The WBTi report on breastfeeding in the UK - and why we need it

Since I got back from the Unicef Baby Friendly conference last week, it’s all been a bit eventful in the breastfeeding world – there was a poorly written and researched article published in New Scientist (the Unicef response is here), longer-term breastfeeding was discussed (again) on This Morning, with a GP who didn’t know her stuff on the subject, there was a furore in the Daily Mail and on social media over a mother refused a parking voucher from Tesco because she only bought infant formula (see Baby Milk Action’s excellent discussion of this here), and we discovered that the CPHVA conference, for health visitors, has sessions (and no doubt exhibition stands) sponsored by formula manufacturers. The publication of the WBTi (World Breastfeeding Trends Intiative) report on breastfeeding in the UK couldn’t be more timely – it’s abundantly clear that we need a strategy if we are to counter the anti-breastfeeding culture that we have in the UK.

The WBTi report, published today (15 November) and launched at the House of Commons tonight, is the culmination of two years of work by a huge number of people and organisations. Using a system developed by IBFAN, data has been collected for 10 ‘indicators’ – these correspond to policies and programmes recommended in the WHO Global Strategy for Infant and Young Child Feeding, which the UK supported when it was adopted by the World Health Assembly in 2002. In other words, although the WBTi system has been designed to be used internationally, it is very relevant for the UK and shows how we are doing against criteria that our government has signed up to. The idea is that the process is repeated every 3-5 years to track trends. On the international WBTi website you can see how other countries have scored.

The report begins with a series of 'Report Cards' that sum up the findings in a simple scorecard, with each country of the UK given a total out of 150, and an amalgamated score for the UK as a whole. The UK scored 81/150. England has the lowest score of all the four nations at 80.5/150; Scotland and Northern Ireland score much better, in part due to the fact that all their maternity units are Baby Friendly. For comparison, Afghanistan scored 80/150 in 2015. If like me you think that this isn't good enough, then the great thing about this report is that it offers a way forward. The work that's been done has identified the gaps in UK breastfeeding policy and made recommendations - that have been agreed upon by the contributors to the report (a host of breastfeeding organisations and public health bodies, among others) - that we could act on, right now.

The report's recommendations echo a growing consensus that currently, women in the UK who want to breastfeed are being failed - not only by a lack of skilled support for breastfeeding (the table in Indicator 5, which shows which health professionals have training in breastfeeding, is well worth a look), but also by an entire culture and society that undermines it. Other recent publications, including the Lancet series on breastfeeding, a special issue of Acta Paediatrica and Unicef's Call to Action make many of the same points. Dr Amy Brown, of Swansea University, has written extensively about the subject in her book Breastfeeding Uncovered.

Turning the situation around is not impossible. We know, from a mountain of published evidence, what works. The main problem - and one of the chief recommendations of this report - is that there is no national strategy on infant and young child feeding, no national coordinator and no means of sharing good practice UK-wide. To address this would be relatively simple and relatively cheap - what's needed is the political will to tackle it. From better national leadership on the issue, other improvements could follow: we could fully implement the Code, we could address gaps in the training of health professionals, we could collect better data, we could ensure that infant feeding is considered in the formation of other policy (like the obesity 'plan')... and then, as all these areas interact like cogs in a machine, we would see a shift in society's attitudes, increased breastfeeding rates, improved health outcomes and cost savings... and happier, better supported mothers. (This isn't just conjecture - see the breastfeeding gear model, which uses Brazil and Mexico as examples, on p68 of the report.)

This report, with its overview of the current situation, could be hugely important - it can inform what we do, and where we direct our campaigning efforts. Do read the whole thing if you can, and reflect on what you could do to make a difference.

Not #scientificandfactual at all – how UK breastmilk substitute ads to health workers break the rules

Most readers of my blog will know that in the UK infant formula (first stage, or from birth formula) cannot be marketed to parents, or be discounted or promoted in shops. Manufacturers use follow-on formula to get around these advertising restrictions, but there are still rules that they must follow and they can be pulled up by the Advertising Standards Agency for breaking them. When shops break the rules on infant formula promotion – by discounting it, or positioning it in premium spots in store – they can be reported to Trading Standards. It’s far from a perfect system; no prosecutions have been brought, and companies are not fined nor have to apologise for infringing the rules, but the principle of challenging misleading marketing does at least exist. Baby Milk Action, with the help of its members and the public, monitors advertising to parents and compiles a report ‘Look What They’re Doing in the UK’ to expose the companies' tactics.

When it comes to advertising aimed at health professionals, however, the situation is very different. Many people don’t know that breastmilk substitutes can be marketed to healthcare professionals: in journals and magazines, on professional websites and at conferences and study days. Although the Department of Health has regulations stating that this advertising must be ‘scientific and factual’, there is no monitoring and no mechanism for reporting marketing that breaks the rules, other than to complain directly to the Department of Health.

First Steps Nutrition Trust’s recently published resource ‘Scientific and Factual – a review of breastmilk substitute advertising to health professionals’ looks more closely at the science used to back up the claims made in advertising in professional journals and magazines. We know from research that advertising is effective – why else would the companies spend vast sums on advertising space? – and that adverts that carry simple, easy-to-understand messages relating to the reader’s own scientific knowledge are very ‘believable’. The companies know this too, and they also know that few health workers will have the time or resources to investigate the references given in tiny print at the bottom of carefully crafted adverts. Graphs, charts and statistics create the appearance of ‘a scientific basis’, even when what they show is not scientifically correct or objective.

The resource looks in detail at adverts that appear in publications including the Journal of Family Health, the Journal of Health Visiting and Dietetics Today, but the same and similar adverts appear in many other publications aimed at health professionals in a wide range of fields. When the references given to support the claims made in the adverts are scrutinised, the findings are often shocking.

