Breastfeeding and infant care as 'sexed' care work: reconsideration of the three Rs to enable women's rights, economic empowerment, nutrition and health.

Women's lifelong health and nutrition status is intricately related to their reproductive history, including the number and spacing of their pregnancies and births, and for how long and how intensively they breastfeed their children. In turn, women's reproductive biology is closely linked to their social roles and situation, including regarding economic disadvantage and disproportionate unpaid work. Recognizing, as well as reducing and redistributing women's care and domestic work (known as the 'Three Rs'), is an established framework for addressing women's inequitable unpaid care work. However, the care work of breastfeeding presents a dilemma, and is even a divisive issue, for advocates of women's empowerment, because reducing breastfeeding and replacing it with commercial milk formula risks harming women's and children's health. It is therefore necessary for the interaction between women's reproductive biology and infant care role to be recognized in order to support women's human rights and enable governments to implement economic, employment and other policies to empower women. In this paper, we argue that breastfeeding-like childbirth-is reproductive work that should not be reduced and cannot sensibly be directly redistributed to fathers or others. Rather, we contend that the Three Rs agenda should be reconceptualized to isolate breastfeeding as 'sexed' care work that should be supported rather than reduced with action taken to avoid undermining breastfeeding. This means that initiatives toward gender equality should be assessed against their impact on women's ability to breastfeed. With this reconceptualization, adjustments are also needed to key global economic institutions and national statistical systems to appropriately recognize the value of this work. Additional structural supports such as maternity protection and childcare are needed to ensure that childbearing and breastfeeding do not disadvantage women amidst efforts to reduce gender pay gaps and gender economic inequality. Distinct policy interventions are also required to facilitate fathers' engagement in enabling and supporting breastfeeding through sharing the other unpaid care work associated with parents' time-consuming care responsibilities, for both infants and young children and related household work.

Breastfeeding grief after chest masculinisation mastectomy and detransition: A case report with lessons about unanticipated harm.

An increasing number of young females are undergoing chest masculinsation mastectomy to affirm a gender identity and/or to relieve gender dysphoria. Some desist in their transgender identification and/or become reconciled with their sex, and then revert (or detransition). To the best of our knowledge, this report presents the first published case of a woman who had chest masculinisation surgery to affirm a gender identity as a trans man, but who later detransitioned, became pregnant and grieved her inability to breastfeed. She described a lack of understanding by maternity health providers of her experience and the importance she placed on breastfeeding. Subsequent poor maternity care contributed to her distress. The absence of breast function as a consideration in transgender surgical literature is highlighted. That breastfeeding is missing in counselling and consent guidelines for chest masculinisation mastectomy is also described as is the poor quality of existing research on detransition rates and benefit or otherwise of chest masculinising mastectomy. Recommendations are made for improving maternity care for detransitioned women. Increasing numbers of chest masculinsation mastectomies will likely be followed by more new mothers without functioning breasts who will require honest, knowledgeable, and compassionate support.

'We make a mistake with shoes [that's no problem] but not with baby milk': Facilitators of good and poor practice in distribution of infant formula in the 2014-2016 refugee crisis in Europe.

The Infant and Young Child Feeding in Emergencies Operational Guidance (OG-IFE) gives direction on providing aid to meet infants' and young children's feeding needs in emergencies. Because of the risks associated with formula feeding, the OG-IFE provides limited circumstances when infant formula should be provided in aid. However, distributions against this guidance are common, reducing breastfeeding so risking increased infant morbidity and mortality. This study sought to identify factors that contributed to following ('good practice') or not following ('poor practice') the OG-IFE regarding infant formula distribution in the 2014-16 refugee crisis in Europe. Thirty-three individuals who supported, coordinated, or implemented infant feeding support in the Crisis were interviewed regarding their experiences and views. Reflexive thematic analysis of transcribed interviews was undertaken. It was identified that presence of breastfeeding support, presence of properly implemented formula feeding programmes, understanding that maternal choice to formula feed should be considered within the risk context of the emergency, and positive personal experiences of breastfeeding contributed to good practice. Presence of infant formula donations, absence of properly managed formula feeding programmes, belief that maternal choice to formula feed is paramount and should be facilitated, and personal experience of insurmountable breastfeeding challenges and/or formula feeding contributed to poor practice. Governments, humanitarian organisations, and donors should ensure that infant and young child feeding in emergencies preparedness and programmes are adequately resourced. Emergency responders should be appropriately trained with training including infant feeding experience debriefing. Health and emergency organisations should provide maternity protections enabling employees to breastfeed as recommended.

