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.
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