An advert for Cow & Gate Comfort milk, marketed as relieving colic, which shows an emotive image of an exhausted mother, appeared in the Journal of Health Visiting in March 2016. The main claim, in red type, is that ‘95% of paediatricians reported an improvement in common infant feeding problems with a formula like Cow & Gate Comfort¹’ [italics added]. Closer reading of the reference given reveals that the study, funded by Numico (Danone) did not use Cow & Gate Comfort milk; the test formula had different energy, protein, carbohydrate and mineral content. NHS Choices says that there is no evidence for any treatment that is beneficial for colic, which resolves itself. The conclusion that the advert is deliberately misleading is inescapable.

SMA, now owned by Nestle, has been rolling out a new product, SMA PRO, and many stores have illegally cleared stock of the previous formula by marking it down in price to make way for the new product (lots of examples have been posted on the Baby Milk Action Facebook page). An extensive advertising campaign to health professionals has accompanied the roll-out. Dietetics Today carried two adverts for SMA PRO in March 2016, a shorter one-page ad and then a longer, more ‘scientific-looking’ ad – this in itself is a tactic designed to reassure the reader that the information given in the simpler advert is supported by the ‘science’ given in the more complex version. The main claim in the simpler advert is that SMA PRO is ‘Clinically proven¹’. This is supported by one reference to a poster presentation given by Nestle employees at a conference – not a peer-reviewed publication as required by the Department of Health regulations. The poster reports a meta-analysis of four studies looking at infants fed with Nan milk (another Nestle product). It is not clear whether this Nan formula is the same as SMA PRO. It is impossible to know how the manufacturers can use this evidence to claim that SMA PRO is clinically proven, or what it is ‘clinically proven’ to do. That such shaky evidence can be used to support a headline claim on a new product shows just how confident the companies are that they will not be challenged.

There is much, much more detail in the resource, which has painstakingly reviewed all the scientific papers the companies have cited to support their claims. If, having read it, you’re outraged by how misleading these adverts are, there are plenty of suggestions for action on the First Steps Nutrition Trust website. Health professionals can demand change, by complaining to the journals and professional bodies that carry advertising and allow it at events, and writing to the Department of Health regulators. The Royal College of Paediatrics and Child Health voted at its AGM in April to ‘decline any commercial transactions or any other kind of funding or support from all companies that market products within the scope of the WHO Code on the marketing of breast milk substitutes’ – other professional organisations can be lobbied to pass similar resolutions. For more information, and links to further reading, see the campaign pages on the First Steps Nutrition Trust website. Baby Milk Action is urging the UK parliament to enforce marketing restrictions on the promotion of formula to parents too – see more on their website here or make a donation to support their work.

UNICEF Baby Friendly conference 2015 - the morning after

I'm back at my desk after two days at the UNICEF Baby Friendly conference 2015 in Harrogate. Like last year I've come away enthused, inspired, outraged and with a whole heap of work to do...

The presentations by Christy Jo Hendricks, IBCLC, and Dr Helen Crawley of First Steps Nutrition, showed us examples of downright dishonest marketing from the formula companies, including a tin that made extravagant health claims for the product, with an asterisk(*). On the side of the tin, in tiny writing, it said '*study applies to an earlier version of this milk'! Even after years of breastfeeding advocacy it seems I (and many others in the audience) can still be shocked by this sort of thing. A US parent information leaflet, sponsored by a formula company, said on the first page 'most doctors* recommend...', while the wording below said '*in this publication doctors refers to midwives, obstetricians, paediatricians and any other health professional you trust'! This is unbelievably misleading. As Christy Jo memorably said: 'Don't go to a formula company for advice about breastfeeding. That's like going to the butcher to ask for advice about being vegetarian.'

Dr Helen Crawley getting the audience fired up.

On the issue of formula company sponsorship of health events aimed at professionals it was great to see some direct action as a result of the conference session. A health visitor in the audience reported that the CPHVA conference, sponsored by several formula companies and related organisations, was taking place in Manchester (overlapping with Baby Friendly - coincidence?). The result was a petition, to be delivered to CPHVA, that will carry the names and membership numbers of health visitors who were at the Baby Friendly conference, asking them to ditch the formula company sponsorship that is a clear conflict of interest for health professionals who want to work within the Code. Hopefully this, along with continued pressure on social media, will prompt a change in direction. National breastfeeding organisations like La Leche League, the ABM and the Breastfeeding Network, along with Baby Friendly, have shown that it is perfectly possible to organise Code-compliant conferences for large numbers of delegates without input from the formula industry.

If you came away from the conference angry, why not join Baby Milk Action? They campaign tirelessly against the formula companies, exposing the marketing tactics and bringing cases to the Advertising Standards Authority and Trading Standards on behalf of the parents who are paying for all this slick, misleading marketing when they buy formula. There's tons of information on the Baby Milk Action website, and if you work for a facility that would like training on the Code, you can contact them directly.

If I sound evangelical it's because I think organisations like Baby Milk Action and First Steps Nutrition are absolutely vital if we are to push back against the widespread, normalised use of formula - a theme that Professor Mary Renfrew explored in her presentation about shifting the curve: she suggested we turn our breastfeeding drop-off rate graph upside down, and look at reducing formula use instead. Between them the speakers had lots of solutions to the problem: tackling the media stance on breastfeeding, reinstating the Infant Feeding Survey in England, freeing research from company influence and forcing companies to release their research, implementing the Code and empowering mothers, through support and education, to resist the marketing and reduce dependency on formula. What's frustrating is that we know what works - the problem is getting the support and funding needed. Infant feeding in the UK is an issue with a unique set of political and social challenges, something that was highlighted when Sue Ashmore talked about the long-term sustainability of Baby Friendly; it's not a programme that can run and then stop. If that happened, our gains would be eroded because of the constant pressure from industry and a lack of political commitment, so what's needed is a way of embedding the Baby Friendly standards into the very bedrock of facilities; an advanced award. (The consultation about how to do this is here, do get involved if you can.)