Current Trends in Research on Human Milk Exchange for Infant Feeding.

Breastfeeding is critical for the healthy growth and development of infants. A diverse range of infant-feeding methods are used around the world today. Many methods involve feeding infants with expressed human milk obtained through human milk exchange. Human milk exchange includes human milk banking, human milk sharing, and markets in which human milk may be purchased or sold by individuals or commercial entities. In this review, we examine peer-reviewed scholarly literature pertaining to human milk exchange in the social sciences and basic human milk sciences. We also examine current position and policy statements for human milk sharing. Our review highlights areas in need of future research. This review is a valuable resource for healthcare professionals and others who provide evidence-based care to families about infant feeding.

Health and nutrition content claims on websites advertising infant formula available in Australia: A content analysis.

The use of health and nutrition content claims in infant formula advertising is restricted by many governments in response to WHO policies and WHA resolutions. The purpose of this study was to determine whether such prohibited claims could be observed in Australian websites that advertise infant formula products. A comprehensive internet search was conducted to identify websites that advertise infant formula available for purchase in Australia. Content analysis was used to identify prohibited claims. The coding frame was closely aligned with the provisions of the Australian and New Zealand Food Standard Code, which prohibits these claims. The outcome measures were the presence of health claims, nutrition content claims, or references to the nutritional content of human milk. Web pages advertising 25 unique infant formula products available for purchase in Australia were identified. Every advertisement (100%) contained at least one health claim. Eighteen (72%) also contained at least one nutrition content claim. Three web pages (12%) advertising brands associated with infant formula products referenced the nutritional content of human milk. All of these claims appear in spite of national regulations prohibiting them indicating a failure of monitoring and/or enforcement. Where countries have enacted instruments to prohibit health and other claims in infant formula advertising, the marketing of infant formula must be actively monitored to be effective.

Shaken but not broken: Supporting breastfeeding women after the 2011 Christchurch New Zealand earthquake.

The 2011 Christchurch New Zealand earthquake adversely affected large numbers of people and resulted in many mothers and infants evacuating the city. In the town of Timaru, an emergency day-stay breastfeeding service assisted evacuee women. The service was established after media messaging alerted mothers to the importance of breastfeeding and the location of breastfeeding assistance. The local hospital provided rooms for the breastfeeding support service, which delivered counselling to mothers experiencing breastfeeding challenges. The vulnerability of infants in emergencies demands that governments and aid organisations plan to support their wellbeing and access to safe food and liquid. Plans should be developed in accordance with the Emergency Nutrition Network's Operationalguidance on infant and young child feeding in emergencies and include breastfed and formula-fed infants. Many countries have existing health resources and personnel with the expertise to support infant feeding in emergencies. However, only comprehensive pre-emergency planning can ensure that infants are protected.

"I'm happy to be able to help:" why women donate milk to a peer via Internet-based milk sharing networks.

