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Tuesday, March 8, 2016

The white gold rush: Why Chinese shoppers are going all-out for foreign formula

I'm lucky enough to live in a neighborhood that is attractive and interesting enough for people to actually pay to come and visit it (i.e. Tourist Central). Japan has seen almost uninterrupted growth in its tourist trade in recent years, especially Chinese visitors. Chinese tourists tend to be quite serious shoppers and the tills are ringing from dawn till dusk in the massive Don Quixote (*1) store that was built here last year in anticipation of growing numbers of tourists. Don Quixote is a.... well, rather quixotic store selling consumer goods of all kind and designed to look like a kind of shopping jungle; very much a store that says Buy Buy Buy! Except, interestingly, in the case of baby goods: the shelves of nappies and formula have signs saying "One pack only per shopper," and the tins of formula now have little security beepers sealed in with tough plastic which the checkout assistant has to remove with a Stanley knife.

Middle-class Chinese families have been going out of their way to avoid Chinese-made formula ever since the melamine scandal of 2008, in which some babies were killed and many more hospitalized after a shady manufacturer decided to doctor its formula mix with melamine to disguise the low protein levels. The fact that Chinese tourists are eager to buy Japanese formula in spite of worries a few years back about radioactive contamination in the wake of the 3/11 earthquake tells you something about just how bad the reputation of Chinese formula is. Meanwhile, many middle-class women prefer not to breastfeed or find it difficult; they may want to get back to to work as soon as possible to fund their children's education, and there is a lack of provision for pumping in most Chinese workplaces. Hence the development of a sizable "grey market" in which Chinese students, tourists and ad hoc entrepreneurs sweep the shelves for formula in places like Hong Kong, Australia and Japan, and then sell the tins in China for several times the price originally paid for them; at the more informal level, many visiting Chinese like to pick up formula as a gift for friends who have babies.

The thing about China is that the sheer, steamroller-like volume of people we are talking about means that a shortage of pretty much anything in that country (whether it's brides or baby milk) is likely to have repercussions for the rest of the world, and parents in Australia, New Zealand and Europe have been taking to social media to vent about being confronted with empty formula shelves and Chinese shoppers toting baskets crammed with tins and tins to take back to China. Chinese parents' desperation to acquire any formula that isn't Chinese is understandable; so, however, is the frustration of parents in countries which have done a better job at ensuring food safety. Last year in Japan, a punch-up developed in an Akachan Hompo between two groups of Chinese tourists who were trying to buy up as many diapers as possible (*2), while other Japanese stores are now rationing formula/nappies and even interrogating foreign-looking women at the till ("What are you buying these diapers for?"). In Australia and Europe, women of East Asian background are increasingly reporting hostile reactions from shop assistants if they try to buy several tins of formula at a time. Tensions are running high.

My first thought upon hearing of this trade was "Why don't the manufacturers just export formula to China?" However, it appears that there is a distinct ranking in terms of formula desirability: formula purchased overseas is top, followed by imported foreign formula purchased at an import store in China, and then, finally, formula manufactured in China by a foreign-affiliated company. Given the extremely high prices that are being charged for foreign formula and China's perennial issues with fake stuff, I suspect there are concerns that someone somewhere may have just slapped a foreign label onto a can of Chinese formula, while China's very serious pollution problems make many Chinese feel that even formula manufactured within a foreign-owned factory located in China is risky. Plus, when it comes to gifts I suppose there is a special value in receiving something that you know someone has dragged through customs and carried back home in a suitcase on a bouncing bus: "This is special and limited in supply, and I made the effort just for you." In any case, I guess that Australian or Japanese formula manufacturers have to limit the amount they export if they do not want to face a social media backlash from parents frustrated at shortages in their local supermarkets.

"Well, why not just produce more formula?" is the obvious response to all this. Long-run, I think that is the plan, and dairy industries in Australia and other countries have been enthusiastically gearing themselves up for expansion over the next couple of decades to meet Chinese demand for high-end milk products.

