The Best and Worst Places in the Industrialized World for Breastfeeding Support

Every year, the non-profit organization and registered charity Save the Children looks at the health status, nutrition, education, economic well-being and political participation of women around the world to come up with their annual  State of the World’s Mothers report. Along with providing rankings for 165 countries around the world, each report has a different theme. This year, the report focuses on the critical impact of nutrition in the first 1000 days of life, starting with pregnancy. The report also contains an Infant and Toddler Early Feeding Score for 73 developing countries and a Breastfeeding Policy Scorecard which looks at breastfeeding practices, support and policies for 36 industrialized countries. You can read more about the best and worst places in the world to be a mother and the Infant and Toddler Early Feeding Score in this companion blog post.

The Breastfeeding Policy Scorecard for Developed Countries is new this year, and it provides an interesting look at support for breastfeeding in the industrialized world. Rankings are based on maternity leave laws, right to daily nursing breaks, percentage of hospitals that are baby friendly, state of policy support for the International Code of Marketing of Breastmilk Substitutes and breastfeeding practices. Of the 36 countries listed, Norway ranks first with a score of 9.2 and the USA ranks last with a score of 4.2. Canada ranks 31st with a score of 5.4.

From the report, we see that Norway is doing a wonderful job of supporting breastfeeding mothers:

“Norway tops the Breastfeeding Policy Scorecard ranking. Norwegian mothers enjoy one of the most generous parental leave policies in the developed world. After giving birth, mothers can take up to 36 weeks off work with 100 percent of their pay, or they may opt for 46 weeks with 80 percent pay (or less if the leave period is shared with the father). In addition, Norwegian law provides for up to 12 months of additional child care leave, which can be taken by both fathers and mothers. When they return to work, mothers have the right to nursing breaks as they need them. Nearly 80 percent of hospitals have been certified as “baby-friendly” and many provisions of the International Code of Marketing of Breast-milk Substitutes have been enacted into law. Breastfeeding practices in Norway reflect this supportive environment: 99 percent of babies there are breastfed initially and 70 percent are breastfed exclusively at 3 months.”

Compare this to the USA:

“The United States ranks last on the Breastfeeding Policy Scorecard. It is the only economically advanced country – and one of just a handful of countries worldwide – where employers are not required to provide any paid maternity leave after a woman gives birth. There is also no paid parental leave required by U.S. law. Mothers may take breaks from work to nurse, but employers are not required to pay them for this time. Only 2 percent of hospitals in the United States have been certified as “baby-friendly” and none of the provisions of the International Code of Marketing of Breast-milk Substitutes has been enacted into law. While 75 percent of American babies are initially breastfed, only 35 percent are being breastfed exclusively at 3 months.”

The differences between Norway and the United States is staggering (and Canada isn’t doing much better than the United States). For all the talk about “Breast is best” North America is doing a very poor job of providing parents with the support they need to actually give their babies the “best”. Most mothers want to breastfeed. Breastfeeding initiation rates are high, but breastfeeding drops off rapidly in the early weeks after birth. This happens not because mothers don’t want to breastfeed anymore, but because they haven’t received the support they need to continue. Breastfeeding is natural, but it is also something that requires community support. Conditions during birth and the first 72hrs after birth are critical for establishing breastfeeding (hence the importance of hospitals being Baby Friendly) and it is important that mothers have sufficient time off of work to establish their breastfeeding relationship which encourages a longer duration of breastfeeding.

Although not specifically about breastfeeding, below are some other key points about the United States from the report that should really be cause for alarm:

In the United States, mothers face a 1 in 2,100 risk of maternal death – the highest of any industrialized nation. In fact, only three developed countries – Albania, Moldova and the Russian Federation – perform worse than the United States on this indicator. A woman in the U.S. is more than 7 times as likely as a woman in Ireland or Italy to die from a pregnancy-related cause and her risk of maternal death is 15 times that of a woman in Greece

The U.S. under-5 mortality rate is 8 per 1,000 births. This is on par with rates in Bosnia and Herzegovina, Montenegro, Slovakia and Qatar. Forty countries performed better than the U.S. on this indicator. This means that a child in the U.S. is four times as likely as a child in Iceland to die before his or her 5th birthday.

The United States has the least generous maternity leave policy of any wealthy nation. It is the only developed country – and one of only a handful of countries in the world – that does not guarantee working mothers paid leave.

The United States is also lagging behind with regard to preschool enrollment and the political status of women. Performance in both areas places it among the bottom 10 in the developed world.”

An interesting (and again alarming!) point about Canada from the Save the Children Canada website:

“Norway’s under 5 mortality rate is half that of Canada (3 deaths per 1000 live births vs 6 deaths per 1000 live births)”

The risks of not breastfeeding are well documented, and there is plenty of research on the best ways to encourage breastfeeding duration and exclusivity. The statistics from this report for the countries at the top of the Breastfeeding Policy Scorecard show that interventions such as requiring hospitals to be Baby Friendly, providing adequate paid maternity leave and supporting the International Code of Marketing of Breastmilk Substitutes DO work.  This report should be a wake-up call for the countries at the bottom of the scorecard!

