Monthly Archives: September 2012

Breast is best. Bottles are good enough.

Food Standards Australia New Zealand (FSANZ) call for submissions; should infant formula have a risk warning?

Food Standards Australia New Zealand (FSANZ) have released a consultation paper on the regulation of infant formula products in the Food Standards Code. You can access the complete documentation and instructions on submission via this link. Below is one section of consultation paper:

6.7 ‘Breast is best’ warning statement

Subclause 14(3) of Standard 2.9.1 requires the label on a package of infant formula product to contain the warning statement: ‘Breast milk is best for babies. Before you decide to use this product, consult your doctor or health worker for advice’. This statement is often referred to as the ‘breast is best’ statement. This requirement aligns with the recommendations in Article 4a of the WHO Code and Article 4.2 in both the New Zealand CoPMIF and the Australian MAIF agreement (see section 2.1.3). The WHO Code also recommends a statement advising consumers to seek advice from their healthcare professional prior to deciding to use an infant formula product.

Some stakeholders have suggested that the ‘breast is best’ warning statement be amended to a risk-based statement about the risks to infant health of not breastfeeding. These stakeholders state that such a statement would reflect a body of evidence showing that compared to formula feeding, breastfeeding is associated with lower incidence of infection and some chronic diseases, and evidence for improved cognitive development in the breastfed infant.

There should not be a risk-based statement about the risks to infant health of not breastfeeding.

First, please let me attempt to establish my credentials to comment. I have hospital-acquired certificates in both general nursing and mental health nursing, I hold a Bachelor of Nursing, a Master of Mental Health Nursing, and a Certificate in Infant Mental Health. I am a Fellow of the Australian College of Mental Health Nurses. I have been working with pregnant women and new mothers since July 2000, initially on a mental health consultation liaison team, since August 2010 I’ve been in a position that is exclusively to do with perinatal mental health. In these roles I have triaged, spoken-with and supported many hundreds of pregnant women and new mothers (we get about 300 referrals every year).

I don’t have expert knowledge in nutrition, I have never breastfed a baby, and I have no relationship with the Infant Nutrition Council (an industry group representing the manufacturers and marketers of infant formula in Australia and New Zealand).

What I have been privileged with is a front-row seat to pregnant women and new mothers discussing, experiencing, managing and recovering-from the two most prevalent mental health conditions: anxiety and depression. This privileged position has provided more insights into being a Mum than I, as a childless bloke, ever expected to have. On a future post I’ll discuss my position and present the biopsychosocial model of perinatal mood disorders in a bit more detail, but for now I’ll highlight just some of the information relevant to the suggestion that there should be a risk-based statement about not breastfeeding on infant formula packaging.

Austin M-P, Highet N and the Guidelines Expert Advisory Committee (2011) Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period. A guideline for primary care health professionals. Melbourne: beyondblue: the national depression initiative.

The 2011 Australian perinatal mental health clinical practice guidelines state that, “While estimates vary, research suggests that depression, anxiety or both are experienced by at least one in ten women during pregnancy and one in six women in the year following birth.”

1 in 10 antenatally. 1 in 6 postpartum. It’s a big deal.

Not one of the women that I have seen in my clinical role has ever told me that bottle-feeding is the healthiest or easiest thing they can do for their baby. None. Zero. Nada. Zip.

In clinical practice, often women report that one of their biggest disappointments in motherhood has been attempting to breastfeed their baby but being unable to sustain it. Unmet expectations about an ideal pregnancy/birth/parenting experience are very common amongst women who experience anxiety or depression.

We (we the health system, that is) don’t help. As one new Mum said, “I get it: I’ve been to the classes, seen the posters, read the brochures. The message is loud and clear: GOOD MOTHERS BREASTFEED. That makes me a bad mother.”

There are other insights that have come from clinical practice;

  • Depression robs you of resilience and dampens your capacity for pain tolerance, so much so that a cracked nipple, mastitis, or baby that chomps can become intolerable.
  • Depression robs you of the skill of being assertive, so that you don’t feel empowered to have a balanced discussion and feel like you’re being heard if the clinician/health system is relentless in reinforcing the single message that breast is best.
  • Depression robs you of sleep and the luxury of feeling refreshed – if I can offload some of the demands on my time I will feel better; hopefully.
  • Depression makes you feel inadequate, ineffective and stupid – that’s why I can’t breastfeed, no matter how hard I try.
  • Depression and anxiety make me so negative, so prone to thinking the worst, that I just don’t feel safe breastfeeding. It doesn’t matter how good breastfeeding is, I feel as if spending time alone holding this baby is a risk that is not worth taking right now.
  • Depression robs you of joy; I don’t hate my baby, but I can’t stand being around him/her as much as I have been.
  • Depression robs you of power. I don’t have a voice. It is ridiculous that every time I bottle-feed the language and attitude of others makes me feel invalidated. I am making informed decisions about what works best for me/my family right now.