In the short-run however, it's not quite as simple as that. Formula is not just plain old cow's milk and contains an ever-increasing number of complex ingredients, which must be sourced according to rigid and complicated guidelines. The rules governing infant formula production are (not surprisingly) very strict indeed, and a producer would have to be pretty daft to risk cutting corners; the lesson of China's infant formula debacle is that for formula manufacturers, if you slip up even once, you will probably never win parents' trust again. Finally, cow's milk-based formula production requires specialist equipment, such as spray dryers (to dry the milk into powder). Australia's stray dryers are working at maximum capacity and constructing new ones requires huge amounts of investment. Meanwhile, Japan's dairy industry is in no situation to increase output; we can't even guarantee domestic butter supplies. The crux of the problem lies in the extremely high standards that parents (understandably) have for the milk they feed to their babies; these standards lead Chinese parents to do whatever they can to avoid Chinese formula, but they also make it hard to greatly increase the formula supply in a hurry. This article here has more.

Ultimately, the answer is for China to clear up its pollution issues, lack of pumping rights in the workplace and food safety frameworks so that a) Chinese families are able to trust Chinese-made formula again, and b) more babies can be fed breastmilk for longer, which will help to take the edge off China's exploding demand for foreign-made formula. In the meantime, let's hope that the dairy industries of Australia, Japan and elsewhere succeed in ramping up supply so that parents in these countries do not face empty shelves when they go to the store for milk to feed to their babies.

(*1) Do try Don Quixote if you ever come to Japan--it's crazy, tremendously fun and the products and customer service are top-notch. And the signs are all hand-made. The shop is deliberately designed to display all sorts of things at random, kind of bursting out of every corner--novelty penknives next to cosplay costumes etcKitKats, that kind of thing.
. It is also a good place to pick up snacks with weird flavors, like green tea caramels and peach-flavored

(*2) As someone who has used Japanese nappies, I can confirm that they are very, very good indeed, especially Merries which are apparently the most sought-after brand among the Chinese. Chinese nappies are said to be pretty dire, and there are worries about dodgy chemicals reacting with the skin on babies' behinds (Alternatively, maybe the parents are sensitive to Sino-Japanese political tensions and are enjoying the idea of Japan getting crapped on... who knows?).

Wednesday, December 9, 2015

Offering a breast across the species barrier

Another one of my occasional forays into what might loosely be termed "weird stuff" (nursing from extra breasts, nursing by males etc.) This time, a look at the odd world of human women who choose to breastfeed other animals.

My recent search for "Amazon" (yup, it's Christmas shopping time again!) brought up a quirky news items about an indigenous group called the Awa in Brazil where the women often adopt wild animals and breastfeed them like babies. ("It highlights how far we have come from where we were. They are so close to nature. In fact, it is not even close--they are part of nature," goes the spiel.)

This bit of news was presented as a new and unique finding, but in fact cross-species nursing is a well-attested anthropological fact. Hawaiian women used to nurse puppies along with their children, as did Australian Aboriginal women with their beloved dingoes. Ainu women in Japan used to suckle bear cubs, bears being sacred to their culture. Indigenous women in the Americas breastfed bear cubs, monkeys, oppossum rats and deer. In Papua New Guinea (PNG), women still sometimes continue their traditional custom of adopting and nursing piglets, especially in the Highlands region, though I did not see this during my own travels in PNG many years ago.

Cross-species nursing does seem to be commoner in cultures which have historically faced population pressures (PNG and the Pacific region being just two examples), and my hunch is that this may not be a coincidence. Population growth has long been a problem for the New Guinea Highlands due to the salubrious climate afforded by its high altitude, and especially since the arrival of the sweet potato in the 18th century which caused a big increase in population. The lack of large fauna and the low protein content of the sweet potato and other local crops result in chronic protein deficiency. Limiting births has therefore been a major concern for this part of the world, and is believed to be a key reason for some of the more unusual aspects of traditional Highland culture--the superstitions that required men to eat, work and sleep more-or-less separately from their wives in men's longhouses, the foregoing of sex for up to two years following childbirth (the mysterious process of birth, like menstruation, was believed to be polluting and dangerous to men), as well as abortion and the abandonment of newborns, which caused mothers terrible grief.

I suspect that adopting and breastfeeding pet animals could have evolved as yet another way of limiting births; in women who work physically hard much of the day and eat meager diets, frequent suckling at the breast substantially reduces the chances of conception, thus spacing out pregnancies. Most people in developed countries have a "yuck" reaction of the sight of a woman allowing an animal to suck on her breast, and Christian missionaries have done their best to stamp out the practice along with many other Highland customs. But perhaps we could also see PNG women's cross-species nursing as rather a smart strategy by women who were doing their best to make their own lives easier and safer, and ensure better nourishment for their existing children. And let's face it, a piglet is a lot easier to take care of than a baby!