With this in mind it was fantastic to see Alison Thewliss, MP at the conference. She's already secured and participated in debates about breastfeeding and a family-friendly parliament, and is setting up an All Party Parliamentary Group on Infant Feeding and Inequalities, which will meet for the first time on 24 November. I've written to my MP asking her to support this and encourage others to do the same.

Me on stage with Sue Ashmore and Robin Grille

Other personal highlights of the conference for me were chairing in the morning session on day two - I was nervous, but very happy to be representing the bloggers and Tweeters who campaign for breastfeeding on social media. I realised I will never, ever get bored of listening to Hollie McNish, and I helped out on the Pinter and Martin stand and talked to a lot of people about books (I love my job!). I came home with a new reading list of my own - Robin Grille's Heart to Heart Parenting landed on the mat this morning. Can't wait for next year in Birmingham...

Why are we working hard to get mothers to breastfeed, then encouraging them to stop?

This week I've been thinking about the messages mothers get from their health professionals, peers and the older generation about breastfeeding past six months, and how this plays out in our culture of infant feeding in the UK. (This train of thought was sparked off by several conversations I've heard

Breastfeeding my poorly 23-month-old

recently between mothers - mostly first-time mothers - and health visitors, Children's Centre workers and doctors. It's not my intention to be particularly critical, more to explore what we are actually saying to mothers, and the effect it has).

There's a lot of focus (at least in my area of Derbyshire, where we've been working towards, and recently obtained, full Baby Friendly accreditation in the community (DCHS) and the county council (DCC)) on improving rates of breastfeeding initiation and continuation (measured at 6-8 weeks). All the hard work, by DCHS, DCC and volunteer organisations such as BEARS, the peer supporters I am involved with, is really paying off and we were delighted to get the UNICEF endorsement - part of which involves interviews with mothers themselves - that shows how far we've come in recent years and how much better we are doing in supporting women who want to breastfeed, at least initially.

But what happens to mothers after six to eight weeks? Peer supporters at breastfeeding groups often have experience of breastfeeding for much longer than six to eight weeks - so they are well placed to offer ongoing support to mothers who continue breastfeeding. But not all mothers attend the breastfeeding groups, and as their babies grow they have more contact with health visitors, practice nurses and Children's Centre workers at baby weighing clinics, developmental reviews and vaccination appointments, and their friends, relatives and casual acquaintances will all have something to say on the subject of continued breastfeeding too. As the weeks and months go by mothers are exposed to an awful lot of misinformation - hardly surprising when as a nation our breastfeeding rates at six months and beyond are so low, with fewer than 1% of mothers exclusively breastfeeding for six months, and only 34% breastfeeding at all at the six-month mark. Our society's collective knowledge about breastfeeding past six months is thus sadly lacking, something it is well worth bearing in mind when weighing up how much importance to attach to people's comments.

When I took my youngest daughter for her vaccinations at a year old I mentioned to the nurse that she was still breastfeeding (as there was a box to tick in her red book for 'still breastfeeding at all at first birthday'). She said, dismissively, 'oh, we don't need to collect that information'. She then went on to tell me how, if she ever had children of her own, she would definitely bottle-feed them, based on her experience with puppies! I was taken aback, but it was only later that I wondered whether, if I'd been a first-time mum rather than an old hand, I might have been more affected, even unconsciously, by the way she casually diminished the importance of breastfeeding.

I've recently heard a mother of a ten-month-old baby, still happily breastfeeding, advised to cut his daytime feeds in order to give him 'healthy' snacks, and to reduce and stop his night-time feeds as he 'doesn't need it nutritionally'. This mum didn't ask for help to stop breastfeeding; she was worried about her baby's wakefulness at night (for which she was advised controlled crying, despite saying that she didn't want to go that route - a whole different post...). The mother of a seven-month-old baby, who is mixed feeding - breastfeeding with one bottle of formula at night - was again advised to offer snacks in the daytime and encouraged to hurry her baby on to more solids rather than breastmilk so that he will 'cut down on his feeds' - she was told that the baby should ideally be moving to three meals a day plus two healthy snacks, and, somewhat confusingly, that he should still be getting a pint of milk a day, which would equate to '2 or 3 breastfeeds at the most', and she was told that her baby needed vitamin drops as part of the same conversation. The implication was that these mothers were now meant to be transitioning away from breastfeeding, when the reality is that for infants under a year, breastfeeding is still a hugely important part of their overall nutrition, and can continue alongside other foods for as long as mother and baby want. We are doing mothers and their babies a disservice if we are, even with good intentions and an eye on the nutrition guidelines, shepherding them down a path that leads to reduced feeds and an early end to breastfeeding.

Another mother I know of, who had a rough start to breastfeeding and was worried she might have to stop despite having fed her first child for a year, was told not to worry as the 'target' was six to eight weeks! The problem here is not the sentiment - I'm sure this person was trying to say something reassuring to a mum who was struggling - but that actually, her comment misrepresented the situation entirely. The immediate target for increasing breastfeeding rates may be the six to eight week measure in terms of the breastfeeding strategy in the county, but for that individual mother the NHS and WHO guidelines, which recommend breastfeeding to two years and beyond, are much more important for her own health and that of her baby.

What's missing, in all of the above, is an understanding and appreciation of the flexibility of breastfeeding an older baby, toddler or child: the way it continues to provide valuable, tailored nutrition, how it can fit in around solid food, going back to work and changing night-time routines, and the way in which it can continue to be hugely important to mothers and their babies for years to come, both in terms of nutrition, and in terms of their relationship (I wish more people could experience breastfeeding an older child who is poorly and miserable and can't stomach anything else, for example). Children grow up so quickly - why hurry the weaning process if there's no need? Why can't we support and encourage women to breastfeed in the longer term, and then support and encourage them when, for whatever reason, they or their children want to stop?

