Decoding the Monster Bill - Part 2

Read Part 1 HERE. 

*Please note that when I wrote this post, it was originally based on the May draft.  There is now a July 9 draft and you can see the quick comparison here - https://docs.google.com/a/chroniclesofanursingmom.com/spreadsheet/ccc?key=0AhSdlPvu96IKdFRqYjVkSmZEMldRSTZHaGxzYmJhUXc#gid=0

The monster bill also seeks to limit the advertising restrictions to products targeted to babies 0-6 months (Sec. 32).  This means that for products for babies 6 months and up, advertising and promotions shall be freely allowed.  There are just so many things WRONG with this provision.  Under the current laws, all advertising, promotions, etc. require prior approval or permit from the IAC.  Here is the position of the Save the Babies Coalition on this matter:

Allowing promotions for products for six (6) months and above, will cause an irreparable damage to the growth and development of our country. Allowing this does not protect and support breastfeeding but it only favors milk industry gains and commercial interests.

This was already surfaced by the late US Senator Kennedy, in 1978, when he himself called for a senatorial investigation on the review of marketing and promotional practices of the milk industry that resulted in requesting UNICEF and WHO to help member countries in developing appropriate measures that will regulate and if necessary prohibit certain marketing practices.

Decoding the Monster Bill - Part 1

*Please note that when I wrote this post, it was originally based on the May 2012 draft.  There is now a July 9 draft and you can see the quick comparison here - https://docs.google.com/a/chroniclesofanursingmom.com/spreadsheet/ccc?key=0AhSdlPvu96IKdFRqYjVkSmZEMldRSTZHaGxzYmJhUXc#gid=0

My Facebook and Twitter accounts have been flooded with updates and messages about killing the monster bill.  But I realized that not everyone really understood what it was.  You can read the text of the monster bill HERE.  The monster bill is a consolidation of 4 bills - namely HB3396 (Bondoc bill which is the good bill), HB3525 (Gunigundo Bill), HB3527 (Noel/Rodriguez Bill) and HB3537 (Mercado/Torres Bill).  Click the names of each HB to get to the actual document from the House of Representative (HOR) website. The HOR website also has a summary and flowchart on how a bill becomes law.

STEP UP for Breastfeeding

Did you know that the Implementing Rules and Regulations of Republic Act No. 10028 or the Expanded Breastfeeding Promotion Act of 2009 has been signed last 22 August 2011?  You can download a copy here.  The IRR was published on 28 August 2011 and will be effective on 12 September 2011.  This means that establishments are now required to have lactation stations and workplaces must set up their lactation programs!

After the successful launch of the Breastfeeding Welcome Here Program, UNICEF, WHO, DOLE, DOH and ILO has another exciting project in the works! Remember my series of posts on setting up a workplace lactation program? Well, the consortium has made things even more easier with their S.T.E.P. Up for Breastfeeding Program!

Breastfeeding + HIV is possible!

Sharing this joint statement I just received via email on the recommendations on breastfeeding, particularly for HIV-infected moms. This was published in the International Journal of Gynecology & Obstetrics.    Relevant portions on HIV provided below. 


IPA/ICM/FIGO joint statement on breast-feeding, including breast-feeding by HIV- infected mothers (June 2011)


Breastfeeding under special conditions such as HIV infection of the mother: 
In light of the changing evidence on transmission risks and recommendations on the use of anti retroviral drugs for treating pregnant women and preventing HIV infection in infants, we welcome the new recommendations on HIV and infant feeding: 

Challenges to the 6-month breastfeeding recommendation

Early this morning, I was tagged in FB by my good friend and fellow breastfeeding mom, Nikki to an article from the Guardian, entitled "Six Months of Breastfeeding Alone Could Harm Babies, Scientists Say" Needless to say, I was alarmed and really bothered by the article! However, reading through the article raised several red flags. First, "the paper acknowledges that three of the four authors 'have performed consultancy work and/or received research funding from companies manufacturing infant formulas and baby foods within the past three years.'" Second, I'm no nutritionist but I was amazed that the authors suggested that the moms give babies fresh food, including MEAT for iron. Okay, so some moms wean early (e.g. as early as 3 months) - but I know none of them gave MEAT as the solid food. According to the authors, they advised babyfood manufacturers because they were specialists in child nutrition - but doesn't this conflict with their own disclosure that they received funds from baby food/infant formula companies? How do you deal with this conflict of interest?

I posted this article to the LATCH yahoogroups this morning and just now, Velvet shared this reply from Francesco Branca, Head of Nutrition at the World Health Organization.