So, with this information in mind, how should we respond to suggestions to concentrate on the risks of not breastfeeding? Perhaps we need a tool to support our decision-making; here’s one I prepared earlier:

We (the health system, the community) need to be respectful of what happens within families – they’re a bit like icebergs sometimes, and we don’t always see what’s going-on below the surface. Obviously infant nutrition is important; infants also benefit from having parents who feel supported in making informed decisions, parents who don’t feel that they have to hide from the health system/their peers, and parents that have their emotional and mental health taken into consideration.

Breast is best, but when breast-feeding doesn’t work-out bottles (like parents) are good enough.

Paul McNamara, 29 September 2012

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SoMe, You + AHPRA

First-up, just in case you’re late to how this story started, let me give a bit of background/context as I understand it.

  1. The Australian Health Practitioner Regulation Agency (AHPRA) lost control of distribution of their preliminary consultation paper on social media policy.
  2. The document started turning-up online – think WikiLeaks-Lite – and was soon being shared amongst health professionals and others via (you guessed it) social media (BTW: social media is often abbreviated as “SoMe”, which I hope is an ironic hat-tip to the assertion that using social media is a narcissistic undertaking – “it’s so about me“).
  3. For a week or so, it was the most dominant topic of conversation on Twitter amongst those who have an interest in Healthcare & Social Media in Australia & New Zealand (HCSMANZ). To get a feel for these conversations see this Storify (collating some relevant Tweets from 03/09/12 to 10/09/12), and this #HCSMANZ transcript (09/09/12)

Here’s a copy of the email I sent to AHPRA (it’s been in the public domain before now):


As part of the consultation process, please follow the link below for a demonstration of how one arm of social media works

AHPRA on Twitter (with images, tweets)

I have found this conversation on twitter informative, thought-provoking, occasionally irreverent, often entertaining, and something that enhances (not risks) my understanding of what it is to be a health professional.

As you will see, health professionals are engaging with social media in a manner that does not conform with the draft guidelines. Health professionals are critiquing matters they find important, some are advertising their services, they don’t always hide their comments from the public (ie: their patients could read them), and are doing so in manner that is probably very similar to how they would interact in a tea room, at the nurses station or while attending a conference. That is the point I would like to make most strongly: social media is not different to real life, it is real life.

Social media does not stand apart from real life anymore than the telephone, email or letter-writing does. Health professionals are trusted to go “behind the curtain” (both literally and metaphorically) when with people (aka patients) often at their most vulnerable time in life. Surely then, health professionals should expect to be trusted in the very public arena of social media.

I submit the suggestion that AHPRA should revisit the draft policy from a completely different standpoint. Acknowledge an assumption of professionalism whenever a health professional is representing themselves as such, and encourage health professionals to embrace the potential of emerging technologies, not fear them.

Paul McNamara

It is a pretty unsophisticated response compared to many of the other comments made. If you really want to get into the detail of what others were saying, follow the links in the Tweets collated on Storify. If you don’t want that level of detail, but still want to understand what all the fuss was about, just read this response from Phillip Darbyshire (07/09/12), which ends:

If AHPRA cannot support this movement [health professionals using social media] positively and enthusiastically, then it should at least have the grace and wisdom to step out of the way and do not obstruct it.

Ironically, AHPRA have motivated me to get more involved in SoMe than I would have otherwise. I found many like-minded people via this Twitter hashtag: #HCSMANZ and have been inspired to do more, not less, with SoMe. I hope AHPRA finds this creative, energetic, kind-of-geeky group worthwhile consulting with in future.

APHRA have sent an email acknowledging receipt of submission to the preliminary consultation paper on social media policy, and advise there will be a round of public consultation.

You Me We haven’t heard the last on this subject.

Paul McNamara, 25 September 2012

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Hello World!

Hello, thanks for dropping by.

My name is Paul McNamara, I am an Australian Registered Nurse. If you’re interested (quite understandable if you’re not) there are twenty questions worth of information about me and meta4RN here.

This Blog and it’s related social media portals – Twitter Facebook YouTube (with more to come) – are all part of what I hope will become a cohesive professional social media strategy to interact with peers. It’s not a big deal, it’s just a networking strategy using some of the tools of our time.

The first step toward that strategy is to begin the process of mothballing the @PiMHnurse Twitter handle that I have been using. The handle is job-specific, and it’s not likely that I will be in the same job for the rest of my working life – that’s why I’ll be winding-back on using that account over the next month or so. Hopefully I will be able to maintain the valued connections I have made by using the new @meta4RN Twitter handle instead.

That’s it for the opening blog post. Thanks again for dropping by, please feel free to leave a comment and/or stay connected via Twitter Facebook YouTube or LinkedIn

Paul McNamara, 24 September 2012