Below is the full list of where the 36 countries placed on the Breastfeeding Policy Scorecard. For the full details, and to see the score for each country, please refer to section 1:43 of the full report:

1. Norway
2. Slovenia
3. Sweden
4. Luxembourg
5. Austria
6. Lithuania
7. Latvia
8. Czech Republic
9. Netherlands
10. Germany
11. Estonia
12. Poland
13. Portugal
14. France
15. Belgium
16. Ireland
17. Italy
18. Switzerland
19. New Zealand
20. Cyprus
21. Denmark
22. Greece
23. Slovak Republic
24. Spain
25. United Kingdom
26. Finland
27. Israel
28. Japan
29. Hungary
30. Liechtenstein
31. Canada
32. Iceland
33. Monaco
34. Australia
35. Malta
36. United States

The Best and Worst Places in the World to be a Mother

Every year, the non-profit organization and registered charity Save the Children looks at the health status, nutrition, education, economic well-being and political participation of women around the world to come up with their annual  State of the World’s Mothers report. Along with providing rankings for 165 countries around the world, each report has a different theme. This year, the report focuses on the critical impact of nutrition in the first 1000 days of life, starting with pregnancy. The report also contains an Infant and Toddler Early Feeding Score for 73 developing countries and a Breastfeeding Policy Scorecard which looks at breastfeeding practices, support and policies for 36 industrialized countries. You can read more about the Breastfeeding Policy Scorecard in this companion blog post.

So what are the best and worst places in the world to be a mother?

Top 10 best places in the world to be a mother :

1. Norway
2. Iceland
3. Sweden
4. New Zealand
5. Denmark
6. Finland
7. Australia
8. Belgium
9. Ireland
10. Netherlands

Top 10 Worst places to be a mother:

1. Niger
2. Afghanistan
3.Yemen
4.Guinea-Bissau
5.Mali
6. Eritrea
7.Chad
8.Sudan
9. South Sudan
10. Democratic Republic of the Congo

From the report:

“The gap in availability of maternal and child health services is especially dramatic when comparing Norway and Niger. Skilled health personnel are present at virtually every birth in Norway, while only a third of births are attended in Niger. A typical Norwegian girl can expect to receive 18 years of formal education and to live to be over 83 years old. Eighty-two percent of women are using some modern method of contraception, and only 1 in 175 is likely to lose a child before his or her fifth birthday. At the opposite end of the spectrum, in Niger, a typical girl receives only 4 years of education and lives to be only 56. Only 5 percent of women are using modern contraception, and 1 child in 7 dies before his or her fifth birthday. At this rate, every mother in Niger is likely to suffer the loss of a child.”

“Conditions for mothers and their children in the bottom countries are grim. On average, 1 in 30 women will die from pregnancy-related causes. One child in 7 dies before his or her fifth birthday, and more than 1 child in 3 suffers from malnutrition. Nearly half the population lacks access to safe water and fewer than 4 girls for every 5 boys are enrolled in primary school.”

Malnutrition is a global crisis and it affects millions of children. Save the Children’s 13th annual report highlights the impact of this crisis and makes suggestions for improving conditions for mothers and children worldwide.

From the report, in answer to the question “Why focus on the first 1,000 days?”:

“Malnutrition is an underlying cause of 2.6 million child deaths each year.1 Million more children survive, but suffer lifelong physical and cognitive impairments because they did not get the nutrients they needed early in their lives when their growing bodies and minds were most vulnerable. When children start their lives malnourished, the negative effects are largely irreversible.”

Save the Children has identified six key nutrition solutions that have the greatest potential to save children’s  lives in the first 1,000 days and beyond. These solutions are ones that could be easily implemented at minimal cost if only there was the political will to do so:

“Three of the six solutions – iron, vitamin A and zinc – are typically packaged as capsules costing pennies per dose, or about $1 to $2 per person, per year. The other three solutions – breastfeeding, complementary feeding and good hygiene – are behavior-change solutions, which are implemented through outreach, education and community support…… All combined, the entire lifesaving package costs less than $20 per child for the first 1,000 days.”

Save the Children has estimated that nearly 1.3 million children’s lives could be saved each year if the six interventions they identify were  fully implemented in the 12 countries most heavily burdened by child malnutrition and under-5 mortality.

One of the things that I really like about the report is that it highlights breastfeeding as an important way to combat child malnutrition, and in their section on barriers to breastfeeding, they address the aggressive marketing of infant formula. For more information about the devastation that is caused in developing countries by this unethical marketing, please read the article Milking it.

This year’s report from Save the Children includes an Infant and Toddler Early Feeding Score for 73 developing countries. The score is based on the percentage of children who are put to breast within one hour of birth, exclusively breastfed for the first six months, breastfed with complementary foods from ages 6-9 months and breastfed at age 2. The scorecard also looks at each countries progress towards the Millennium Development Goal of reducing child mortality by two-thirds by 2015 and the degree to which they have implemented the International Code of Marketing of Breastmilk Substitutes (although these last two indicators are not included in the calculation of the overall score). Only 4 countries out of 73 score “very good” on these indicators, and more than two-thirds fall into the “fair” or “poor” category. The top 4 countries are Malawi, Madagascar, Peru and Soloman Islands. The bottom 4 are Equatorial Guinea, Botswana, Côte d’Ivoire and Somalia. The top 4 countries on the Infant and Toddler Early Feeding Scorecard have made an effort to address child malnutrition, and their efforts are paying off. Change is possible!