It's been heartening to see Sharon Spink in the news in recent months talking about breastfeeding her five-year-old, after Michelle Atkin did so earlier in the year. And I loved this story about a mother breastfeeding her toddler on Australian TV. I hope that stories like these, and the debates they provoke, will help us as a society to improve our collective knowledge of longer-term breastfeeding so that we can offer better support to mothers, who in many cases have struggled to establish breastfeeding, only to have it suggested, after a few short months, that they should be 'moving on'.

There's a point to be made here, too, about how that 'moving on' message is one that's frequently heard and seen in advertising for follow-on formula and 'growing-up milk'; if we think babies and toddlers need milk, what better milk for them than that of their own species, delivered by their own mothers, rather than an unnecessary product developed to circumvent the regulations governing the advertising and composition of infant formula, which exists to line the pockets of the big baby food companies? Those companies work hard to target health professionals and mothers to get their messages across - so it is not just that our collective knowledge is lacking, it is also being undermined by those with vested interests. (For much more on this see the Baby Milk Action website; good information about formula milk is available from First Steps Nutrition.)

I'm sorry the blog has been so quiet in recent months; I've been busy working on all sorts of exciting projects, of which more news in future posts...

Doctors and breastfeeding - room for improvement

Image from Fit to Bust by Alison Blenkinsop,
published by Lonely Scribe. It appears opposite
a page criticising Dr Jessen for overlooking the
importance of breastmilk for toddlers in 2010.

This post has been prompted, in part, by the Twitter-storm yesterday about Dr Christian Jessen's comments on breastfeeding, published in Closer magazine this week. He complained he'd been misquoted; Closer issued an online clarification - my feeling was that although he had been misquoted, there was still quite a lot wrong with what he'd actually said. Luckily I don't need to take his words to pieces - the fabulous Analytical Armadillo, IBCLC and Tracy at Evolutionary Parenting have already done a brilliant job, complete with plenty of references to actual research. Baby Milk Action have issued a comment, and Milli Hill has written a piece for Best about it.

Coincidentally, I was thinking about doctors and breastfeeding yesterday anyway. I came across this PDF about the management of thrush in breastfeeding women, written by an Infant Feeding Specialist in Derbyshire, which distils current thinking and best practice for doctors and prescribers, and circulated it to our group of peer supporters. We encounter a lot of mums who struggle to get the treatment they need from GPs and I thought it might be helpful if we could point them to this resource. We shouldn't really have to: I don't think it's unreasonable to expect GPs to have an up-to-date working knowledge of breastfeeding.

Dr Christian Jessen is a high-profile example (there are others: Dr Ranj Singh, Dr Carrie Ruxton, Dr Ellie Cannon) of a doctor who is regularly invited to comment on general health matters, including breastfeeding, despite having no specialist knowledge in the field. In this, he's not unlike GPs across the country who see breastfeeding mothers in their surgeries day in, day out. What comments like Dr Jessen's show, writ large across our national media, is how little our doctors often know about breastfeeding - not only in terms of actual lactation, but also in terms of how a breastfeeding relationship affects the lives of mothers and their babies. The implications of this are profound: the high-profile media doctors' inaccurate pronouncements undermine the efforts of those striving to improve breastfeeding rates, in pursuit of gains in public health and reduced cost to the NHS, and provoke online rows that often divide breast and bottle feeders and reinforce tired stereotypes. And
GPs in their surgeries nationwide, if they do not have training in breastfeeding or prescribing for breastfeeding mothers, are being equally unhelpful.

Every peer supporter I know has a story to tell about breastfeeding advice from GPs (sometimes unsolicited when attending for something unrelated!). Here are just a few examples we've come across recently in our own area:

- a mum told to stop breastfeeding for 48 hours while on high-dose antibiotics. It transpired she wasn't taking a high dose and that it was safe to continue breastfeeding.
- a mum told to stop breastfeeding for two weeks (!) in order to pump all feeds to 'see how much she was making'.
- a mum referred to GP to request a tongue-tie referral (HV sent mum to GP after peer supporter raised issue). In our area this simply requires GP to fax consultant. However, GP insisted that tongue-tie would split on its own, that it didn't affect feeding (it was) and that he would prescribe Gaviscon for the infant's reflux (which was probably due to the tongue-tie...)
- one mum mentioned the WHO guidelines to her GP, and was told they only applied in developing countries (they don't).
- a mum with persistent ductal thrush was told no further treatment was possible, despite having been told by another GP at the same practice to come back for stronger/longer meds if necessary. Dr eventually looked it up and realised this was true.
- a mum whose GP called her 'ridiculous' for still breastfeeding her 18-month-old.

Earlier this week I saw a status from Wendy Jones, on her Breastfeeding and Medication page, bemoaning the number of calls she's had recently from mothers of young babies, who've never experienced pain-free breastfeeding, who've been 'diagnosed' and treated for thrush which is not resolving. These women need help with position and attachment (and possibly tongue-tie!), not thrush treatment, and their GPs should realise this.

I;m not interested in bashing doctors here. We can't leave doctors out of breastfeeding. They have a crucial role to play, particularly where, as is the case in my area, there's no way of referring women on for BFC or IBCLC support for breastfeeding problems. If the peer supporters and health visitors can't help, mums must go via the GP for any onward referral. But our GPs need to be up to speed, and the examples above show that many are not.

I've done a bit (and only a bit) of digging into where the problems arise. GPs in practice now may have followed quite different training pathways from each other. It's entirely possible that a doctor qualified as a GP having never done an obstetrics/gynaecology/paediatrics rotation in training, which it seems is where exposure to breastfeeding problems would come in. However, even then trainee doctors may have been warned off by midwives from giving breastfeeding advice - disempowering them from the start and leaving them with the distinct impression that breastfeeding is something dealt with by 'others'. While this might be true in a teaching hospital situation with highly trained midwives and infant feeding specialists on staff, it doesn't help that doctor a few years later when faced with a waiting-room full of mothers and babies. Not all doctors find it easy to say to patients that they are unsure about something and need to look it up; not all doctors are aware of the importance of breastfeeding to the breastfeeding mothers themselves. Some doctors have personal experience of breastfeeding issues - and I don't discount the value of that - but in the absence of additional training, using one's own experience to advise patients can cause its own problems. Indeed, peer supporters, health visitors and midwives who are trained to support breastfeeding mothers are encouraged to debrief their own experiences and then leave them aside when dealing with other mothers, whose circumstances may be very different, to concentrate on giving good, evidence-based information.