WHO's global public health recommendation is for infants to be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health. Thereafter, infants should be given nutritious complementary foods and continue breastfeeding up to the age of 2 years or beyond.

WHO closely follows new research findings in this area and has a process for periodically re-examining recommendations. Systematic reviews accompanied by an assessment of the quality of evidence are used to review guidelines in a process that is designed to ensure that the recommendations are based on the best available evidence and free from conflicts of interest.

The paper in this week's BMJ is not the result of a systematic review. The latest systematic review on this issue available in the Cochrane Library was published in 2009 ("Optimal duration of exclusive breastfeeding (Review)", Kramer MS, Kakuma R. The Cochrane Library 2009, Issue 4). It included studies in developed and developing countries and its findings are supportive of the current WHO recommendations. It found that the results of two controlled trials and 18 other studies suggest that exclusive breastfeeding (which means that the infant should have only breast milk, and no other foods or liquids) for 6 months has several advantages over exclusive breastfeeding for 3-4 months followed by mixed breastfeeding. These advantages include a lower risk of gastrointestinal infection for the baby, more rapid maternal weight loss after birth, and delayed return of menstrual periods. No reduced risks of other infections or of allergic diseases have been demonstrated. No adverse effects on growth have been documented with exclusive breastfeeding for 6 months, but a reduced level of iron has been observed in developing-country settings.

The authors of the paper criticized BabyMilk Action who challenged the findings of their paper and said that BabyMilk Action only chooses to quote their papers when it supports breastfeeding. See below and click this link to read BabyMilk Action's press statement on this matter. Really, is there anything else better than what Mother Nature gives?

WHO breastfeeding recommendations under attack from industry-funded scientists.

Press release 14 January 2011

The BBC, the Guardian and other media are carrying stories about a new review which published in the British Medical Journal today. Three of the four authors of this study, Mary Fewtrell, Alan Lucas and David Wilson, receive funding from the baby food industry. Prof Lucas in particular plays a key role in advising the UK baby food industry, and has opposed the WHO recommendation for many years. In 2003 he went so far as to appear for the defence when one of the largest baby food companies, SMA Wyeth was successfully prosecuted for illegal advertising by Trading Standards.

www.babymilkaction.org/press/press31july03.html

http://www.babymilkaction.org/update/update33.html#2

http://www.babymilkaction.org/www.babymilkaction.org/update/update29.html#2

http://www.babymilkaction.org/www.babymilkaction.org/update/update23.html#11

Baby Milk Action expects this new study and the media coverage it is generating to be used by companies in their attempt to weaken national policies and legislation requiring complementary foods to be labelled for use from 6 months. In the UK, baby food companies are already labelling complementary foods for use from 4 months of age despite Government policy recommending 6 months exclusive breastfeeding or formula feeding.

When looking at this data the following points should be borne in mind:

• the four authors are not attacking the recommendation that breastfeeding continue alongside complementary foods or the WHO recommendation of breastfeeding into the second year of life and beyond.
• this is not a report on new data - it is observational only.
• WHO’s policy arose from a review of 3,000 studies on infant feeding.
• Keeping recommendations under review is good practice and randomised controlled trials in progress; this paper is pre-empting the results of these.
• The study implies that delayed introduction of solid foods may be linked to increased obesity - this is total conflict with the studies which show that early introduction - particularly of sugary foods is an important factor behind the obesity epidemic. Breastfeeding may actually help in the development of taste receptors.
• The argument to introduce solids at 4 months to prevent coeliac disease and allergies was summarised by ESPGHAN in late 2009 and was considered by many to be flawed. see our press release: http://www.babymilkaction.org/press/press23dec09.html
• the UK Scientific Committee on Nutrition (SACN) and the Committee on Toxicity (COT) are reviewing the evidence on solid foods and coeliac disease. The draft opinion is NOT FINAL BUT Is on the SACN website with the Agenda papers for next week's SACN meeting. See paper SMCN/11/01 downloadable fromhttp://www.sacn.gov.uk/meetings/sub_groups/maternal_child_nutrition/1901...
• SACN use international growth charts to describe the optimal pattern of infant growth in the UK (UK-WHO charts). These are based on studies of babies in 7 countries around the world and no significant difference was found between their growth profiles. The proposal from the four scientists that babies are treated differently depending on where they live conflicts with this research evidence. The mean age at introduction of solids to this cohort of breastfed infants in the WHO studies was 5.4 months (or "..about 6-months").
• The UK policy is to introduce complementary foods at around 6-months and progress responsively, in line with individual babies' progress and acceptance. Not all babies need solids at the same time: in every aspect of infant development there is a wide range of normal. Very importantly the introduction of the new policy in 2003 has been associated with a marked reduction in the numbers of mothers giving solids very early (i.e. before 4-months). Since it is widely accepted that very early introduction carries greater risk (particularly of coeliac disease), the UK policy could be considered from this perspective a success.
• The practice of ‘baby-led weaning’ is becoming more widespread, where babies are allowed to play with appropriately prepared solid foods and decide for themselves when to eat. Experience in this area suggests that babies naturally start to ingest complementary foods at around 6 months of age, when various developmental factors (hand-eye coordination, mastication ability etc) come together. This may be an evolved natural behaviour that has been lost through the practice of spoon feeding prepared paps. Further research is required in this area.
• Marianne Monie, Chair of the nationwide Breastfeeding Network, made an important point about the risk of swine flu: “The evidence supports introducing food when a baby is developmentally ready at around 6 months. Introducing food or infant formula before that time increases the risk of infections. Questioning the wisdom of the six-month guideline at a time when babies are at risk of catching swine flu is unfortunate, because exclusive breastfeeding reduces the risk of secondary infections that can be serious enough to need hospital admission. Parents should not feel pressured into rushing their baby onto solid food. Waiting until around six months gives another two valuable months of additional protection against chest and stomach infection."