In addition to preventing the appearance of additional mouths requiring feeding, you can of course go one better by actually eating the animal itself. Although the Awa apparently refrain from eating animals that have ever been nursed by a woman, PNG villages are often not so solicitous and it is normal for breastfed pigs to be slaughtered and eaten at some stage; given that protein shortages in this part of the world were historically so severe that cannibalism of dead human relatives or enemies was commonplace, this is perhaps not surprising. Islands in the Clouds by Isabella Tree (a fascinating book, if you are interested in this part of the world) describes the slaughter of a pig thus nurtured in a Highland village, the ceremony being punctuated by cries of grief from the woman who was losing her "baby."

Pet-keeping is often seen as being exclusively a product of developed societies, but the affection that the women of PNG and elsewhere lavish on their beloved "fur-babies" is real and moving. That basic impulse--"It's so cute--I want to look after it!" ensures that isolated cases of cross-species nursing continue to crop up even in societies where such practices are no longer the norm, as we see in the occasional "well-who'd-have-thought-it" news feature on a pet-owner or wildlife-worker who has chosen to save the life of a baby animal by offering a breast across the species barrier. Breastfeeding animals may be a bit weird, but the stories and motivations that lie behind it are both interesting and touching.

Tuesday, September 15, 2015

No-BS Book Reviews: "Work. Pump. Repeat" by Jessica Shortall

There are a lot of breastfeeding books out there, and quite a few that I wouldn't recommend to anyone who has to work outside the home in their baby's first year. So it's refreshing to come across a nursing-while-working book which I feel I could actually give to a new mother without worrying that I am going to send her off into a tailspin of anxiety and depression. The book is "Work. Pump. Repeat" by Jessica Shortall, and I got an advance preview of it shortly before its recent release.

The most striking thing about the book is its briskly efficient use of floor-space. As the author tells us, she is not going to tell us about the football hold or lactation cookies, because there are about 2,500 breastfeeding books that do that already. Nor does she waste time on giving us reasons to breastfeed--if we've bought the book, we've probably made our decision by now. 

As a result, almost the entire book is freed up for the most fantastically detailed, practical advice--real stuff, hands-on, mum-tested. The sort of stuff you hear on your favorite forums and Facebook groups, yet somehow never get round to actually copying and pasting into a single place so that you will have all the tips when you need them; it's all here, digested, sorted and put into readable form. Are you looking for advice on how to speed things up if your company has assigned a pumping room in another building? It's here. Practical hints on the best type of clothing to disguise milk leaks? Look no further. What to do if you have no alternative other than to pump in a toilet cubicle? Sorry you had to look for it, but there's detailed advice about that too (did you know that keeping some Post-it notes in your handbag can come in handy for this situation? If you are wondering why, read the book). 

Pump choice, pump usage, bottles, freezers and getting your baby ready for taking breastmilk at daycare are discussed, followed by discussion on practical clothing choices, your rights at work, and how to handle your boss and coworkers. All sections are full of concrete, non-judgmental advice that has a "been there, done that" feel to it. The workplace section is really, really pragmatic. Shortall's research for the book included talking to large numbers of HR /management people, trying to work out what are the best tactics for the average Jane who does want to pump at work but cannot afford to antagonize her boss and lose her job/damage her career prospects with a "These are my rights!" attitude. And the book also gives practical tips on "guerrilla pumping"--how to get by at work as best you can if no proper accommodation is made for your needs. The book puts a lot of emphasis on the everyday realities of breastfeeding, with the workplace plan-of-action broken down in detail to include things like how and how often to wash pump parts, dealing with special and unusual pumping situations, flying with breastmilk, and how to approach HR to suggest improvements for pumping facilities. 

Things I would have liked to have seen? I would have preferred slightly more specific info on the freezer storage times/nutritional value question, including differentiation between chest freezers versus regular freezers. I also think that the discussion on lipase/funky-tasting frozen milk would have been better placed closer to the beginning rather than in the troubleshooting section at the end; given the number of women who end up wasting hours and hours producing freezers full of undrinkable milk, every woman who is going to store serious amounts of the stuff should consider testing for lipase before she gets going. One final point is that I would have attached a brief health warning before advising mothers to read books like The Womanly Art of Breastfeeding and The Nursing Mother's Companion. Not that they aren't potentially useful resources too, but a working mother would be well advised to take some of their advice and philosophies with a pinch of salt, especially since some of it (like advising mothers to leave bottle introduction really late) could potentially sabotage one's ability to return to work and stay sane. Lactation consultants as a group perhaps need a health warning as well, for similar reasons.