The process by which women came to donate milk via online milk sharing networks was explored via a questionnaire administered to 97 peer milk donors. Seventy-one respondents stated that they were motivated to donate milk because they wanted to help someone. Many described milk donation as an empathic response to women with insufficient milk. Seventy-four respondents donated milk that they had previously expressed but did not need. Their desire to ensure that their milk was not wasted contributed to their decision to donate. Fifty-one respondents expressed milk specifically for donation, including 20 donors who initially donated previously expressed surplus milk but then expressed milk specifically for recipient peers. The motivations of peer-to-peer donors are the same as those reported for women donating to a milk bank. Respondents who donated previously expressed milk had originally expressed so they had milk when separated from their baby, to manage an overabundant milk supply, because their baby was unwilling or unable to breastfeed, in case of emergency, and to maintain milk supply. This study is the first to clearly identify that some women express milk because they believe this is required for milk supply maintenance. Peer milk donors appeared satisfied with their experience of donating milk. The importance of altruistic motivation should be considered in discussions of the desirability of financial compensation for milk donation. Further research is needed on why women express their milk and whether such expression is beneficial to them.

'A better alternative': why women use peer-to-peer shared milk.

The process by which women came to use internet-facilitated peer-to-peer shared milk was explored via a written questionnaire administered to 41 peer milk recipients from five countries. Respondents were universally unable to provide some or all of the milk their infants required. Twenty-nine dyads had a medical condition that could have affected their ability to breastfeed. Many respondents had had great difficulty in finding health workers who could assist them with their breastfeeding challenges. Before obtaining peer-shared milk, respondents had tried to increase their own milk supply, used infant formula or sought donor milk from personal contacts. Health workers dealing with breastfeeding women require greater training in the recognition and treatment of conditions that adversely affect breastfeeding including a physiological incapacity to fully breastfeed. Peer-to-peer milk recipients appear to be very satisfied with the solution milk sharing provides to their problem of being unable to fully breastfeed their infants.

Peer-to-peer milk donors' and recipients' experiences and perceptions of donor milk banks.

OBJECTIVE: To explore the intersection of peer-to-peer milk sharing and donor milk banks. METHODS: A descriptive survey design containing closed and open-ended questions was used to examine women's perceptions of peer-to-peer milk sharing and milk banking. Closed-ended questions were analyzed using descriptive statistics and conventional qualitative content analysis was used to analyze open-ended responses. SETTING: Participants were recruited via the Facebook sites of two online milk-sharing networks (Human Milk 4 Human Babies and Eats on Feet). PARTICIPANTS: Ninety-eight milk donors and 41 milk recipients who had donated or received breast milk in an arrangement that was facilitated via the Internet. RESULTS: One half of donor recipients could not donate to a milk bank because there were no banks local to them or they did not qualify as donors. Other respondents did not donate to a milk bank because they viewed the process as difficult, had philosophical objections to milk banking, or had a philosophical attraction to peer sharing. Most donor respondents felt it was important to know the circumstances of their milk recipients. No recipient respondents had obtained milk from a milk bank; it was recognized that they would not qualify for banked milk or that banked milk was cost prohibitive. CONCLUSION: Peer-to-peer milk donors and recipients may differ from milk bank donors and recipients in significant ways. Cooperation between milk banks and peer sharing networks could benefit both groups.

Media messages and the needs of infants and young children after Cyclone Nargis and the WenChuan earthquake.

Infants and young children are vulnerable in emergencies. The media plays an important role in aid delivery and has a positive impact when reports are accurate. However, the media has been implicated in encouraging harmful aid in the form of donations of infant formula and other milk products. Internet-based media reports were collected after Cyclone Nargis in Myanmar and the WenChuan Earthquake in China (2008) and examined for content related to infant and young child feeding. Common messages identified included that: babies are vulnerable; stress prevents breastfeeding; and providing infant formula saves lives. Messages rarely reported included that: artificial feeding is dangerous; and breastfeeding protects infants. This analysis suggests that current patterns of media reporting may encourage harmful aid and increase child morbidity and mortality. Aid organisations should encourage the media to report accurately on the needs of infant and young children in emergencies so as to improve aid delivery.

Milk sharing and formula feeding: Infant feeding risks in comparative perspective?