There is some good news: doctors-in-training today should have at least a cursory knowledge of breastfeeding. At Keele University, for example: "...there is formal teaching about breastfeeding, to support problem-based learning in the context of a growing family, for students in their first year. Thereafter students will meet the issues [diagnosing and treating breastfeeding problems like thrush and mastitis, prescribing for lactating women] as part of their learning on placements – they have units on Child Health and Women’s Health in secondary care; and extensive patient contact in primary care placements (22 weeks across the curriculum, of which 15 are in final year). One difficulty is that much of the peri- and ante-natal care that GPs used to do is now done via midwives and students have much less contact with them for learning opportunities." (my italics)

What more can be done to improve GPs working knowledge of breastfeeding? In Derbyshire, where we're aiming for full Baby-Friendly Accreditation, we're encouraging local GPs to do the UNICEF Baby-Friendly GP E-learning module: it costs around £10, takes around 25 minutes to complete, and is endorsed by the Royal College of General Practitioners. The problem is that many doctors don't know that it even exists! Mothers everywhere: contact practice managers at your local surgeries and ask them if your GPs can do this training. It counts for their CPD (continuing professional development). If mothers are better informed, they can push for better service from their GPs. Ask your GP to check whether medication is suitable while breastfeeding, or ask them to look up the relevant Breastfeeding Network fact sheets on the condition they're treating. Ask them who else might be able to help with a breastfeeding problem. Ask your peer supporters which local GPs are most clued-up about breastfeeding.

I've focussed on GPs today but really, the same applies to any doctor who meets breastfeeding women and their infants regularly. I'm not suggesting all doctors should be breastfeeding specialists, and I understand the pressures that GPs and indeed all doctors operate under - but I would like to see fewer women on the receiving end of poor advice.

You can read my follow-up piece to this post here.

What do you think? Have you had poor breastfeeding advice from a GP? How do you think the situation can be improved? Leave your thoughts in the comments!

Advertising infant formula - WHO cares?

Last month, online retailer Ocado distributed, in print and online, a magazine that carried a feature advertising first-stage infant formula. They've now (after an initial delay) amended the online version of the magazine, which you can see here. The article on p34 originally had an image of a box of six ready-to-feed SMA bottles in the 'S is for Sleep' section (see right) - in fact the whole section looked as though it spelt out S.M.A. The first problem? It's illegal in the UK to advertise first-stage infant formula: the relevant legislation is here.

So far, so simple. Ocado were pulled up on their mistake, and they responded with an apology:

The SMA First Infant Milk product was included in the feature by mistake. The mistake occurred purely through human error and we are satisfied this is an isolated incident. We are very sorry that this has happened and we have made some changes to the ocadolife production process to ensure this cannot happen again. We take compliance very seriously at Ocado and as a responsible retailer we have voluntarily approached the relevant authorities to discuss this matter with them. We can also confirm SMA did not provide any funding for the inclusion of their product in the feature and we also extend our apologies to them for our error.

An end to the matter? Not really. The whole incident brought some of the issues affecting infant feeding in the UK sharply into focus. So much is wrong with the picture. That this image of formula milk appeared in the 'sleep' section of the article reflects a common misconception that formula feeding aids infant sleep (when in fact it increases the risk of SIDS). That the image appeared at all demonstrates a worrying lack of awareness of the law among editors, copyeditors, proofreaders... And a storm of comments on Facebook (I saw them on the Association of Breastfeeding Mothers page, and on the Ocado page) demonstrated just how poorly the general public understand the law itself, and the reasons for it (which reminded me of the comments made about breastfeeding in swimming pools that I blogged about here.) A small selection:

I don't see what's wrong with this. Some people formula feed, so what!!!

In today's world of equality and freedom of choice its a disgrace that such a law even exists... it hits a bit of a raw nerve when I read so many people trying uphold a law that in my opinion should never have been passed.

...not allowing advertising of first milk is making some mothers' failure at breastfeeding even more apparent... don't we need to be looking at the nhs midwifery service and the support (or lack of) that new mothers receive rather than the advertising...?

If these infant formulas were actually bad for baby and caused harm... then they wouldn't be allowed to be produced never mind advertised.

Adverts are allowed for everything else under the sun claiming to be healthy such as high sugar cereals, breakfast bars and alcohol!!!... but adverts aren't allowed when it comes to offering choice or advice on formula milk!!!

So why is it illegal to advertise formula?

I just don't get why people are so up in arms about a very small picture in a publication.

The law exists because of pressure groups who don't feel that people should be allowed to make their own choices.

The problem with this law is that it prevents the balanced info that you claim you want parents to have. 

Let me make it clear. The law exists to protect mothers and young babies, whether breastfeeding or artificial feeding. We know (and by we, I mean that it is common knowledge) that breastfeeding is the normal way to feed human infants, and we know, thanks to an ever-expanding wealth of scientific research, that not doing so carries a host of increased health risks for both babies and their mothers. Yes, even in the UK. It seems logical then that the marketing of breastmilk substitutes for infants, which are artificially-fed babies' sole source of nutrition, should be subject to checks and controls.

It's also clear, from even the most cursory look at the advertising practices of the formula manufacturers, that they will go to great lengths to promote their products, often making pseudo-scientific claims that do not stand up to scrutiny (cases have been brought against them, and won), adding ingredients of unproven benefit and cynically targeting health care professionals when they are denied direct access to parents. Baby Milk Action, and the UK Baby Feeding Law Group, monitor the activities of the various formula companies: you can find a great deal of further reading on their websites (my most-read post ever is about this topic too, here.) It seems obvious that companies aiming to maximise their profits are not best placed to offer objective information about formula feeding.

