International Breastfeeding Journal - Latest Comments

A response to readers comments and questions

Karleen Gribble — 2012-01-29T02:58:18Z

After the publication of our paper ¿Emergency preparedness for those who care for infants in developed country contexts¿ the authors received questions, helpful comments and suggestions for possible modification of emergency kits for babies. We would like to respond.

Several health professionals and mothers questioned whether there was a place for a chemical sterilisation process in emergencies. Chemical sterilisation could be used in an emergency situation however, there would be little benefit to doing so. Thorough washing using hot water of feeding and preparation implements is required before sterilisation. Furthermore the water used for chemical sterilisation needs to be renewed every 24 hours. Thus, avoiding sterilisation by boiling by using chemical sterilisation would only save a small amount of water and fuel.

Some have questioned the volume of water required for hand washing, suggesting that much less water is required. The authors allowed 500 mL for each hand washing. This figure was chosen after discussion with Water, Sanitation and Hygiene (WASH) specialists in the humanitarian sector. It should be recognised that in an emergency situation, contamination of surfaces with waste is common and hands can become very soiled. Five hundred millilitres to thoroughly clean dirty hands is a conservative estimate based on field experience. However, the authors recognise that there is no research to indicate how much water is needed to thoroughly clean hands and that such research would be welcome.

Reducing the volume of water required to be stored in the ready-to-use infant formula kit is possible if disposable knifes can be used to open the containers of ready-to-use infant formula. This would reduce the amount of water required to be stored to 56L. Disposable knifes might be either high quality plastic knives that are intended to be disposable or metal knifes that are intended to be reusable but are disposed of after a single use. Care needs to be taken to ensure that the knives are sharp enough and strong enough to open the containers.

The authors have been made aware that in some locations it is possible to purchase ready-to-use infant formula in disposable bottles and with disposable teats. This option may be more cost effective and take less space to store than purchasing ready-to-use infant formula and bottles and teats separately. However, use of this product still requires the opening of the bottle before assemblage with the teat. Therefore water to clean hands and a preparation area are still required. This option does not materially change the requirements for the ready-to-use infant formula kit.

Some mothers expressed confusion about the amount of ready-to-use infant formula that needs to be stored, stating that they believed that the volume suggested was excessive. It should be understood that the amount of ready-to-use formula stored needs to be based both on the anticipated volume of milk that the infant would be expected to consume and the number of feeds per day that the infant is expected to need. This is because once a package of formula is opened it must be fed immediately to the infant and any leftover formula discarded; left over infant formula cannot be saved to be fed to the infant later. Thus, if an infant requires frequent small feeds (most likely in a very young infant), the amount of formula that needs to be stored may be much greater than the volume that the infant will actually consume because of the number of feeds required each day.

One mother suggested to the authors that it would be possible to reconstitute powdered infant formula with stored water in disposable bottles, negating the need for heating water for cleaning and sterilisation. This would require storage of the same number of bottles and teats as for the ready-to-use infant formula kit but also make it more feasible to use powdered infant formula in an emergency situation. This option has some risks. In particular, reconstitution of powdered infant formula with cool water does not deactivate any bacteria present in the infant formula. Whilst intrinsic contamination of powdered infant formula is common [1], infection causing illness as a result, is rare. However, it should be noted that medical resources required to treat infections may not be readily available during emergencies.

It should also be noted that the risk of infection differs depending on characteristics of the infant with newborns, premature or low birth weight infants and infants otherwise immunocompromised over represented amongst those infected [2]. Mothers with healthy older infants may decide that the risk posed by intrinsic contamination of powdered infant formula is acceptable and that they are willing to reconstitute infant formula with water at ambient temperature.

The other factor to consider is the quality of water for reconstitution. Ordinary bottled water is not sterile and can contain levels of microbes greater than that in tap water [3]. Tap water itself can be contaminated with disease causing organisms [4-6]. Long-term storage of water can allow bacterial proliferation [7]. Guidelines for the safe storage of water for emergency use are available and include practices such as rinsing storage containers with bleach prior to use, limiting storage to six months and chlorination of water [8, 9]. In some locations it is possible to purchase sterile water for reconstitution of infant formula.