Malnutrition in developing countries may seem like a distant problem and one that doesn’t affect us, but the children of the world not just our own neighbourhoods, are our future. The malnutrition crisis in the developing world is not new. It is an ongoing problem, and what is so frustrating is that the means exist to address the issue! Despite this fact, children in these countries have been suffering for years and will continue to do so unless the governments of the world decide to stop their posturing on these important issues and take action. Imagine how much good could be accomplished if some of the hundreds of millions of dollars that are spent every at the G8 and G20 summits were actually spent on taking action on some of the issues they are discussing. We don’t need more research or discussion, we need for people, governments and individuals alike, to step up and say “We’re going to do something about this“.

Breastfeeding, Weight Gain and Growth Charts

A baby’s weight can be a big source of stress for breastfeeding mothers. Is my baby gaining too little or too much? Are they on the right percentile? Am I making enough milk? Often, these concerns stem from parents, and even health care providers, not having a good understanding of what is normal when it comes to babies and weight.

So what is normal? Well, to start with, it is normal for babies to lose some weight after birth. Peak weight loss usually happens on day three (just before mom’s milk “comes in”). Weight loss in hospital is often a big concern, and unfortunately, often a reason for breastfed babies being unnecessarily supplemented with formula. Most hospitals use the measurement of 7% loss from birth weight as an indicator of a problem. The latest research however is giving us new insight into normal newborn weight loss. Dr. Joy Noel-Weiss recently completed a research study looking at newborn weight loss and how that weight loss is affected by IV fluids given to mom during labour. Her findings confirmed what many in the lactation community have thought for some time. IV fluids can artificially inflate a baby’s birth weight. Her study found that IV fluids given to mom during labour and delivery, particularly in the two hours immediately prior to birth, have an impact on how much weight a baby loses after birth. All of that extra fluid has to go somewhere, and some of it goes to baby. After a baby is born and gets rid of the extra fluid, it can look like that baby has lost too much weight. One of the recommendations of the study is that all babies be weighed at 24hrs to allow babies to get rid of any extra fluids they may have in their system, and to use the 24hr weight to calculate weight loss/gain rather than birth weight.

In terms, of weight gain, a healthy term newborn should regain their birth weight by about 7-10 days. A healthy newborn baby who is transferring milk well, is a baby who is growing and gaining weight (after about day 3). If your baby isn’t gaining, or is gaining very slowly, it’s a red flag that something isn’t quite right and breastfeeding needs to be assessed. The first course of action should always be to figure out what is causing the slow weight gain. Whether it’s an issue with mom’s milk production or a problem with baby’s ability to transfer milk effectively, the cause of the problem needs to be determined by someone knowledgeable about breastfeeding. In the first few days in hospital, if your baby is not nursing well and weight gain is a concern, then constant skin-to-skin contact and frequent hand expression and spoon feeding of colostrum are the best approach. If you are being pressured to give formula, you can ask for more time and then get help from an IBCLC.

Once breastfeeding is established, we expect babies to gain at a rate of about 5-7 oz per week (close to an ounce per day), for about the first 3 months. Between months 3-12, weight gain tends to slow down. It is normal for the rate of weight gain to slow down, but it is not normal for weight gain to stop completely or for babies to lose weight. The average breastfed baby doubles their birth weight by about 5-6 months, and at 1 year, they typically weigh 2.5 times their birth weight.

The Centers  for Disease Control and Prevention (CDC) and the Canadian Pediatric Society (CPS) both recommend that children’s growth be plotted on the new World Health Organization (WHO) growth charts. The WHO charts, unlike the old CDC charts, are based on the growth of babies under biologically normal conditions (breastfeeding, mothers who don’t smoke etc). When looking at a child’s growth, it is important to be comparing their growth with the biological norm.

For many parents (and health care providers!) growth charts can be a source of great confusion and misunderstanding. When you visit your child’s doctor, their weight is usually plotted on a weight for age growth chart. These charts are used to compare your child to others of the same gender and age.  If (for example) your baby’s weight falls on the 25th percentile, it means that statistically speaking, 25% of all babies are that weight or below. Or, to look at it the other way, that 75% of all babies are above that weight. It is very important to understand that the percentile itself is NOT an indicator of health. A baby on the 97th percentile is not healthier than a baby on the 3rd percentile, they just weigh more. Someone has to fall in the 97th percentile, and someone has to fall in the third. What is important is whether or not your child is following their own curve. It is also very important to understand that the 50th percentile does not equal “normal” or “healthiest weight”.  The 50th percentile simply means that 50% of all babies are that weight or below. Parents should never be instructed to supplement with formula simply because their breastfed baby is following the 3rd percentile or reduce feedings because their baby is on the 97th percentile. That is NOT how growth charts are meant to be used.

Growth charts are screening tools, not diagnostic tools. This means that if a child is not following the expected pattern according to where they are on the chart, then the doctor needs to look closer to see if something else might be going on. It does not automatically mean that there is a problem.  If a doctor has concerns about a child’s growth then that doctor needs to looking closely at all aspects of that child’s growth and development. There are several different types of charts available from the World Health Organization, and the weight for length charts or BMI for age charts provide a more accurate picture of an individual child’s growth than the the weight for age ones do.

Weight is only one indicator of growth and should never be looked at in isolation. It is necessary to look at the big picture. The most important thing for parents (and health care providers) to remember is  look at your baby, not just the scale. If your baby is alert and happy, content after feeding, pooping, peeing, meeting developmental milestones, feeling heavier, and outgrowing clothes and diapers, then everything is good (look how many other factors besides weight can tell you that your baby is thriving on your milk!).

