Finding the Right Formula for Nursing

Just three per cent of Quebec mothers breastfeed exclusively until their babies are 6 months old, statistics show. A big part of the problem, says one mom, is the difficulty and cost of finding medical professionals who offer support.

Alex Roslin

The Montreal Gazette, Saturday, October 4, 2008

When Marie-Andrée Bossé had her first baby in 2005, she was all set to breastfeed. She knew breastmilk was the best food for her child.

But she soon started to feel pain and burning sensations during breastfeeding sessions. She consulted a long list of medical professionals—CLSC and hospital nurses and several private lactation consultants—but the problems only got worse.

Soon, there was intense pain in her breasts even when she wasn’t breastfeeding. She was advised to change how the baby latched onto her breast, but the changes helped only a little.

Adding to the pain, she learned she had contracted a host of breastfeeding-related illnesses with strange names she had never heard of before: candidiasis of the nipple, vasospasms and something called bleb—painful blisters around the nipples.

Still, Bossé, a sexology instructor at the University of Quebec in Montreal, insisted on breastfeeding. It was three months before the pain and ailments finally went away with the help of lactation consultants, who showed her how to improve her baby’s latch, and a sympathetic doctor who prescribed medications.

A big part of the problem, she said, was the difficulty in finding medical professionals specialized in breastfeeding issues and the cost of the help. She estimates her expenses for the consultations and drugs at $400 to $500.

“My problems required specialized expertise, and it’s very hard to find those services. That’s why most mothers stop breastfeeding when they encounter problems,” she said.

Breastfeeding experts say Bossé’s story is common and a key reason why, according to a 2006 study by the Quebec government’s statistics institute, just three percent of Quebec moms breastfeed their babies exclusively until they’re six months old. That’s the period of time recommended by Health Canada and the World Health Organization.

Seven years after Quebec adopted one of Canada’s most ambitious policies to promote breastfeeding, the province still has one of the lowest rates of sustained breastfeeding in the country.

For comparison, 19 percent of mothers Canada-wide breastfeed exclusively until six months; in Sweden, the rate is 70 percent.

Now, health officials are reviewing the province’s breastfeeding policy and trying to figure out the reasons for the glacial progress.

The problem, say breastfeeding experts, is that while most Quebec women start out breastfeeding their babies, health professionals are failing to provide proper support and advice when women encounter problems like a bad latch, soreness or poor milk supply.

That, coupled with abundant supplies of infant formula that companies give for free to most Quebec hospitals, makes it hard for women to keep breastfeeding when they encounter problems, said Howard Mitnick, a family doctor at the Jewish General Hospital’s Goldfarb Breast-Feeding Clinic.

“We live in a world where people don’t see breastfeeding and don’t know what it looks like. They have a baby and are suddenly expected to be experts, and people are not around to help them,” he said.

The stakes in the battle over the breast are huge. Research shows breastfed babies have fewer ear and respiratory infections, reduced allergies and diarrhea, a stronger immune system, higher IQ, less risk of diabetes later in life, better development of speech, jaw muscles and baby teeth, and better bonding with mom.

Mothers also benefit by losing weight quicker, experiencing faster contraction of the uterus and having lower risk of osteoporosis and ovarian and breast cancers.

In some cases, research shows breastfeeding is literally a life-and-death issue. A May 2004 U.S. study of 9,900 infants published in the journal Pediatrics found a 27-percent higher chance of death among kids who had never been breastfed compared to those who had, including a 19-percent greater risk of sudden infant death syndrome and 69 percent more chance of death by injury.

“Promoting breastfeeding has the potential to save or delay approximately 720 post-neonatal deaths in the United States each year,” the study said.

The poor situation in Quebec is especially ironic because it was the first Canadian province to officially mandate in 2001 that its hospitals and CLSCs get certified under an international pro-breastfeeding program called the Baby Friendly Initiative.

The initiative, created by the World Health Organization, sets out 10 measures for hospitals to adopt to encourage breastfeeding.

They include training for maternity-ward nurses and doctors, better education on breastfeeding techniques for moms and reduced reliance on formula.