The advent of Internet forums that facilitate peer-to-peer human milk sharing has resulted in health authorities stating that sharing human milk is dangerous. There are risks associated with all forms of infant feeding, including breastfeeding and the use of manufactured infant formulas. However, health authorities do not warn against using formula or breastfeeding; they provide guidance on how to manage risk. Cultural distaste for sharing human milk, not evidenced-based research, supports these official warnings. Regulating bodies should conduct research and disseminate information about how to mitigate possible risks of sharing human milk, rather than proscribe the practice outright.

Mechanisms behind breastmilk's protection against, and artificial baby milk's facilitation of, diarrhoeal illness.

It is well known that exclusive breastfeeding provides protection against diarrhoeal infection, but the mechanisms behind this protection are poorly understood. In addition, it is well known that feeding a baby artificial baby milk dramatically increases the risk of diarrhoeal illness severe enough to require medical treatment, including hospitalisation, but the mechanisms by which artificial baby milk facilitates infection are largely unrecognised. This paper uses non-technical language to describe some of the known ways in which breastmilk provides infants with external immune support. Detailed knowledge of the importance of breastfeeding and the risks associated with the use of artificial baby milk will assist more mothers to exclusively breastfeed.

Emergency preparedness for those who care for infants in developed country contexts.

Emergency management organisations recognise the vulnerability of infants in emergencies, even in developed countries. However, thus far, those who care for infants have not been provided with detailed information on what emergency preparedness entails. Emergency management authorities should provide those who care for infants with accurate and detailed information on the supplies necessary to care for them in an emergency, distinguishing between the needs of breastfed infants and the needs of formula fed infants. Those who care for formula fed infants should be provided with detailed information on the supplies necessary for an emergency preparedness kit and with information on how to prepare formula feeds in an emergency. An emergency preparedness kit for exclusively breastfed infants should include 100 nappies and 200 nappy wipes. The contents of an emergency preparedness for formula fed infants will vary depending upon whether ready-to-use liquid infant formula or powdered infant formula is used. If ready-to-use liquid infant formula is used, an emergency kit should include: 56 serves of ready-to-use liquid infant formula, 84 L water, storage container, metal knife, small bowl, 56 feeding bottles and teats/cups, 56 zip-lock plastic bags, 220 paper towels, detergent, 120 antiseptic wipes, 100 nappies and 200 nappy wipes. If powdered infant formula is used, an emergency preparedness kit should include: two 900 g tins powdered infant formula, 170 L drinking water, storage container, large cooking pot with lid, kettle, gas stove, box of matches/lighter, 14 kg liquid petroleum gas, measuring container, metal knife, metal tongs, feeding cup, 300 large sheets paper towel, detergent, 100 nappies and 200 nappy wipes. Great care with regards hygiene should be taken in the preparation of formula feeds. Child protection organisations should ensure that foster carers responsible for infants have the resources necessary to formula feed in the event of an emergency. Exclusive and continued breastfeeding should be promoted as an emergency preparedness activity by emergency management organisations as well as health authorities. The greater the proportion of infants exclusively breastfed when an emergency occurs, the more resilient the community, and the easier it will be to provide effective aid to the caregivers of formula fed infants.

Supporting breastfeeding in emergencies: protecting women's reproductive rights and maternal and infant health.

Women have the right to support that enables them to breastfeed. Supporting breastfeeding in emergencies is important because artificial feeding places mothers and children at risk. In emergencies, artificial feeding is dangerous to the infant, difficult and requires substantial resources. In contrast, breastfeeding guards infant health. It is also protective against postpartum haemorrhage, maternal depletion, maternal anaemia and closely spaced births and should therefore concern not only nutritionists, but also those involved in reproductive health. However, it is common for women's ability to breastfeed to be undermined in emergencies by the indiscriminate distribution of breast-milk substitutes and the absence of breastfeeding support. Controlling the distribution of breast-milk substitutes, providing supportive environments, and appropriate medical and practical assistance to breastfeeding women safeguards the health and well-being of mothers and babies. Greater collaboration between the nutrition and reproductive health sectors is required to promote best practice in protecting breastfeeding women and their children in emergencies.

Milk sharing: from private practice to public pursuit.