It’s thrush – or is it?

Beware of Ducks! Photo credit: “Kicki” on Flickr Creative Commons

This article of mine was originally posted on the Best for Babes blog, and is re-posted here with permission.

If it looks like a duck and walks like a duck, it must be a duck right? Not necessarily if that “duck” is thrush in a breastfeeding mom. Thrush (a yeast infection most commonly caused by the fungus Candida albicans) is a common diagnosis whenever a mother presents herself to a doctor with nipple or breast pain. Unfortunately, thrush is not as common as many health care providers seem to think, and many women suffer needlessly due to misdiagnosis. There are countless stories of mothers being treated repeatedly for “recurrent thrush”. These women struggle, sometimes for weeks or even months, with painful breastfeeding. They usually try numerous different treatments but never find complete relief from the discomfort.

Here’s a common scenario: Your nipples are sore and cracked and you have shooting pain through your breast while nursing . You go to the doctor and he diagnoses thrush, gives you a prescription for Nystatin (an antifungal) and sends you on your way. After a week, the Nystatin doesn’t seem to be helping so you try Gentian violet on the advice of a friend, and things seem to improve. Two weeks later however, the pain is back, so you go back to the doctor and he prescribes Diflucan (fluconazole), assuring you that this will get rid of the yeast. There’s minimal change after a week, and you find yourself on and off Diflucan for weeks, diagnosed with “resistant thrush” and desperately looking for answers. What’s going on and why can’t you get rid of the pain?

The symptoms attributed to thrush include burning nipple pain, itching, shiny, flaky skin on the nipples/areola, and deep or shooting pain in the breast. The problem with these symptoms, is that there are many other possibilities besides thrush. These include (but are not limited to):

• poor latch
• sucking issues in baby
• tongue tie
• vasospasm
• Reynaud’s phenomenon
• eczema on the nipple
• allergic dermatitis
• psoriasis on the nipple
• damage from pumping
• bacterial infection

By far, the most common cause of nipple and deep breast pain is poor latch. Any time a mom has nipple or breast pain, the first thing that needs to be looked at is baby’s latch and sucking ability. This needs to be done by someone skilled at breastfeeding assessment. Sometimes a baby’s latch can look “perfect” from the outside, but something is going on inside their mouth that is causing problems. If your nipple looks compressed or pinched when it comes out of your baby’s mouth (like a new tube of lipstick), then something is not right and it needs to be addressed (no matter how “good” it looks from the outside!).

Issues such as tongue-ties and sucking issues caused by birth interventions (such as vacuum, forceps, or C-section), or even muscle tightness due to your baby’s birth or position in the womb, can also cause a lot of pain. Issues such as these are unfortunately often missed however because most health care providers are not trained to look for, or properly assess them. Because of this, finding skilled help is important. If you have been told that your baby’s latch is “fine” but you are in pain and your instincts are telling you that something isn’t right, then keep looking until you find someone with the experience to help you.

If your baby’s latch and suck truly are not the problem, then current research tells us that bacterial infection is a more likely cause of breast/nipple pain then thrush. It had been believed that deep breast pain was caused by yeast within the ducts of the breast (ductal yeast). Current research however calls into question the existence of “ductal yeast” and tells us that bacterial infection (usually Staphylococcus aureus) is actually a far more common cause of nipple and/or deep breast pain. Despite all the fear that exists over using antibiotics because they might cause thrush, some cases of “resistant thrush” actually need antibiotics!

I’m not suggesting that thrush doesn’t exist, certainly it does. However, it is no where near as common as it would seem from the number of women who are diagnosed as having it. The most important point here is this: If it looks and walks like a duck but doesn’t quack or behave like a duck, then it’s time to start looking at who’s pretending to be a duck. In other words: If appropriate thrush treatments don’t solve the problem in a timely manner, it most likely isn’t thrush, and it’s time to look at what else could be causing the pain!

Nighttime bottle usually doesn’t mean more sleep

I often talk to moms who want to have their partner give their baby a bottle through the night so that they can get some more sleep (or dads who want to give a bottle at night to help their partner). Unfortunately, this idea rarely works, or if it does, it can have negative (and usually unintended) consequences.

Breastmilk production works according to supply and demand. When milk is removed from your breasts, it tells your body that it needs to make more. If milk is not being removed, then milk production slows down because your body gets the message that the milk is not needed.

In order to make sure that your body continues to produce the amount of milk your baby needs, it is important that milk removal continues. This means that if someone else is giving your baby a bottle, you should ideally be pumping at the same time to make sure that your body gets the message that milk is still needed. It is important to your overall milk production, and obviously if you are up pumping, then you are not getting any extra sleep! If you decide to skip pumping, you’re likely to find that you’re not able to sleep anyway. Your breasts know it’s time to nurse your baby, so there’s a good chance that you’re going  to be leaking and feeling full (and possibly uncomfortable). Also, if your baby starts crying while waiting for your partner to warm up a bottle, you’re likely going to be awake thanks to those wonderful mama hormones that make you so aware of your baby.