Given that the option of reconstituting powdered infant formula in disposable bottles involves practices that are more likely to result in the infant formula containing higher levels of bacterial contamination than is usually the case, it is even more important that the formula be fed immediately to the infant and the unused portion discarded immediately.

If considering using powdered infant formula with disposable bottles in an emergency kit, caregivers should ensure that the volumetric measurements on the feeding bottle are accurate. Clinical experience has shown that volumetric measurements on feeding bottles can be inaccurate and if the bottle is used to measure water for reconstitution, errors resulting in over or under-dilution of the infant formula can occur

Thus, while reconstitution of powdered infant formula in disposable bottles is certainly feasible, the risks associated with it require careful consideration. It is unlikely that this option would be recommended by health authorities because of these risks. If individual caregivers decide that this option is one that they wish to use, ensuring that they understand how to minimise the risks is important. The risks of this option are decreased if the infant is older, has no history of low birth weight, prematurity or immunocompromise, if sterile water is used for reconstituting the powdered infant formula and if the formula is fed immediately to the infant.

Some concerns were raised about the cost of the emergency kits for formula fed infants. The figures provided were based on the cost of purchasing the products at one of Australia¿s major supermarkets. The cost is likely to vary widely depending upon location and the ability of the individual to source the cheapest possible products. It should be recognised however, that in the event of an approaching emergency (such as a cyclone or hurricane) that caregivers will have limited options for sourcing the items in the kits and costs may be much greater than those provided in the paper.

The authors would welcome further comment and questions from health professionals and parents.

Karleen D Gribble
Nina J Berry

1. Forsythe SJ: Enterobacter sakazakii and other bacteria in powdered infant milk formula. Maternal and Child Nutrition 2005, 1:44-50.
2. WHO, FAO: Enterobacter sakazakii and other microorganisms in powdered infant formula. Geneva: WHO; 2004.
3. Lalumandier JA, Ayers LW: Fluoride and bacterial content of bottled water vs tap water. Archives of Family Medicine 2000, 9:246-250.
4. Almeida A, Moreira MJ, Soares S, Delgado ML, Figueiredo J, Silva E, Castro A, Cosa JM: Presence of Cryptosporidium spp. and Giardia duodenalis in drinking water samples in the north of Portugal. Korean Journal of Parasitology 2010, 48:43-48.
5. Rudi K, Tannaes T, Vatn M: Temporal and spatial diversity of the tap water microbiota in a Norwegian hospital. Applied and Environmental Microbiology 2009, 75:7855-7857.
6. Xi C, Zhang Y, Marrs CF, Ye W, Simon C, Foxman B, Nriagu J: Prevalence of antibiotic resistance in drinking water treatment and distribution systems. Applied and Environmental Microbiology 2009, 75:5714-5718.
7. Morais PV, Da Costa MS: Alterations in the major heterotrophic bacterial populations from a still bottled mineral water. Journal of Applied Bacteriology 1990, 69:750-757.
8. Food and Water Concerns [http://www.bt.cdc.gov/disasters/earthquakes/food.asp]
9. Water [http://www.fema.gov/plan/prepare/water.shtm]

Querying conclusions

Kasia Williams — 2012-01-03T22:35:53Z

This is an interesting article that provides an introductory overview of feeding practices. I am a little concerned about the areas noted requiring 'immediate intervention'. In particular, "too frequent breastfeeding and overnight feeding of older children". Many children will require feeding overnight until they are developmentally ready to have unbroken sleep. Feeding is also a matter of psychological and emotional development and provides a source of comfort and bond in addition to other health benefits. The concern about feeding too frequently is also puzzling as there is no identifiable 'maximum' number of feeds and a mother and child should feed as often as they need to or wish to. Again, breastfeeding is also for psychological and emotional development. I would be interested to hear if there is any evidence to back up the author's concerns on these two issues.