Thank you, Velvet, for sharing these articles!

Update: 1/15/2011

Click HERE for UNICEF UK's response.

Breast Crawl

What is a breast crawl? According to Breastcrawl.org, "every newborn, when placed on the mother's abdomen, soon after birth, has the ability to find its mother's breast all on its own and to decide when to take the first breastfeed." This technique is being promoted by UNICEF, WHO and WABA and is part of the Ten Steps to Successful Breastfeeding.

As part of the L.A.T.C.H. module what to expect in the first 2 weeks, we usually present a video of a breast crawl. Previously, we used a video depicting an Indian mother filmed in 2005. We have been fortunate enough to obtain a video filmed in the Philippines likewise depicting a breast crawl. I'm still trying to obtain a copy of the video for uploading but in the meantime, I'm sharing the video of a Maharashtra mom and baby doing the breastcrawl.

Recently, fellow L.A.T.C.H.er Mec shared about the institution of the Essential Newborn Care protocol in Asian Hospital - where she's giving birth. The breast crawl is included in this protocol, which is said to reduce infant mortality. I'm not sure which other hospitals have instituted this protocol but this definitely something to consider when choosing which hospital to give birth at in the Philippines.

Update - 28 July 2010. Thanks to Claire for sharing the Philippine breast crawl video!

Medical Reasons for Breast Milk Substitutes

During the breastfeeding classes I've attended and conducted, it is always emphasized that from birth to six months, exclusive breastfeeding is best for babies, unless there medical reasons prescribing otherwise.

These “medical reasons” vary though from doctor to doctor, with some doctors even saying that moms who underwent caesarian births cannot breastfeed for x number of days!

In 2009, the World Health Organization and UNICEF released a 12-page publication entitled “Acceptable medical reasons for use of breast-milk substitutes”. According to WHO and the UNICEF, they first developed a list of medical reasons for supplementation in 1992, as an annex to the Baby-friendly Hospital Initiative tool package.

With new and emerging scientific evidence, WHO and UNICEF agreed to update the list with the participation of the departments of Child and Adolescent Health and Development and Nutrition for Health and Development. Other additional evidence sources used were (1) The Drugs and Lactation Database, a peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed, hosted by the United States National Library of Medicine; and (2) The National Clinical Guidelines for the management of drug use during pregnancy, birth and early development years of the newborn, review of which was done by the New South Wales Department of Health, Australia in 2006.

The WHO and UNICEF posit that only a small number of health conditions of the infant or the mother may justify temporary or permanent cessation of breastfeeding. Further, these conditions concern very few mothers and infants. In recommending the cessation of breastfeeding, the WHO and UNICEF mandates that the benefits of breastfeeding should be weighed against the risks posed by the presence of the listed conditions.