If you do manage to regularly sleep through a feeding while your partner gives a bottle, you run the risk of having issues with your milk production. Although some moms may be able to skip nighttime feedings without a negative impact, for many moms and babies, those night feedings are extremely important to maintain overall milk production. Prolactin, which is the hormone responsible for milk production, is highest at night, and the surge in prolactin that happens in response to your baby nursing is also higher at night than during the day.  If milk is not being removed at night through nursing or pumping then you are missing out on those higher levels of milk making hormone. If you unintentionally cause a decrease in your milk production due to skipping those night feedings, then you’re looking at needing to increase feedings or pumping sessions through the night to rebuild your supply, and again, you’re not getting that extra sleep that you were hoping to get! If you really feel like you need to have someone else give a bottle while you sleep, having them give it during the evening, would be preferable to through the night so that you can still take advantage of those higher prolactin levels.

Current research shows that breastfeeding moms actually get more sleep than those who don’t breastfeed. That doesn’t however, change the fact that parenting a new baby is exhausting and leaves many moms looking for ways to get more rest.  So how can partners help and how can moms get more rest? First of all, keep your baby close to you at night so that you’re not having to get up (and therefore fully wake up) each time your baby wants to nurse.  Having your baby in bed with you, while following the guidelines for safe co-bedding, can be a great way to minimize disruptions to your sleep. If you’re not comfortable having your baby in bed with you, or if medications etc create an unsafe environment for co-bedding, then have your baby next to your bed in either a crib or bassinet. Your partner can always help by getting up to put baby in bed with you and help you get him positioned to nurse, and then taking him after he’s done nursing and settling him back to sleep.

Along with keeping your baby close at night, try to maximize your rest during the day. We’ve all heard the saying “sleep when your baby sleeps” and although it can be very hard to do, it really is a good way to get more sleep. It can be temping to use the time that your baby naps to do chores around the house, but (unfortunately!) the housework isn’t going anywhere, so leave it and go to sleep! In the early weeks of having a new baby, it can feel like all you do is nurse and sleep, and that’s OK. That’s exactly what you’re supposed to be doing. Many of us have unrealistic expectations about being home with a baby, and the reality is that if you make it to the end of the day with both of you fed, you’re doing really well!

Photo credit: Bighugelabs.com

Breastfeeding is not supposed to hurt

In my post about The Truth Behind Common Breastfeeding Myths, the following myth received a lot of comments on both my blog and on my Facebook page:

Myth: It’s normal for breastfeeding to hurt. Truth: If breastfeeding  hurts something is wrong. Nursing may be a little uncomfortable during the early days as your body adjusts to a new sensation, but it should never be painful. Poor latch is the most common cause of pain in the early weeks, but there are other possibilities including sucking issues with baby from birth interventions or physical characteristics such as tongue-tie. If nursing hurts, get help as soon as possible. The earlier breastfeeding problems are addressed, the easier they are to fix. If you go to someone for help and the problem isn’t solved, keep trying until you find someone with the knowledge and experience to help.

A number of people have responded to say that they disagree with this, and that breastfeeding for them hurt for the first few weeks even though they had been told that nothing was wrong. A couple of comments on my blog pointed out that pain with breastfeeding is common with hormonal changes during pregnancy and ovulation, and asked why would this be different in the postpartum period? It’s an interesting question, and I don’t have a good answer. It’s certainly a possibility, and obviously everyone has a different pain threshold. The hormonal makeup of a mother after birth is different however than that of a mother who is pregnant or ovulating. It doesn’t make sense biologically for breastfeeding to be painful. Breastfeeding is supposed to be a pleasurable experience so that we’ll keep doing it to ensure that our species survives.

From my perspective as an RN and IBCLC, pain when breastfeeding indicates a problem. Breastfeeding can certainly be uncomfortable in the early days, but I strongly feel that it shouldn’t hurt. When assessing latch, it is really important to remember that a  good latch is defined by how it feels, not by how it looks. Sometimes a baby’s latch can look perfect from the outside, but something is going on inside the baby’s mouth that is causing the pain.

Latch is very important, but so is a baby’s ability to suck effectively. I frequently see moms and babies where mom is experiencing pain and yet she has been told by someone else that her latch “looks perfect” and “nothing is wrong, your nipples just need to toughen up”. Usually in these cases something is going on in baby’s mouth that is causing the pain for mom. Tongue and/or lip-tie are a common cause, but another cause that is far less obvious is a sucking issue related to the birth process and/or baby’s position in utero. Birth interventions can have a huge impact on a baby’s ability to suck effectively. Vacuum and forceps in particular almost always result in sucking issues. Think about how you would feel if you were stuck in a small space and someone stuck a vacuum on your head, or grabbed your head in a pair of vice grips and pulled! Your head would hurt! Vacuum and forceps can cause irritation to a baby’s cranial nerves, and those nerves control the jaw and tongue, so it’s not surprising that those interventions tend to cause some issues with sucking. I also see sucking issues with C-sections, very quick deliveries, deliveries where there has been a very long pushing phase and sometimes the issues seem to be related to muscle tension in the baby that has likely been caused by their position in utero.

Sucking issues are not always obvious, and they usually require someone knowledgeable to identify them. Even issues such as tongue-tie are often missed by health care providers. Thankfully, sucking issues caused by birth interventions can usually be resolved with time spent breastfeeding and/or body work such as craniosacral therapy. They can however, cause a lot of pain for mom in the mean time even though everything looks “right” from the outside. So what do we do? Some people feel that telling women that breastfeeding shouldn’t hurt is doing them a disservice because it causes them to think that they’re doing something wrong if it does hurt. For most women however, pain indicates that something is wrong, although it may be something that baby is doing rather than anything the mom is or isn’t doing. It’s hard to know what is the best approach – do we tell moms that breastfeeding might hurt and encourage them to persevere through it, despite the fact that we then run the risk of moms not seeking help soon enough when there really is a problem, or do we say that it shouldn’t hurt so women know to seek help?