Sometimes the book made me feel sad. Because when you're reading a section which gives hints about how to get your pump parts clean at work without anyone seeing them, or how to multitask while pumping to deflect criticism from coworkers about your constant "breaks," part of you thinks "Oh, that's a clever idea," and the other part of you thinks "This is so depressing. Because you have all these women working full time with tiny babies, driving themselves nuts trying to pump and store their babies food all day long, waking up all night long, and then having to hide their pump parts from coworkers because God forbid anyone should suffer the disgusting situation of glimpsing a clean breast pump." And it's just all so sad. But given that this is the crappy reality that US mothers face, I am glad that at least writers like Shortall are doing their bit to try and make things a bit easier for mums.

The other thing that makes the book a standout (other than the level of detail) is the emotional care that the author shows towards her fellow WOH breastfeeders. When she says that "this is a judgment-free zone" she really is not kidding. It is rare and refreshing to see a breastfeeding book that talks about formula choice, preparation and supplementation simply as another option, rather than as some kind of existential failure on a mother's behalf. Shortall also describes her own personal journey from exclusive-breastfeeding obsession to a more pragmatic approach with her second child, and it's clear that is part of the reason why she urges mothers to safeguard their mental health--advice that is not confined to an occasional vague disclaimer about "not judging people," but rather is something that is built into the very structure of the book, influencing all the advice it gives.

In short? Without a doubt, the best and most practical book for WOH nursing mothers that I've encountered, and an excellent buy or gift.

Here is an excerpt from Chapter 3 of the book. Enjoy.

Pumping School

Welcome to School

Pumping makes many women feel like farm animals. For me, it is everything actual nursing is not: sanitized, cold (sometimes literally, if you’ve just washed the parts or tend to keep them in the fridge at work in between sessions), and industrial. It was also totally and completely foreign to me, up until the first time I tried doing it, which is where Pumping School comes in.

Unless they make you pump in the hospital (which can happen), you might find yourself at home, with a baby and a very porn-star-esque pair of boobs, wondering who the hell is going to show you how to use this thing.

I needed someone who could see me with my shirt off to show me how to do it. So my best friend took me to Pumping School.

How to Get Taught

Between weeks three and six of your baby’s life, invite to your home a mother with recent experience with pumping breastmilk. This should be a woman with whom you are comfortable seeing both of your newly gigantic boobs. 

Tell her that she is coming over to teach you how to use a breast pump. You should have your pump and its basic parts, breastmilk storage bags, and a Sharpie or other permanent marker. Time this date so your friend comes by just before the first morning feeding (or during, if she has a key or you have someone else to open the front door for her while you have a baby attached to you). If she has a toddler, suggest that she leave this lovely small person at home. 

You’re going to feed your baby as normal, then pump immediately after the feeding. I recognize how silly and arbitrary a term like “first morning feeding” is. Just pretend that any feeding at or after 6:00 A.M. is the first one of the day, even if it isn’t and it makes you want to throw this book against the wall.

The reason you’d shoot for the first morning feeding for pumping is that your body is making more milk at this time of day. Also, it can help trick your body into making a bit more milk throughout the day. If for some reason you just can’t do this time of day, it is not the end of the world. 

Once you’ve nursed, your friend will set you up with the pump—placing the parts onto your boobs if need be—and have you pump for the first time. She will show you how most pumps have an initial “letdown” setting, which pumps quickly and with less suction, to simulate the way your baby sucks when she is first on your breast. Your friend will show you how it then switches over to the general setting, resulting in slower and deeper suction cycles, again to simulate what your baby does once the milk starts flowing. 

Break for Questions 

Here’s what you might worry about in this process:
1. If I pump after I feed the baby, will I have enough milk for the next feeding? Yes, you’ll be fine. Your breasts are always making milk and you don’t need to “fill up.” In fact, you will probably produce more milk that day because of the increased demand.
2. Will there be any milk to pump since my baby just finished eating? Maybe. Maybe not. This first time around is just for practice, so don’t sweat it if all you see is a few drops.
3. Am I really going to do this several times a day when I go back to work? Um, yes. That’s why you bought this book, honey. If you want to breastfeed after you’re back at work, you are probably going to pump a lot at work. It’s not fun, but it is doable. 
4. Who is going to hold the baby while I do Pumping School? Options: your Pumping School teacher, your spouse, a baby swing or chair, or the floor.