The above has been known for some time, and is recognised worldwide. Hence WHO (the World Health Organisation) created the International Code of Marketing of Breast-milk Substitutes, adopted in 1981, the aim of which is to:

...contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.

Can anyone find anything there to disagree with? It sounds perfectly sensible. In 2003, WHO and UNICEF, as part of a global strategy for infant and young child feeding, called for governments to 'review progress in national implementation of the Code, and consider new legislation or additional measures as needed to protect families from adverse commercial influences.' Unfortunately, in the UK we have still only partially implemented the WHO Code, which, as Emma Pickett IBCLC, co-chair of the ABM, explains:

...could be argued to have done more harm than good. It has led directly to the 'invention' of follow-on formula, which is not subject to the same advertising controls as first-stage formula. In countries that have fully implemented the Code, there is no follow-on formula at all - if it really were a distinct and medically necessary product, as the manufacturers would have UK parents believe, surely it would be available worldwide? Here in the UK we have evidence from the Diet and Nutrition Survey that 32% of parents have given follow-on formula before six months: proof, if any more were needed, that advertising really works.

She also describes a situation that breastfeeding supporters everywhere will recognise:

You meet mothers every day who use formula alongside breastfeeding and end exclusive breastfeeding because the messages they receive from advertising are far more powerful than the information they are drily given about the benefits of exclusive breastfeeding. The TV adverts stick in the mind long after someone mumbling something about gut flora and allergy prevention.

It's grimly ironic that those parents complaining about the law against advertising first-stage formula are the very same parents that are being ripped off, both financially and through misinformation, by the formula manufacturers. Rough calculations (companies won't reveal their figures) suggest that of an annual spend by parents of £436.54 on Aptamil powdered formula, for example, between £231 and £349 goes on marketing and profit. Still think the companies are acting in the best interests of consumers?

As for where parents should go for better information, UNICEF, First Steps Nutrition, Which? and others all have guides to artificial feeding for those who need them, freely available on the internet.

But there's even more to it than this. Want to see how deep the rabbit-hole goes? In this post on the Alpha Parent James Akre describes our culture of acceptance of formula feeding thus (my italics):

Given the mass of compelling scientific and epidemiological evidence about the harm caused by routine artificial feeding, it’s hardly farfetched to qualify as collective delusion the unquestioned faith that the general public and health professionals alike in many settings continue to place in infant formula...

...Infant formula will sustain life in a pinch, and thank goodness this is so. But as I describe elsewhere, from a nutritional and developmental standpoint, most people do not understand just how hugely inferior it is to breast milk...The idealized view of normalized infant formula feeding that manufacturers are so adept at portraying – and, regrettably, so many consumers, health professionals and politicians are inclined to accept – doesn’t allow for even a hint of this disenchanting reality.

Given all the evidence, why do you think we haven't fully implemented the Code in the UK? And why don't we make more use of the laws we have? Don't be fooled into thinking that the reasons have anything to do with any doubts about the benefits, in terms of public health, of doing so. It's an uncomfortable truth that we cannot rely on governments to act as they should, even in the face of overwhelming evidence and firm guidance from WHO (which has no power to compel countries to implement the Code). The pressure, on governments and other organisations, from vested interests within the baby food industry and elsewhere, is immense: the power of corporations, at the highest levels of politics and policy-making, cannot be dismissed as conspiracy theory. When so much profit is at stake, the interested parties will do all they can to exert an influence. This month a letter appeared in the Journal of the World Public Health Nutrition Association about conflicts of interest in the area of infant nutrition:

...concerned with the equally deep penetration of the transnationals and their associated or supportive organisations, into the scientific community, into nutrition policy-making at the highest level, and into public health programmes that affect the health and lives of hundreds of millions of people.
We see this largely as a consequence of the failure of elected governments to fulfil their first duty, which is to govern. We also feel that some policy-makers and many scientists, including those working at the highest level, underestimate or overlook the consequences of their own actions.
The influence of Big Food can be subtle, and may, in the opinion of reasonable people, be seen to affect the judgement of public policy agenda-setters who act in good faith and whose personal integrity is not at issue. We are not questioning the motives of any of the people mentioned in this letter. We are though, deeply concerned about the possible effects of their activities.

Our specific situation in the UK is part of a global issue that has far-reaching implications for mothers and babies. Just today Baby Milk Action posted this press release on their website about formula companies bribing hospitals in China - yes, those same formula companies that advertise and sell products in the UK.

I've covered a lot of ground: from a tiny image of first-stage formula in an Ocado magazine, to global politics, nutrition policy and economics, in one helter-skelter ride. And really, this is still only scratching the surface. I just hope I have gone some way towards showing how that one little article is part of a much bigger picture that should concern us all.

Baby milk shortages - formula manufacturers, the politics of infant feeding, breastfeeding

The news that Danone, which makes Aptamil and Cow & Gate formula milks, has imposed sales restrictions on parents in the UK has been all over the media this week. Shoppers are now limited to purchasing two packs of powdered infant formula per day. Supposedly this is to prevent bulk buying and informal export of formula to China - at least, that is the explanation that Danone have given on the brands' respective websites, in a letter from managing director John Sykes.

However, there can be no denying that the story has generated massive publicity for the brands involved. For example, in this segment on the BBC website the mother is filmed using Aptamil formula, and this article from the Daily Mail carries a prominent shot of both Danone brands on supermarket shelves, complete with shelf-edge explanation of the buying restrictions.