The Quebec government set a target of having 20 hospitals and 40 CLSCs certified as Baby Friendly by 2007, as well as 75 percent of moms breastfeeding exclusively at birth—meaning no infant formula, water or other food—and 10 percent doing so at six months.

Quebec has fallen well short of those goals. Just 13 Quebec hospitals and CLSCs are now Baby Friendly, while only half of moms breastfeed exclusively at birth and just three percent do so at six months.

The failed targets don’t come as a big surprise to Mitnick. He said the province has devoted few funds to train medical staff on breastfeeding techniques, provide more breastfeeding education to parents, create more free lactation clinics or reduce reliance of formula in hospitals.

“The more money the health system puts into breastfeeding, the more money it saves through reduced hospital re-admissions, infections and malnutrition,” he said.

***

Why do so many moms stop breastfeeding early on? A study of Quebec moms in August found the main reasons for giving up are latching problems, pain and poor milk supply.

Most of these problems can be resolved with some expert help, said Louisa Ciofani, a lactation consultant at Royal Victoria Hospital.

Just three percent of moms actually can’t produce enough milk to breastfeed their babies exclusively, usually due to damage to the breast from cancer, burns or surgery, Ciofani said. But even these women can still usually breastfeed to some extent. Less than one percent of women can’t breastfeed at all, she said.

Long ago, it used to be that new moms got help for breastfeeding problems from their mothers, aunts and grandmothers. But after infant formula companies started touting their product as being as good as breastmilk in the 1950s—a belief that numerous studies have since discredited—several generations of women lost that knowledge.

Today, most women must rely on doctors and nurses for help. But few of those professionals have taken the 20-hour training course on breastfeeding that the WHO recommends for maternity-ward staff, Mitnick said.

“People (in hospitals) don’t have the skill set,” he said.

Without help from experts, many breastfeeding moms end up giving up, said Carole Dobrich, a lactation consultant at Mitnick’s clinic and president of the Quebec Association of Lactation Consultants.

“Mothers who are well-supported can get through it, but you have to have that support,” she said.

Tammy Sawyer, a registered massage therapist in Montreal, said she encountered unhelpful hospital staff when she gave birth to her daughter Sophie in August. Her daughter was born with a cleft lip and palate, and medical staff told her to avoid breastfeeding because they believed her baby wouldn’t be able to suck well.

“They said my baby was pretty much going to starve if I breastfed,” Sawyer said.

She said hospital staff advised her use to a pump to manually extract breastmilk, but didn’t show her how to use one.

She later discovered Mitnick’s clinic, where she learned how to breastfeed her baby successfully. She said Sophie is now growing nicely.

Dobrich said hospital staff are often too overworked to teach moms breastfeeding techniques. The result: infant formula is often seen as a quick-fix to feeding problems, she said.

“The quick answer is, ‘Let’s give mom formula because we don’t have time to teach her,’” she said.

Provincial government statistics show half of moms who breastfeed while in hospital are not doing so exclusively and are being given formula to supplement their babies.

The problem is early use of formula can disrupt the establishment of breastfeeding and, later, make it harder for moms to stick with it when they encounter problems or one too many sleepless night, Dobrich said.

The high rate of formula supplementation in hospitals runs counter to WHO guidelines on breastfeeding. The WHO says formula should be used only in cases of dire medical necessity, such as when babies or their mothers are severely ill or the baby has birth weight under 1.5 kilos.

Dobrich said the WHO guidelines are routinely flouted. Mitnick said Quebec hospitals also accept free formula from companies in violation of the WHO guidelines, which call on hospitals to pay at least 80 percent of the market price.

What’s wrong with hospitals accepting free formula? If it’s free, staff hand it out too readily, Mitnick said. “The more formula that’s around, the more it’s going to leak into the maternity rooms.”

And the province’s support for breastfeeding may soon actually diminish, said Isabelle Cloutier, president of the Nourri-Source Federation, a group of volunteers who help moms with breastfeeding problems. She said proposed government cuts to prenatal education classes will make it even harder for mothers to get breastfeeding information.