Back to School

During the first fifteen minutes or so (which aren’t going to feel awesome), you might produce a couple of drops, or you might produce 4 ounces and feel awesome. There is no definition of success, other than learning how to do it so it stops seeming so foreign and weird. (Note: It will never completely stop seeming foreign and weird.)

You are going to see, for example, that your nipples are stretching to a greater length than you thought possible (a friend described seeing his wife pumping for the first time as “two thumbs in a garden hose”). 

You are going to wonder what will happen to your sex life if/when (it’s a “when,” trust me) your partner sees this process. It will be awkward, but you’ll both survive it.

You might be surprised to see what your breastmilk looks like. It can be thin and watery or thick and creamy. It can be white, yellowish, bluish, or greenish. In fact, it will be all of the above (which is normal) at different times of the day and over time.

Congratulations. You’ve just joined the most exhausted, most multitasking, most ass-kicking club of women in the world. 

Tuesday, August 11, 2015

Fat vaginas and shrinking newborns in Japan

When I got pregnant I weighed 53 kilos at 170cm (118 pounds, 5’8); I gained 13 kilos or 28 pounds over my pregnancy. My daughter was born at just 2.6 kilos (5 pounds 11 ounces). By British or US criteria my gain was fine, and indeed I found myself wondering if I should have gained a bit more, judging by my baby’s rather modest size. Yet by Japanese standards I had gained an excessive amount. Welcome to the insane world of the incredible shrinking Japanese pregnancy.

Official guidelines in Japan recommend that women gain 7-12 kilos if they are normal weight, and 9-12 kilos if they are underweight—significantly lower than the guidelines of the UK and US. However, these figures mask the reality that is going on in clinics and hospitals where doctors routinely pressure women to gain even less than the official limits. “My doctor told me I should stop eating all fruit and carbohydrates,” complains one mum (whose weight gain was picture perfect according to the US guidelines). “I was scolded by the nurses every time I went in; they said I wouldn’t be able to push the baby out,” says another. Others reveal stories of doctors telling them they should be losing rather than gaining weight during pregnancy, or informing them that they would get a “fat vagina” unless they drastically restricted their calorie intake. No, I don’t know what a fat vagina looks like either.

What are the trends in newborn weight?
Perhaps part of the anxiety about gaining too much weight comes from the widespread misconception in Japan that average the average newborn is getting heavier. In fact, birthweights did rise through the 1960s and 1970s in Japan, but from about 1980 the trend went into reverse, with birth weights falling by 125g in the past 25 years. It seems that previous decades' anxieties about “babies getting too big” may have lingered on into the present, distorting doctors’ and the public’s perceptions.

To a certain extent it is understandable that Japanese medical authorities became worried by fact that babies and mothers were growing a bit heavier during the 1960s and 1970s. If a woman genuinely does gain too much during pregnancy, it does indeed increase the risk of difficult births, and this may be particularly true for Asian women. Asian women who gain too much are significantly more likely to develop gestational diabetes than other ethnicities. Big babies may be more likely to wreak havoc on an Asian mother’s body, as there is also some evidence that women of Asian ethnicity are more likely to sustain serious perineal tears in childbirth. Nobody is quite sure why—perhaps it is because Asian babies are proportionally larger compared to their relatively small mothers. In most developed/middle income Asian countries, this problem is increasingly being circumvented through very high cesarean rates (40-50% in countries like China and Vietnam). But the Japanese remain emotionally and culturally committed to the idea of natural childbirth; not surprisingly, a “Keep ’em small at all costs” mentality has tended to develop. 

I suppose there is a sort of “sunk-cost fallacy” in such matters—if you have spent the last decade or two telling women to severely restrict their weight, the possibility that this advice may have been harming babies may be too painful to confront. Easier to keep telling yourself that your advice is correct and always has been. It’s not like Japanese healthcare providers are exactly great at accepting questioning at the best of time.

Oh, and it’s very, very hard to get an epidural in Japan, due to a critical shortage of anesthesiologists and the cultural belief that mothers are “supposed” to suffer in childbirth, and this has probably also encouraged doctors and midwives (all of whom will have watched women suffering in long, hard labors) to encourage mothers to keep their bellies and babies small. In fact, a small baby does not always equal an easy birth--I know women who’ve torn badly pushing out five-pounders--but when you are staring down the barrel of a completely unmedicated labor with absolutely no way out of it, you are naturally going to clutch at whatever straws are available to you which might, maybe, just make things a bit easier. Add in standards of beauty which demand insect-like thinness in women even before pregnancy, and you have a perfect storm for extreme weight restriction in pregnant women. 