What better way to add cachet to the Danone brand than to let its UK market know how highly prized its products are in China? The fact that millions of Chinese consumers (in a country beset by formula milk scandals, where formula advertising is aggressive and unregulated, and breastfeeding rates are on the way down) trust the brand and will pay inflated sums for it is surely something worth (from Danone's perspective) instilling in the minds of UK consumers. In addition, products in short supply have 'rarity value' - it's like must-have toys at Christmas, or petrol, or limited-edition designer handbags - that 'value', in the minds of consumers, is great news for retailers and manufacturers. Crucially, 'news' stories are not seen as 'advertising', although in practice, as anyone involved in the media knows, they fulfil the same function - there is truth in the old maxim 'all publicity is good publicity'.

The knock-on effects of all this on our culture of infant feeding on the UK are more subtle. A slew of articles about formula feeding normalises it further - a shortage that affects millions of parents across the UK gives the message that 'everyone' is using formula as opposed to breastfeeding. Images of specific brands accompanying the articles make it more likely that parents, faced with a shelf full of products and with little access to accurate, unbiased information about infant formula, will reach for the product they recognise. As shown by the Daily Mail article mentioned above, a focus in the media on formula feeding can bring with it a wave of anti-breastfeeding feeling. The author of the article claims that "the breastapo are out in force, berating the formula feeding pariahs who feed our babies this manufactured 'poison'." I don't believe this or see any evidence of it; all this article shows is that, given a convenient peg to hang it on (news of a formula shortage), the same tired elements of a FF v BF argument that helps no one and only serves to divide women and line the pockets of the formula manufacturers, can be trotted out yet again.

(A separate, but I suspect related, article in the Mirror about vitamin D deficiency mentioned Cow & Gate Growing Up Milk by name, causing me to wonder whether the article had been 'inspired' by a Danone press release... the formula companies are very keen for parents to know that children consuming more than 450ml of first stage or follow-on formula per day do not need vitamin D supplements.)

Consider the context of all this. We already know from the Infant Feeding Survey 2010 that in the UK many parents are unaware of the differences between infant (first stage) formula and follow-on formula (suitable from six months) - the latter being an unnecessary product specifically designed to circumvent the restrictions on marketing infant formula imposed by the WHO code on the marketing of breastmilk substitutes, which is not even fully implemented in the UK. We also know that the formula companies will battle incessantly for market share with a huge array of marketing tactics (carelines, baby clubs, marketing to health professionals, roadshows... the list goes on). All this is funded by marketing budgets, paid for by formula consumers. Increased market share means increased profits. In this sort of climate a shortage of product makes perfect sense as an aggressive marketing ploy.

In case you think I'm overstating the case here, I'd like to highlight the work of Baby Milk Action, which has recently published a new report Look What They're Doing in the UK!. In the press release that accompanies the report Mike Brady, Campaigns and Networking Coordinator, says:

"Given the massive production capacity that Danone has in nearby Ireland there is something about this story that does not ring true: it is surely more likely Danone that is prioritising other markets than people exporting supermarket stocks. Danone is locked in fierce competition with Nestlé, particularly in Asia. Danone is gaining massive publicity for its products on the back of this shortage scare, but parents who use formula can heed Department of Health advice and switch to other brands. Claims made that one particular brand is better than another do not stand up to scrutiny. As our Look What They're Doing in the UK report demonstrates, companies are endlessly imaginative in how they push their products."

In the BBC report on the issue, Nestle, the second largest formula manufacturer in the UK market, said that it had not seen an increase in demand due to unofficial exports, and that there was no shortage of its products. (Nevertheless, some supermarkets are limiting sales of Nestle brands too.)

It seems to me that what's needed, as usual in reference to infant feeding, is wider access to clear, unbiased information that doesn't come from the formula manufacturers themselves, and this article in the Telegraph made the same point. UNICEFs Babyfriendly initiative publishes A guide to infant formula for parents who are bottle-feeding, which is a great place to start. Another good source (aimed at health professionals, but anyone can download the report) is Infant Milks in the UK.

It's also not unreasonable, as part of the ongoing discussion, to talk about breastfeeding. It's not shaming of those who use formula to point out that, on a population level, increased breastfeeding would mean both improved public health and less reliance on commercially-driven formula milk manufacturers. The 'shortage' story could be seen as demonstrating perfectly some of the most amazing qualities of breastfeeding: most mothers can produce hundreds of litres of breastmilk (incomparable to formula) for a zero carbon footprint - no food miles, no energy costs of manufacture or reconstitution, no supply-chain issues. 

I've been considering the implications of all this for breastfeeding support. I had a conversation with a formula-feeding mother while I was planning this article: she asked me what, as a breastfeeding peer supporter, I would do if someone asked me about formula feeding. I thought hard about what I could do in this situation, aside from talking to the mother about her reasons for switching to see if there was anything I could help her with before she stopped breastfeeding, and discussing the option of mixed feeding (on the grounds that any breastfeeding is better than none). I realised there's a lot of information I can give, although I would be upfront about my lack of personal experience of bottle or formula feeding. I do, however, know about the most recent guidelines for making up bottles and the reasons for them, and am happy to talk to mothers about them. I have also read the guides above and feel that I could tell a mother that since the composition of formula in the UK is regulated, and claims about differences between brands don't hold water, her decision can be based on price and what her child seems to prefer, and she needn't be restricted to one brand. I'd hope, in doing this, to leave the mother feeling better-informed about her options, and not let-down by a sudden lack of support when her circumstances change. I'd love to hear what other breastfeeding supporters think about this.

Breastfeeding, guilt, feminism, the media... and UNICEFs new report

As is normal for me, when new breastfeeding research is published and discussed widely in the media, I've found myself alternately depressed and encouraged by the response to the publication yesterday of UNICEFs report: Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK.