“We need the will and the cash to change practices,” she said.

Oct. 1 to 7 is breastfeeding week in North America and will be marked with a world-wide "breastfeeding challenge" on Saturday, Oct. 11, when organizers are trying to get the most women possible to come together to breastfeed at one time. In Montreal, last year's winning city with the most moms participating, there are 10 locations this year, including the Palais des Congrès, where the breast-in starts at 11 a.m. For more information and registration, visit Babyfriendly.ca.

For more info on breastfeeding:

Quebec government's statistics institute 2006 report on breastfeeding

Ask Lenore: website of Montreal lactation consultant Lenore Goldfarb

Quebec Nourri-Source Federation's website

Toronto lactation consultant Dr. Jack Newman's website

Breast-feeding Gets Cold Shoulder in B.C. Hospitals

By Alex Roslin
July 3, 2008
The Georgia Straight
[original story]

Breast is best; it’s widely known. But just 29 percent of B.C. moms breast-feed their babies exclusively for the first six months of their lives as recommended by Health Canada and the World Health Organization.

Why so few? One key reason, say breast-feeding advocates, is the solid grip that infant-formula makers have on doctors and nurses. Case in point: the controversy over Nestlé that erupted last month in the maternity ward at Burnaby Hospital.

When Nestlé Nutrition, a leading formula company, invited health professionals in Burnaby for cocktails and dinner at the city’s Hilton Vancouver Metrotown hotel in June—oh, yes, and a little talk on infant nutrition and formula titled “The Infant Feeding Maze”—a staff member at Burnaby Hospital e-mailed the invitation to employees via an internal mail list.

When word got out to breast-feeding advocates, they mobilized and bombarded Nestlé and health authorities with angry e-mails. They said the event violated the World Health Organization’s 1981 International Code of Marketing of Breastmilk Substitutes. The code, which Canada and the B.C. Health Ministry have signed, says formula makers shouldn’t offer “financial or material inducements” to health-care providers to promote their products.

Even B.C. Health Minister George Abbott waded in with a letter in which an official writing on his behalf said “it is clear that Nestlé is violating the [WHO] code.”

Nestlé bowed to the pressure and cancelled the event after getting “over 100” protest e-mails, said Catherine O’Brien, a spokeswoman at the company’s office in Toronto. Yet she rejected Abbott’s letter (“He had no knowledge at all of what the event was all about”) and insisted the meeting wouldn’t have violated the WHO code because “refreshments” and a meal are not a “material inducement”.

In fact, the event was the second in B.C. that Nestlé has had to cancel. Last September, staff at Burnaby Hospital invited the company to put on a similar information session, which was to have been held in the hospital itself, O’Brien said. That event was also cancelled after community protests. (The WHO code prohibits any promotion of formula products within hospitals.)

Michael Bernard, a spokesman for the Fraser Health Authority, which oversees Burnaby Hospital, said he would call back with a comment, but he had not done so by press time.

Although breast-feeding advocates were rejoicing at the latest cancellation, the dispute left maternity-care professionals at the hospital divided and prompted the resignations of lactation consultants Linda Good and Renee Hefti-Graham. “Women in Canada are paying the price for these free meals,” Good said in reference to Nestlé’s wine-and-dine. Hefti-Graham said many of their coworkers at the hospital were ambivalent about supporting breast-feeding, while one manager dismissed WHO literature on the subject—as well as documented international information on Nestlé WHO code violations—as “propaganda”.

The conflict sheds light on the persistent obstacles to breast-feeding in B.C. and Canada nearly three decades after the adoption of the WHO code. Despite Abbott’s support in the Burnaby dispute, many experts fault his government and the broader medical community for not doing enough to promote breast-feeding or reduce the sway that formula companies have over infant feeding.

The stakes in the battle over the bottle are huge. Research shows that breast-fed babies have fewer ear and respiratory infections, fewer allergies, less diarrhea, a stronger immune system, higher IQ, less risk of diabetes later in life, better oral development, and more bonding with Mom. Mothers also benefit by losing weight quicker, experiencing a faster contraction of the uterus, and having a lower risk of osteoporosis and ovarian and breast cancers.

