drives further scientific study and a possible later change in policy or recommendations.  And this is very true in breastfeeding.  If you read this article about Dr. Jack Newman, he pioneered several ideas (based on expert opinion) which have now been adopted as part of basic breastfeeding advice or guidelines.

Secondly, Dr. Z emphasized that guidelines are not laws but are "best practice" suggestions. For example, for newborns, it is recommended that you feed from 8-12 times a day (or every 2-3 hours).  But as moms we know that this is not always true because there are some babies who feed every hour - and this does not mean that there is anything wrong with your baby or your supply.

Thus, to reconcile, I would choose to be conservative if my circumstances permit me but still apply Arugaan's guidelines as my maximum range. For instance, the milk I express early morning (6am) sits at room temperature ready for E's consumption at about 9am.  However, if he doesn't completely finish the milk by 1-2pm, we don't throw it out but keep it in the refrigerator for consumption later in the day.  In the same manner, if I know I won't be using Monday's expressed milk, I don't wait until Wednesday before we move it to the freezer.  We freeze it right away.  However, if on Thursday we still find some Monday milk, we don't throw it out.  We either give it to E or freeze it.

As a final note, to convince yourself that the milk you are giving your baby is not spoiled, I would suggest that you purposely spoil some of your breastmilk.  Take half an ounce or even less of your  milk and leave it outside or in the refrigerator for such a time until it spoils.  Then smell your milk - it will smell really BAD!  Then once you and your caregiver knows how spoiled breastmilk smells like, then you can be sure that you won't ever be giving your baby spoiled milk!

Edit from Velvet of Arugaan: The reason why there is so much concern about the life of breastmilk is because our society is used to the standards set for formula milk.  While formula milk expires within 1 hour from the time it was made, breastmilk is much more potent.  So even when abused, breastmilk is still alive and much like babies, breastmilk is sturdier than we think it is!

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