Breastfeeding Definition

Mahsa Jessri — 2011-10-24T09:29:37Z

Dear Editor,

I very much appreciate the article by Thompson et al1, which clearly shows that women with greater blood loss after a significant PPH are less likely to continue ¿full breastfeeding¿. However, I am concerned with the definition of breastfeeding used in this study. Authors indicate on page 2, under the heading ¿Quantitative data¿, that they have used the 2008 WHO definition2 for categorizing the breastfeeding practices. However, they have grouped infants who were being either ¿exclusively¿ or ¿predominantly¿ breastfed into one category of ¿fully breastfeeding¿; while this method of categorization is merely based on the older WHO3 breastfeeding definitions and are not suggested in the latest version2.

In addition, authors define ¿bottle feeding¿ as the state in which infants are ¿not fed any breast milk¿; this does not match the 2008 WHO definition of ¿bottle feeding¿ which is ¿receiving any liquid (including breast milk) or semi-solid foods from a bottle with nipple/teat¿2.

Since breastfeeding definitions suggested by the WHO are the most reliable and widely-used, this comment serves to bring this issue to readers¿ awareness.

Mahsa Jessri

Human Nutrition Division, University of Alberta

Edmonton, AB, Canada

References:

1. Thompson JF, Heal LJ, Roberts CL, Ellwood DA. Women's breastfeeding experiences following a significant primary postpartum haemorrhage: A multicentre cohort study. Int Breastfeed J. 2010 May 27;5:5.

2. World Health Organization: Indicators for assessing infant and young child feeding practices: conclusions of a consensus meeting held 6-8 November 2007 in Washington D.C., USA. Geneva: World Health Organisation; 2008.

3. World Health Organization: Indicators for Assessing Breastfeeding Practices: Reprinted report of an informal meeting, 11-12 June 1991 Geneva, Switzerland. Division of Child Health and Development. World Health Organization; 1991, WHO/CDD/SER/91.14.

Breastfeeding Challenges World-wide Evident in Nacogdoches, TX

Carrie Wright — 2010-11-15T08:54:37Z

In 2010 I see many of the same challenges outlined in this article mirrored for mothers in rural America. Certainly the challenges that the health care workers in Niger are dealing with are heightened in comparison to our workers, however the end result for the mothers in Niger is the same as that of those here in rural Nacogdoches, TX. Mothers here receive conflicting advice about breastfeeding, rarely receive breastfeeding education from their primary care provider, and are plied with commercial advertisements of formula during their extremely short hospital stay (24-48 hrs on average). Although we boast a 75% initiation rate in my home state, less than 1/2 of those mothers leave the hospital exclusively breastfeeding. This is a sad reality for mothers and easily solved by a change in hospital policy and expectation. I appreciate this type of qualitative study which continues to highlight the plight faced by new mothers and babies world-wide.

Editor's response to comment

Lisa Amir — 2010-04-18T01:10:56Z

I agree that we must be clear about definitions of breastfeeding. I spend a lot of time asking authors to clarify their definitions. In this paper, the authors had initially used the term "breastfeeding" to include breastfeeding at the breast and feeding expressed breast milk. At my request, the authors changed the wording throughout the paper to "breast milk feeding". Unfortunately, the authors and I did not notice the sentence in the Conclusion still referred to "breastfeeding". After publication of the comment by Valerie McLain, the authors asked the publisher to change the wording of that sentence. This sentence has now been corrected.
Lisa Amir
MBBS MMed PhD IBCLC FABM
Editor-in-Chief
International Breastfeeding Journal

competing interests

Valerie McClain — 2010-03-22T10:06:49Z

M. Thomas Clandinin is the President and CEO of BioLipids Inc. in Canada. He is a listed inventor to a US Patent #6998392 called "Formulation to treat or prevent parasitic infection." The formulation is a method of using human milk gangliosides (complex lipids) for placement in infant formula, baby food, etc. MTI Meta Tech Inc. owns the patent and M. Thomas Clandinin is involved with this company, too. I would think that this would be considered a competing interest.