What do you think?

Why the WHO code isn’t working

The World Health Organization (WHO) International Code of Marketing of Breastmilk Substitutes is intended to protect and promote breastfeeding by preventing the inappropriate marketing of breastmilk substitutes, bottles and nipples.

There seems to be a lot of confusion however about what this actually means, and why it is important. The WHO code does not prohibit the sale or use of formula, bottles or nipples. It is not a statement that moms who use formula or bottles are bad moms, and it is certainly not a statement that formula is evil. The WHO code simply deals with the way the products covered under the code are marketed. This is important, because whether we want to admit it or not, we are all influenced by the marketing that happens all around us every day. There are those who feel that they are smart enough not to fall prey to marketing, but formula companies spend millions of dollars on marketing every year, and they would not be doing so if it didn’t work. I have blogged before about the subtleties of formula marketing, and ALL of us are vulnerable. Marketing of formula, bottles and nipples, has a negative impact on breastfeeding initiation and duration, and there are 30 years of research to back that up. The WHO code is an important document that is sound in theory, but seems to have little impact in practice. Why is that?

The answer is simple. Following the WHO Code is voluntary, and following it means limiting marketing and potential sales, so why would any company want to?  The way things stand right now, it is not in a company’s best interest to be compliant with the WHO code. Since compliance is voluntary, and most companies have no interest in complying, those companies who do try to comply are put at a disadvantage.

Evenflo decided to try being WHO code compliant, and subsequently became the first bottle manufacturer to gain compliance with the code.   This was a wonderful accomplishment, and it shows that it is possible. Recently however, they backtracked on that commitment and they are no longer compliant with the WHO code. Although I do not like the recent changes at Evenflo, I do understand why they happened. Evenflo (and other companies like them) are for profit companies. They exist to make money, and they answer to their shareholders. Following a code that limits the marketing of their products results in lost sales, and if their competition is not following that same code, it’s inevitable that eventually market share is going to become more important than upholding the WHO code.

The WHO code is great in theory but with no legislation behind it to force compliance, it is never going to be effective. Until the government gets serious about supporting breastfeeding and makes it a requirement for all companies, doctor’s offices, etc to be compliant with the code, there will never be any real change. I feel that when we see companies who are not complying with the code we should provide feedback to the company, but at the same time we need to be directing more of our energy towards putting pressure on our government.  There will not be lasting change until governments decide to get behind the WHO code and make it mandatory to comply with it.

Can Social Media Help You Breastfeed?

World Breastfeeding Week happens each year during the first week of August (in Canada it is celebrated during the first week of October). This year, the theme is “Talk to me: Breastfeeding – a 3D experience”. The focus this year is on communication, with an emphasis on the role that digital media can play in protecting, promoting and supporting breastfeeding.

Recent statistics show that:

• 79% of all adults are online
• 95% of millennials (ages 18-33) are online
• 86% of generation x (ages 34-45) are online
•  Searching for health information is the 3rd most popular online activity for all Internet users ages 18 and older (after e-mail and search engine use)

These same statistics show us the percentage of people using social networking sites by age group:

•  83% of millennials (ages 18-33)
• 62% of generation x (ages 34-45)
• 50% of younger boomers (ages 46-55),
• 43% of older boomers (ages 56-64)

From these statistics, it’s easy to see that if we are not reaching out to moms and moms-to-be via social media, we are missing out on a wonderful way to connect with them and provide accurate information and support. For millennials, social networking sites are the fourth most popular online activity. It’s obvious that if we want to reach moms-to-be, and moms with young children who are breastfeeding, social media is the way to go.

I remember as a new mom spending a lot of time online. I was able to find information, get support from others going through the same things as me, and sometimes help others who were looking for support with their own issues. Peer-to-peer support is so important when it comes to breastfeeding. Humans are social creatures by nature, and we are not meant to breastfeed or parent in isolation. In today’s world, social media is one of the ways that many moms are seeking out the support they need.

Along with peer-to-peer support, parents also need accurate, evidenced based information from experts, to help them make informed decisions. This is where we see a gap with social media use. There just are not as many of the older generations (the ones who often have the knowledge and expertise that moms are looking for) using social media. A common reason for this that I have heard among those that I have talked to, is not seeing the value of social media. “How can you help someone in 140 characters?” was something I heard once when talking about Twitter, and I know many people feel the same about other forms of social media.

So, in light of this year’s World Breastfeeding Week theme, I wanted to collect stories from those people who have been impacted by social media (for better or worse) during their breastfeeding journey. Has social media been a source of information or support for you? How did /does it impact your breastfeeding? Have you found help through social media with problems that you were having? Where did you find that support? Are there any drawbacks you’ve found to using social media as a source of information/support? Please tell me your story by posting in the comments, e-mail me at fleur@nurturedchild.ca or let me know your thoughts on Twitter or Facebook.

I look forward to hearing from you!

Why Formula Companies Love “Breast is Best”

My husband and I often talk to our children about marketing. We want them to be aware of how companies try to get people to buy their product(s), so that they can make more informed choices and don’t fall prey to clever marketing tactics (“Do you think those shoes can really make you fly?”).