In fact, research shows breast-feeding is literally a life-and-death issue in some cases. A May 2004 U.S. study of 9,000 infants published in the journal Pediatrics found a 27-percent higher chance of death among kids who had never been breast-fed compared to those who had, including a 19-percent greater risk of sudden infant death syndrome and 69 percent more chance of death by injury.

“Breast-feeding is associated with a reduction in risk for post-neonatal death,” the study said. “Promoting breast-feeding has the potential to save or delay approximately 720 post-neonatal deaths in the United States each year.”

In B.C., officials like to tout the fact that 95 percent of women breast-feed at birth, the highest rate in the country. “We play that up and pat ourselves on the back,” said Karyn-grace Clark, a lactation consultant in Nanaimo. “Though we get them breast-feeding, we can’t keep them breast-feeding.”

Less known is the fact that hospital staff give many of those women infant formula even when their babies are healthy and breast-feeding. The practice is a violation of guidelines established by the WHO and UNICEF in 1991 as part of a program called the Baby Friendly Initiative. The initiative, which the B.C. Health Ministry and Health Canada have endorsed, is intended to reform hospital practices worldwide in order to promote breast-feeding and reduce reliance on formula.

The Baby Friendly guidelines say there are only a few exceptional situations in which formula truly is a medical necessity for newborns, such as when they or their mothers are severely ill.

Yet as many as 60 percent of healthy, breast-feeding newborns are being given supplementary formula in B.C. hospitals, estimated Sandra Yates, a doyenne of the province’s lactation consultants who teaches courses on breast-feeding to health-care providers at Douglas College.

“Nurses are overworked; formula is used as a quick-fix solution,” Yates said. “Often the problems are shovelled off to the next level because there isn’t time to do it. It takes time to sit with a mom through an entire feed.”

Sharon Prindle-Collins, chair of the Fraser Health Authority’s Breast-feeding Practice Council, estimated that about 40 percent of healthy babies get formula in the eight maternity hospitals in her region. She agreed that many of the cases aren’t motivated by any medical necessity.

“There is a bed crunch,” she explained; in order to make way for new arrivals, formula is sometimes given in order to promote a baby’s weight gain so she can be discharged. “If weight [of the baby] is not up by the time they go home, sometimes the health-care provider would recommend formula to get the weight up,” she said. The recommendation typically happens in the event of weight loss of 10 percent or more, she said.

There’s just one problem: it’s normal for breast-fed newborns to lose up to 10 percent of their birth weight due to fluid loss, according to the WHO/UNICEF guidelines. Weight gain usually doesn’t start until day four or five after birth—after the baby goes home. (The usual postnatal hospital stay is one to three days.) In other words, a lack of weight gain in hospital is pretty much the norm.

In fact, the Baby Friendly Initiative says the only weight-related situations in which formula is a medical necessity are when a baby has “very low” birth weight—less than 1.5 kilograms—or hasn’t regained his birth weight after two to three weeks. “For babies who are well enough to be with their mothers on the maternity ward, there are very few indications for supplements,” the guidelines state.

Aren’t some women just unable to breast-feed? Linda Good, one of the lactation consultants who resigned from Burnaby Hospital, said just three percent of moms can’t produce enough milk to breast-feed their babies exclusively, usually due to damage to breast ducts or nerves from cancer, burns, or surgery. But even these women can still usually breast-feed to some extent. Fewer than one percent of women can’t breast-feed at all; even women who adopt can produce breast milk, Good said.

Yet formula use in B.C. hospitals actually appears to be on the rise. Between 2005 and 2007, the percentage of all breast-feeding new moms (including those with pre-term babies and cesareans) who got some formula while in hospital went up from 24.2 to 25.3 percent, according to the B.C. Health Ministry’s Perinatal Health Program. The rate rose in four of the province’s six health authorities. (Barbara Selwood, a perinatal nurse consultant with the program, speculated that the higher numbers may just be due to more accurate data collection.)