The following are the conditions for infants not to receive breast milk or any other milk except specialized formula:
1. infants with classic galactosemia (a special galactose-free formula is needed) – a rare genetic metabolic disorder that affects an individual’s ability to metabolize the sugar galactose (one of the components of lactose) properly
2. infants with maple syrup urine disease (an inherited disorder in which the body is unable to process certain amino acids or protein building blocks properly. If untreated, this leads to severe brain damage and death) – special formula free of leucine, isoleucine and valine is needed
3. infants with phenylketonuria (a genetic disorder that is characterized by an inability of the body to utilize the essential amino acid, phenylalanine) - a special phenylalanine-free formula is needed – some breastfeeding is possible, under careful monitoring

For all other infants, breastfeeding is best although the following infants may need other food aside from breast milk for a limited period:

1. a. infants with very low birth weight – weighing less than 1500g
2. b. infants born too early – at less than 32 weeks of gestational age
3. c. newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand, if their blood sugar fails to respond to optimal breastfeeding or breast-milk feeding

• preterm
• small for gestational age
• have experienced significant intrapartum hypoxic/ischaemic stress
• those who are ill
• infants with diabetic mothers

Just because a baby is premature, it does not mean that s/he should be given formula or any other fortifier (like Cell Life a.k.a. spirulina). WHO/UNICEF listed above specific instances when fortifiers are necessary.

As for maternal conditions that may justify permanent avoidance of breastfeeding, only one is listed – HIV infection, only if replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS). WHO/UNICEF however recognizes that the most appropriate infant feeding option for an HIV-infected mother depends on individual circumstances – mother’s health status, health services available and most importantly whether there is replacement feeding AFASS.

Certain conditions justify the temporary avoidance of breastfeeding, such as severe illness that prevents a mother from caring of her infant (e.g. sepsis), herpes simplex virus-1, certain maternal medication (sedating psychotherapeutic drugs, anti-epileptic drugs, opioids, radioactive iodine-131, excessive use of topical iodine or iodophors (povodine-iodine), cytotoxic chemotherapy.

Meanwhile, the publication lists down certain conditions wherein breastfeeding can still continue, although health problems may be of a concern, namely: breast abscess, hepatitis B, hepatitis C, mastitis, tuberculosis, substance abuse. I highly recommend that you peruse the short publication to read the details on these conditions.

Clearly, there is a limited number of conditions for both infants and mothers to recommend the cessation of breastfeeding. I would definitely recommend that pregnant moms to read this WHO/UNICEF publication so they will be informed and know what questions to ask their pediatricians and ob-gynes. And if your doctor gets irritated when you ask questions, then I believe that it is time to look for a new medical provider.

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.

New growth charts for babies - now out!

When I posted about growth charts based on breastfed babies in May last year, Kate (a fellow nursing mom who works at the National Nutrition Council) shared that the the NNC was working on the adoption of the 2006 WHO charts to the Philippine setting. About 2 weeks ago, I got an email from Kate telling me that the chart was now ready and they are now trying to disseminate it among health professionals. You can check out the National Nutrition Council's growth chart here.

From what I understand, the NNC's growth charts are more forgiving especially if your baby is not quite that big. For instance, in the NNC charts, at 3 months, normal weight for a baby girl would be 4.5-7.5kg. However, if you check the CDC chart, at 4.5kg, your baby will be between the 5th and 10th percentile and I'm sure your pediatrician will be saying that you are not feeding your baby enough and will direct you to supplement. How's that for a confidence buster?

On the other side, if your baby is about 7kg, she would still be considered within the normal range under the NNC charts but be overweight in the CDC charts as she will be above the 95 percentile.

In Naima's case, she is almost 26 months and currently weighs about 28lbs. or 12.7kg. Using the NNC chart, the normal range for her age would be 9.4-15.4kg. In the CDC chart, it's at 10.25kg (3 percentile) to 15.5kg (97 percentile). I realize that the difference in the charts would really matter if your baby is on the borderline of underweight and overweight. And usually, it would mothers with borderline babies who would be more vulnerable to supplementation or eventual cessation of breastfeeding.

You can download the CDC growth charts here and download this for the girls height/weight charts for birth-36 months.

New WHO recommendations for Pregnancy and Breastfeeding

I recently received an email from Alex, a WHO/UNICEF consultant in the Philippines. He shared that the World Health Organization just released new recommendations for pregnancy and breastfeeding in the context of HIV. Alex shares:

In line with several recent clinical studies that have demonstrated the efficacy of (anti retro viral) ARVs in preventing HIV transmission from mother to child during breastfeeding, the new guidelines call on all HIV-infected pregnant women to begin ARV treatment during pregnancy and for the mother or baby to continue ARV treatment for the duration of breastfeeding.
The new guidelines encourage HIV-positive mothers taking ARVs to exclusively breastfeed their infants for the first 6 months, introducing appropriate solid foods while continuing to breastfeed for the first 12 months of life.
WHO states that there is now enough evidence to support the use of ARVs while breastfeeding.
"We are sending a clear message that breastfeeding is a good option for every baby, even those with HIV-positive mothers when they have access to ARVs," said Daisy Mafubelu, WHO's Assistant Director General for Family and Community Health.

You can access the full text of the release here.