I think this is something that we need to be aware of when talking about infant feeding as well. When I get into a conversation about formula companies, I often hear “Well formula companies can’t be all bad because it says right on their website and on the cans that “breast is best!”. This is very true. If you go to any formula company website, or if you look at a can of formula, you will see messages about “breast is best”. Does this mean that formula companies truly believe that and want all moms to breastfeed? The answer to that is a resounding  No!  What is does mean is that their marketing division with their millions of dollars has determined that putting that message on their product won’t hurt sales. The formula industry is worth billions, and it is not against throwing it’s weight around to make changes to anything that it feels might jeopardize it’s profits. In 2004, they did just that when they opposed the new breastfeeding ads that the US government was planning to unveil. The ads were eventually replaced with a watered down version due to pressure from the formula companies. So if formula companies believed that putting the phrase “breast is best” on their websites and products would hurt sales, you can be sure that they would be making a fuss about it.

So why do formula companies love “breast is best”? Well, as outlined in Diane Wiessingers very insightful article “Watch Your Language“, “breast is best” frames formula feeding as the norm and breastfeeding as a nice extra if you’re able to do it. The message that parents receive has become “breast is best, but formula is OK too”. “Breast is best” allows formula companies to say “We fully support breastfeeding. See – it says so on our website and products”. It allows the companies to give the appearance of caring about breastfeeding while they go about undermining it. Breastfeeding is after all their main competition! I wonder what the reaction would be from the formula companies if they were required to put messages such as “Formula feeding increases your baby’s risk of obesity” on their websites and products?
Formula companies spend millions on marketing, and everything on their websites is designed to subtly turn mothers off of breastfeeding. The website for the new BabyNes machine from Nestle is a perfect example of their marketing tactics at work.

When you first open the page, you are greeted with a beautiful mother and her (formula fed) baby who are quite literally glowing thanks to the special effects on the page. Underneath, we see a woman breastfeeding her baby. Great that they’re showing breastfeeding right? Well, if we look closer at it, the breastfeeding mom is sitting on the floor, is barefoot, is half undressed and her dark roots are showing through her blond hair colouring (compare that to the beautifully highlighted hair of the formula feeding mom).  All of this is subtle, but it creates an emotional reaction (which is exactly what it was designed to do). The reaction may not even be a conscious one for many people, but it plays on the stereotype of women who breastfeed being barefoot “hippies” who just “whip it out”. It also plays into the fear of having a baby who ties you down and nurses so often that you can’t even get your hair coloured. Even the graph behind the mom with the downward slope to it produces a negative feeling about breastfeeding.

On the right is a picture of this same breastfeeding mom and baby with a doctor standing beside them.  The text surrounding this picture is talking about the service that Nestle offers where you can talk to their “experts” to get customized advice about feeding your baby. In using the image of the breastfeeding mother however, the implication is that breastfeeding is complicated and likely requires the help of a health professional.

Smack dab in the middle of these two pictures of the poor breastfeeding mother, is Nestle’s new “comprehensive nutrition system” to save you from having to expose yourself to the world, miss out on “you” time and spend lots of time at the doctors office due to those cracked and bleeding nipples you’re bound to have if you’re breastfeeding. A wonderful example of marketing tactics at work. Formula companies also use pictures of breastfeeding moms to convey the message that their formula is the next best thing to breastmilk. The breastfeeding mother in the pictures on the Nestle site is wearing white (which implies purity), and so is the formula feeding mom. The emotional message? Our product is just as good (pure) as breastmilk.

Along with the “breast is best” messages, formula websites often contain information about breastfeeding. This information is not placed there due to a desire to help breastfeeding moms however. The information is again designed to undermine breastfeeding. There is often talk of cracked and bleeding nipples, embarrassing leaks, the need to maintain a special diet etc. etc. When I gave birth to my son, I remember there was a “breastfeeding” booklet by the side of my bed (produced by a formula company). One thing I really remember was in the section on pumping where it started out with the  line “First, fully expose your breasts”. Who wants to pump if it means “fully exposing” yourself? Much easier to just go to formula right? It was a classic example of how the language the formula companies use is designed to make moms feel uncomfortable about breastfeeding, feel like it’s too much work or too restricting etc.

Formula companies spend a lot of money on getting their marketing right. To me, that means if the formula companies are happy to use the phrase “Breast is Best” on their cans of formula, then it’s definitely a phrase that we should not be using to try to encourage more moms to breastfeed. Breast is not best, it is normal.

My 8 year old’s tongue tie

This afternoon my 8 year old had his tongue tie released. I’ve known for a couple of years now that he was tongue tied,  but it was missed when he was a baby. When he was born I was not yet a lactation consultant, and although I was a registered nurse working on the mother baby unit of our local hospital, I had no idea my son was tongue tied, and no one else picked up on it either. I discovered it years later as I was studying to become an IBCLC. For those who don’t know, tongue tie (or ankyloglossia) is when the frenulum (thin membrane) that attaches the tongue to the floor of the mouth is unusually short/inelastic or attaches to the tongue in a manner that restricts normal movement of the tongue. Since tongue mobility is important for achieving and maintaining a good latch and effective milk transfer, a tongue tie can have a negative impact on breastfeeding. A tongue tie that prevents a baby from effectively breastfeeding can have other implications as well such as difficulties with speech, jaw development and placement of teeth.