After only six months, a commerce-free internet-based milk-sharing model is operating in nearly 50 countries, connecting mothers who are able to donate breast milk with the caregivers of babies who need breast milk. Some public health authorities have condemned this initiative out of hand. Although women have always shared their milk, in many settings infant formula has become the "obvious" alternative to a mother's own milk. Yet an internationally endorsed recommendation supports mother-to-mother milk sharing as the best option in place of a birth mother's milk. Why then this rejection? Several possibilities come to mind: 1) ignorance and prejudice surrounding shared breast milk; 2) a perceived challenge to the medical establishment of a system where mothers exercise independent control; and 3) concern that mother-to-mother milk sharing threatens donor milk banks. We are not saying that milk sharing is risk-free or that the internet is an ideal platform for promoting it. Rather, we are encouraging health authorities to examine this initiative closely, determine what is happening, and provide resources to make mother-to-mother milk sharing as safe as possible. Health authorities readily concede that life is fraught with risk; accordingly, they promote risk-reduction and harm-minimisation strategies. Why should it be any different for babies lacking their own mothers' milk? The more that is known about the risks of substituting for breast milk, the more reasonable parental choice to use donor milk becomes. We believe that the level of intrinsic risk is manageable through informed sharing. If undertaken, managed and evaluated appropriately, this made-by-mothers model shows considerable potential for expanding the world's supply of human milk and improving the health of children.

Long-term breastfeeding; changing attitudes and overcoming challenges.

The experiences of 107 Australian women who were breastfeeding a child two years or older were gathered via a written questionnaire with open-ended questions. Eighty-seven percent of women had not originally intended to breastfeed long-term and many had initially felt disgust for breastfeeding beyond infancy. Mothers changed their opinion about long-term breastfeeding as they saw their child enjoy breastfeeding, as their knowledge about breastfeeding increased and as they were exposed to long-term breastfeeding role models. It was common for mothers to be shocked the first time they saw a non-infant breastfeed but this exposure was also a part of the process by which they came to consider continuing to breastfeed themselves. Women often found long-term breastfeeding role models as well as information and moral support for breastfeeding continuance within a peer breastfeeding support organisation (the Australian Breastfeeding Association). Previous breastfeeding experiences had assisted women in their current breastfeeding relationship. Mothers had overcome many challenges in order to continue breastfeeding and breastfeeding was sometimes discontinuous, with children weaning from days to years before resuming breastfeeding. This study suggests that postnatal interventions may be successful in increasing breastfeeding duration. Such interventions might include: continuing provision of breastfeeding information throughout the lactation period, facilitation of exposure to long-term breastfeeding, and referral to peer breastfeeding support organisations.

Breast is no longer best: promoting normal infant feeding.

The recent release of new growth charts by the World Health Organization (WHO) heralds a fresh understanding of what constitutes normal infant growth and development. The Multicenter Growth Reference Study that underpins these new growth standards 'establish[es] breastfed infants as the normative model for growth and development'. This is in contrast to past practice, which treated breastfeeding as the optimal, rather than the normal, way to feed babies. This idealization of breastfeeding has been counterproductive, because it has reinforced a perception that formula feeding is the standard way of feeding babies. It is, therefore, suggested that breastfeeding promotion and education programmes should abandon the 'breast is best' message in favour of messages that normalize breastfeeding, and that future research ought to use infants breastfed according to WHO recommendations as the norm reference or control group in every instance.

A model for caregiving of adopted children after institutionalization.

TOPIC: Optimizing caregiving for newly adopted postinstitutionalized children. PURPOSE: To consider a template of care for postinstitutionalized children based on experiences that physiological measures suggest are expected by infants postbirth. SOURCES: Published literature and clinical experience. CONCLUSION: Based on an understanding of physiologically expected care postbirth, special care for postinstitutionalized adopted children might include: close physical contact via use of a sling and cosleeping; breastfeeding or nurturing through food; and responsive caregiving. In replicating earlier missed experiences, parents may assist emotional development in their child and promote attachment development.