As well, none of the province’s six health authorities managed to hit the WHO/UNICEF standard of 80 percent of all babies getting nothing but breast milk while in hospital (including those born by cesarean section). Overall, 69.2 percent of B.C. moms exclusively breast-fed their babies while in hospital last year, down from 69.5 percent in 2005.

It’s really no big surprise that health care in B.C. falls short of the WHO/UNICEF standards. Just one hospital in the province has thus far been certified as a Baby Friendly facility—Quesnel’s G. R. Baker Memorial Hospital, which got the designation last January.

To be sure, the situation isn’t much better elsewhere in Canada. Seventeen years after Health Canada endorsed the Baby Friendly Initiative, only 18 of Canada’s some 500 hospitals and health facilities offering maternity care have gotten the certification. (Thirteen are in Quebec, the only province to mandate all its maternity facilities to achieve the designation.) About 20,000 hospitals have been certified worldwide, but only 500 are in industrial countries.

In B.C., authorities have talked a good talk about Baby Friendly. Back in 2003, the province’s deputy health minister, Dr. Penny Ballem, wrote a letter to the CEOs of the six regional health authorities urging them to get certified. But no funds were attached to the recommendation, and it remains up to each authority to decide whether or not to go for it.

The B.C. Women’s Hospital and Health Centre has been working toward accreditation since 2004 and hopes to get it this month. That process, which typically takes five to 10 years, is just beginning for the Vancouver Coastal Health Authority, whose senior executive team will decide whether or not to pursue the designation in coming weeks, according to spokesperson Viviana Zanocco.

Baby Friendly would usher in a sea change in hospital routines in B.C. Getting certified means changing practices like taking babies from mothers right after birth in order to do a physical exam, administer a shot and eye ointment, and swaddle them. That process, which can last five minutes, has been shown to interfere with the establishment of breast-feeding, Yates said. Instead, Baby Friendly rules say newborns should be immediately placed on Mom’s chest so they can start trying to suckle; nurses can examine the baby there.

The WHO/UNICEF guidelines would also mean education for all maternity-care providers and moms on breast-feeding techniques. It used to be that a new mother’s aunts or mother would show her what to do, but after doctors and nurses started touting infant formula as being as good as breast milk in the 1950s—a belief that numerous studies have since discredited—several generations of women lost that knowledge.

Today, the 40 percent of mothers who encounter problems with breast-feeding—like sore nipples, infections, failure of the baby to latch, or poor milk supply—usually turn for help to public-health nurses and family doctors, but few of those professionals have undergone the breast-feeding training that the WHO/UNICEF guidelines recommend.

In early 2007, the B.C. Health Ministry brought 90 nurses from across the province to Vancouver to take a 20-hour course on breast-feeding, with the idea that they’d return to their facilities and teach the course to their coworkers. That second phase has stalled, however, amid squabbling between the ministry and health authorities over who will pay for staff to take time off work for the training.

Lactation consultants say change is also needed at the federal level and in the broader culture. Ottawa has yet to adopt the 1981 WHO code on formula marketing as law, which means formula companies are free to flout the code’s admonishments against formula ads in the media and giveaways of product samples to parents at Vancouver’s frequent baby fairs.

“Formula is so ubiquitous and integrated into our thinking that when we think of a baby, we think bottle. When there are breast-feeding challenges, the first thing women try is the bottle,” Yates said.

Good, who worked as a midwife in South Africa before she emigrated here 25 years ago, agreed. “I was shocked when I came to Canada. It felt like it was almost a different species. Mothers [here] live in a culture where we never see a baby on a breast. The whole society doesn’t know what breast-feeding should look like.”

On the other hand, many breast-feeding experts are heartened to see new generations of women challenge the medical community and formula companies like Nestlé. “As a culture, women have to take their power in breast-feeding,” Yates said. “They should do the research beforehand and know the potential problems [with breast-feeding], much as they plan out the birth. Then women won’t be as easily misled by health professionals.”

For more on this subject, check out Pieta Woolley's blog post on the trials and tribulations of being a breast-feeding mother in Vancouver.