There was certainly plenty of media attention for the story: newspaper articles, blogs, TV, news programmes. Having blogged about the report myself, I kept a close eye on how it was being reported by others. I found myself increasingly disappointed in the way it was handled (if not surprised). Lorraine Kelly, on ITV, framed discussion of the report as 'Is there too much pressure on women to breastfeed?' and a poll, conducted among viewers, concluded that 60% of respondents thought there was. (I linked yesterday to a great post on 'pressure': you can find it here). Lorraine's guest, Natalie Cassidy, was actually a great example of someone who was both culturally at a disadvantage when it came to breastfeeding (she explained how her father would not want to see her feeding, and how she'd felt, even among family, that she needed to go into another room) and the victim of poor support (she'd been told, and felt herself, that the latch was fine, but her story of cracked and bleeding nipples, and a baby with poor weight gain, suggested problems that could have been resolved with more skilled help). However, the context of the 'debate' meant that her contribution perpetuated many of the ideas that breastfeeding supporters are working hard to challenge - about breastfeeding as something that is difficult, time-consuming, painful, isolating. Dr Hilary Jones made a few points 'in favour' of breastfeeding, but the whole thrust of the discussion missed the point of the new report entirely (of which more below).

At 7pm on Channel 4 presenter Cathy Newman interviewed a breastfeeding mum feeding her three-week old baby on air, again questioning her on the 'pressure to breastfeed' angle, which she handled with aplomb, and Krishnan Guru-Murthy refereed a 'debate' between report author Prof. Mary Renfrew and Dr Ellie Lee from the Centre for Parenting Culture Studies in Kent (whose role was to present 'the other side'). This set-up did not make for illuminating discussion: it consisted of Dr Lee claiming that the report was one-sided, based on flimsy evidence and just one more stick to beat women with, while Prof Renfrew had to use up her minutes of air-time refuting these points rather than talking about the importance of the new report.

Have you spotted a trend? That trend continued... on Newsnight at 10pm three women were interviewed (very briefly!) about breastfeeding: one breastfeeding support worker, one bottle-feeder (again a good example of cultural barriers to breastfeeding: she explained how in her family two generations had bottle-fed, and she'd always thought of it as normal, and thus felt challenged and pressured when, during antenatal appointments, midwives explained the risks of bottle-feeding.) The third lady, calmly breastfeeding her young baby, explained how she'd planned to breastfeed and had welcomed the support she was given, although she qualified this by saying that the information she'd had 'was very biased in favour of breastfeeding.' Arguably this is spot on - breastfeeding and artificial feeding are not comparable. Gabrielle Palmer, in the Politics of Breastfeeding, sums this up very well:

'The infant feeding issue is often represented as one of individual choice between two parallel methods,"the breast or the bottle". Neither the products nor the method are equal and the true cost to society and the individual is seldom mentioned or measured [except, perhaps, in this new report?]. Women have the right to choose how they use their bodies and they cannot (and should not) be forced to breastfeed, but that does not mean that evidence about the risks of not breastfeeding should be censored.' (p7)

Newsnight then featured a 'debate' hosted by presenter Emily Maitliss between Rosie Dodds of the NCT, Francesca Entwhistle, a midwife and lecturer, and Charlotte Faircloth (of the aforementioned Centre for Parenting Culture Studies), who also had a piece in the Independent. (In which she said, among other things, that we spend enough money promoting breastfeeding already - £6m per year. Nestle spends £42m promoting its products.) It was an interesting discussion, although for me it was again derailed by the opposition set up between Faircloth (who described the report as one-sided and explained that as a feminist she believed we should not blame women for society's ills and  make them feel guilty about feeding; she also dismissed the notion that breastfeeding could address health inequalities) and the other contributors, who had to explain, again, that the report was not designed to make mothers feel guilty and that the evidence shows that 81% of women want to breastfeed and are forced by many circumstances to give up before they want to. Once again, the key message of the report played second fiddle to a different agenda.

A comment piece today by Victoria Summerley returns again to the question of guilt/pressure. It seems that despite the best efforts of the report's authors, and those of commentators welcoming the findings, we can't get away from these entrenched positions. Gabrielle Palmer again:

'I know that stating these facts can be painful or even enraging to some women who have not breastfed their children, but the continued denial of the risks of not breastfeeding and the value of breastmilk, supposedly to spare women's feelings, is a patronising deception. The whine about "not making mothers feel guilty" is such a cop-out... No woman need feel guilty for 'failing' to breastfeed, though she has the right to feel angry or sad for being denied support when she needed it.' (p85)

So what is the point of the report, and what is wrong with the way it's been covered so far? This is a report about the economics of breastfeeding. It presents information about infant feeding in a new way - we have not previously had these figures, of cost savings and potential returns on investment, available for the UK in this form. The report is a tool for the decision-makers who have to manage the limited resources of our health service in tight financial times.

Where were these decision-makers yesterday? Where were the health ministers, politicians, economists, health service bigwigs? Yesterday someone commented on my blog that her PCT had recently laid off three IBCLCs who had increased initiation and continuation rates in their locality. An interview with the person who made that decision would have been interesting in the light of the new report, surely? Where were the tough questions, the demands for assurance that the new report will be taken seriously? The report itself contains two fascinating case studies of areas that have implemented breastfeeding programmes that have improved breastfeeding rates and cut costs: Lancashire and Harrow (Harrow now has admissions for gastroenteritis of 16% below the national average). No one involved in these programmes was interviewed yesterday to explain how they had implemented change and seen results.

I think, so far, the mainstream media has taken the view that this new report on breastfeeding is a 'women's issue' and has covered it accordingly. I find that more than a little patronising. The report's main message, which is that programmes of breastfeeding support are cost-effective, improve public health and address health inequalities, is being lost among the bickering about 'guilt' and 'pressure'.

Some suggestions for what to do if you're irritated about this: Read the actual report - it's well worth it. Email your MP about it. Join Baby Milk Action - they are respected lobbyists in the political arena. Buy and read The Politics of Breastfeeding and become more aware of the issues. Support breastfeeding, and women who want to breastfeed, however you can - by doing it yourself or supporting those who do. It's perfectly possible to campaign for breastfeeding politically and be an enthusiastic, sympathetic and genuine supporter of women at an individual level as well.