Breastfeeding is not breast milk feeding

Valerie McClain — 2010-03-18T08:39:36Z

It is great that we have the data that shows that the use of donor milk banking lowers the use of infant formula. This is an important conclusion. But this study has two fatal flaws that need to be addressed by the authors for future studies. First, the abstract states that "the aim of the study is to assess the impact that a human milk bank has had on the proportion of infants receiving exclusive breast milk at discharge." (1) The conclusion states that, "We demonstrate how milk banks do not cause reduction in the rates of breastfeeding or in promoting its protection and support."(2) The authors defined exclusive breastfeeding and exclusive breast milk as the same. Are they the same? What is the impact on observations and conclusions in a study, when we define them as the same? Did this study demonstrate how milk banks do not cause a reduction in the rates of breastfeeding? There is no data on the rates of breastfeeding, unless you define breastfeeding as equivalent to breast milk feeding. Table 2 of the study shows that exclusive mother's milk in the year 2006 was 40% but in the year 2008 it was 13%. (3) I believe the author's explanation of the earlier use of donor milk in the neonatal unit does not sufficiently relieve my concerns. Definitions of infant feeding methods are critical in understanding outcomes. Science should be clear, we need precise definitions. The aim of the study should match the conclusion of the study. This was not done and makes it a less valuable contribution.

1. Torres et al.,"Does opening a milk bank in a neonatal unit change infant feeding practices? A before and after study,"International Breastfeeding Journal 2010, 5:4
2. Torres et al, IBJ 2010, 5:4
3. Torres et al, IBJ 2010, 5:4, Table 2

Re: confounding of pre-birth and post-birth: Authors' reply

Imran Morhason-Bello — 2010-01-03T06:43:43Z

As mentioned in the method section of this paper, primigravid mothers’ data were separately analysed to see the interval of breastfeeding initiation time [1]. Details of the obstetric outcomes such as labour duration, satisfaction and others have been published elsewhere [2]. Presence of companion is associated with better labour outcomes. All the companions were present from onset of established labour till 2 hours after delivery as per our protocol. It is possible from your comment that duration of companion’s stay could influence the outcome of breastfeeding initiation but, we do not have subset of companions that were either solely present pre-birth or post-birth as suggested.

We also feel that the better obstetric outcomes as well as childbirth satisfaction are intermediate variables in the effect of social support on breastfeeding initiation and not confounders per se [3]. Social support will affect these birth outcomes which may then influence initiation of breastfeeding. Hence, we did not include them in multivariable model analysis.

Thank you.

References
1. Morhason-Bello, IO, Adedokun BO, Ojengbede OA Social support during childbirth as a catalyst for early breastfeeding initiation for first time Nigerian mothers. International Breastfeeding Journal 2009, 4:16 doi:10.1186/1746-4358-4-16
2. Morhason-Bello, I.O., Adedokun B.O., Ojengbede A. O., Olayemi O., Oladokun A: Fabamwo A. O. Assessment of the effect of psycho-social support during childbirth in Ibadan, South-West Nigeria: a randomised controlled trial. Aust N Z J Obstet Gynaecol 2009, 49(2): 145 - 50.
3. Rothman KJ & Greenland S. Modern Epidemiology 2nd ed. Pg 123-125. 1998 Lippincott Raven, Philladelphia

New breast milk in old bottles

Martha Wardrop — 2009-12-15T10:53:08Z

I was fascinated to look at the different doors concept presented by the author, and believe that if we all consider these different influencers on a womans decision to breast feed or not, or wean early or not, we can collectively come up with some better ideas on changing the negative ideas that some people have about providing the very best for infants around the world. I appreciated the article very much.

confounding of pre-birth and post-birth

G Becker — 2009-12-12T22:52:18Z

Thank you for an interesting article. I wonder if the companion during labour and birth resulted in a shorter labour, baby in a better state, and the mother generally feeling more competent and this facilitated early initiation of breastfeeding? Or if the companion post-birth encouraged mother etc. Did you have any women in your study who only had a companion post-birth (not during labour)? Or during labour but not post-birth? And the effect on breastfeeding initiation when companion was only there for one aspect.