Looking back we did have issues nursing, but I didn’t realize it at the time. My son used to nurse for an hour at a time, every hour and a half. At the time I figured it was normal newborn nursing and just went with it. At five months however, he starting biting me when he was nursing, and biting badly. I was in tears every time we nursed, and I started to dread nursing him. Not knowing then what I know now, and having not yet discovered the right kinds of support, I weaned my son to formula. Looking back, the severe biting will have been caused by my son’s inability to keep his tongue over his teeth due to the tongue tie, and the long frequent feedings were likely due to him not transferring milk very effectively. Thankfully, because I went with the flow with his frequent nursing we were able to compensate and his weight gain was never an issue.

We decided to have his tongue tie released because he has needed some speech therapy for articulation difficulties, and we have already been told that he will need braces due to the crowding of his teeth. In a baby with no restriction of movement in their tongue, sucking is what shapes their palate and jaw because muscle moves bone (and the tongue is a muscle!). Normal tongue movements and sucking at the breast help to spread out the palate and widen the jaw, allowing for adequate room for teeth. When there is restriction of movement due to a tongue tie, this spreading of the palate doesn’t happen the way it should and it can lead to a lot of problems with a child’s teeth. You can see in the pictures that my son’s bottom teeth are very crowded and his two front teeth on the bottom are turning inward into almost a v shape, which is typical with a tongue tie.  (For anyone who’s wondering about the black marks on his bottom front teeth, we went to the appointment straight from school, and I assume he was chewing on something black during the day – probably a pencil or something. Amazing what kids will put in their mouths!).

Our family has been talking for a while about whether or not we were going to have his tongue tie released, and the appointment to talk to the dentist was made after our son said he wanted it done because it hurt to stick his tongue out too far. After talking through the procedure with the dentist, our son decided that he wanted to go ahead. The dentist started by putting some numbing gel under his tongue, and then due to his age, put in some local anesthetic (this was the worst part because of course it stings a bit. For babies, no local anesthetic is needed). Once the anesthetic was in, he felt nothing, and the actual procedure (called frenotomy or frenectomy depending on the procedure) literally took seconds. The dentist we saw used an electrocautery tool, but it can also be done with special scissors, or by laser. There was a little bleeding afterwards that was easily controlled with some pressure on it (for babies, there is usually only a drop or two of blood, and nursing immediately after the procedure is a great way to stop any bleeding). Below are some before and after pictures:

My son sticking his tongue out before the release. You can clearly see the dimpling in the middle of his tongue (typical with tongue tie).

Under my son's tongue before the tongue tie was released. You can see the frenulum, and you can also see how crowded his teeth are.

Not as clear, but another shot of under my son's tongue before the release. Notice the difference between this picture and the one above. In order for him to elevate his tongue more (above) he has to close his mouth somewhat. In the after pictures below, you'll see that he can now elevate his tongue with his mouth wide open.

Under his tongue about an hour after the release was done. Already he has better elevation of his tongue.

Under his tongue the next morning

Sticking his tongue out the morning after the procedure.

Healing on day two. It looks good, and with frequent exercises no adhesions are forming.

The morning after the procedure he was a little tender under his tongue, but the discomfort was easily managed with some ibuprofen. It has been really interesting to be able to hear from my son about the experience. The morning after he said that he felt like he couldn’t stick his tongue out. This tells me that already some adhesions were starting to form (the area was basically starting to heal back together). This can happen with babies too, and it is why it is so important to do exercises after the release to prevent reattachment and the need to do the procedure again. With an 8 year old it’s easy, because he can follow directions and he thinks it’s fun to stick his tongue out at mom and dad. There are exercises that can be done with babies as well, and your IBCLC/doctor/dentist whoever you are working with should provide you with information on this. By the time he went to school the morning after, we had done some exercises and the area had stretched out again. In the picture of him sticking his tongue out the morning after, you can see that there is still dimpling of his tongue when he sticks it out. I am finding that his ability to extend his tongue (stick it out) is slowly improving with the exercises we are doing. It will take time because he’s had 8 years of adapting to the restricted movement of his tongue, and now we have to work on overcoming those adaptations. Along with the exercises, I will be taking him for some craniosacral therapy (very effective at helping to overcome the adaptations to the restricted movement). When he does stick his tongue out now, I can see that one thing that has really improved is his ability to spread his tongue (rather than it bunching up when he sticks it out).

Overall the experience has been a positive one for our son. He was so excited to go to school the next morning and tell his friends all about it! Have you had a child who was/is tongue tied? I’d love to hear about it in the comments.

Update:

Two weeks after the procedure, my ds can stick his tongue out much further (without it hurting!) and the dimpling in the tip of his tongue is almost gone.

For more information about tongue tie, please see the links below:

Is My Baby Tongue-Tied? By Catherine Watson Genna

Why does it hurt when I breastfeed? from Dr. Kotlow DDS

Congenital tongue-tie and it’s impact on breastfeeding by Elizabeth Coryllos, Catherine Watson Genna and Alexander C. Salloum (from the AAP newsletter – contains pictures and is great for sharing with your doctor)

www.tonguetie.net articles, pictures and FAQs

Articles and presentations from Dr. Brian Palmer DDS

Handout about post frenotomy care by Fleur Bickford RN, IBCLC and Beth McMillan IBCLC

Lip-tie can also cause problems with breastfeeding. See the links below for more information:

Why can’t my baby breastfeed: The effects of an abnormal maxillary frenum attachment by Dr. Kotlow DDS

Introducing… the maxillary labial frenulum