The consequences
Slowly, however, awareness is growing in Japan about the risks of too little weight gain in pregnancy. Japanese midwives are still heard to express enthusiasm about the idea of keeping fetuses small and then feeding them up after delivery, but as the doctor quoted in the Bloomberg article puts it, “Being born small and growing big is the worst possible scenario for risk of disease." Babies undernourished in the womb and born small may be at elevated risk of problems such as obesity and hypertension later in life,  possibly because such undernourishment sends out signals that cause the fetus's body to prepare for famine conditions in the outside world (an extreme form of this was seen in the babies born after the Dutch Hunger Winter of 1944-45, who have proven to be more prone to problems such as cardiovascular disease as adults).  

A need for balance
It’s not that we need a complete free-for-all either. Most women I know who gave birth in the UK report that they were never weighed or given any advice on weight gain, a fact which is almost certainly connected with the fact that the percentage of deliveries assisted by forceps has doubled over the last 10 years as mothers start their pregnancies heavier, gain more and have bigger babies. It’s completely reasonable for healthcare providers to be honest with patients about the fact that excessive weight gain increases the risk of difficult births, not to mention the fact that (in my own experience) women who gain huge amounts are more likely to feel uncomfortable during pregnancy and have an difficult psychological transition to motherhood afterwards. 

Nevertheless, there is mounting evidence that excessively strict weight guidelines in Japan are putting the health of babies at risk, and making pregnancy--which is supposed to be one of the happiest times in a mother's life--into a period of unnecessary anxiety, guilt and embarrassment for women. While a certain amount of caution regarding weight gain is probably advisable for Japanese women in particular, given ethnic factors relating to gestational diabetes and the problem of perineal trauma, the advice to restrict weight in pregnancy seems to have become unnecessarily extreme and to have taken on a life of its own. For mothers' and babies' sake, it's time for Japanese healthcare providers to swallow their pride and review their policies on gestational weight gain.

Further reading:

Sunday, June 21, 2015

Is there a need for more nuance in the vaccine "debate"?

Alice Dreger--an academic whose gutsiness in taking up controversial issues I have a lot of respect for--has recently written an article on yet another hot-button topic: A heretic in
the academy: What if not all parents who question vaccines are foolish and anti-science? on the book Vaccine, by Mark Largent.

Prof. Largent is basically in favor of vaccination and wants to increase coverage; however, he also criticizes some of the doctors, journalists and bloggers who have pushed the pro-vaccine line. Largent suggests that some of these people have made things more difficult by adopting all-or-nothing arguments about vaccination, as though refusing the chickenpox vaccine were the same as refusing the polio vax. He points out (correctly) that the US vaccination schedule is not based exclusively on medical evidence but is also influenced by commercial interests. He suggests a distinction between hard-core anti-vaccinators versus parents who are merely a bit anxious or who reject one or two vaccines, stating we might have more luck if we showed empathy with their worries. Dreger, describing Largent's ideas, also adds some personal stories about the gut-level fear she felt about the number of needles coming towards her child, in spite of her own strong conviction that vaccination is safe and necessary.

By using terms like "zealots" to describe some of the pro-vax people, Largent and Dreger aren't certainly out to win any friends, and both have already attracted some fierce criticism among science-based-medicine blogs on the grounds that they are going soft/pandering to parents who believe stupid things about vaccines. I do know what they mean, sort of. I personally was never one of those parents who felt gut-level "anxiety" about needles being stuck in my child, so Dreger's description of her own fears didn't resonate with me at all. The number of vaccines which are given to children in the United States certainly does sound like a lot at first glance... then again, I live in Japan with its relatively "light" vaccine schedule (Japan tends to be incredibly conservative about new vaccines and tends to panic and ban any shot that is even rumored to have created an adverse reaction); this has not been a roaring success. Japan has long been known as an "exporter" of measles due to frequent outbreaks--and as someone with no hearing in one ear due to mumps I was horrified to learn that the mumps vax is still not standard here, and that mumps regularly makes the rounds in Japanese universities.

And yet
That said, when the writer uses the phrase "vaccine zealot," honestly, I do know what she is talking about. Examples:

1) A mother posts online asking for advice about the chickenpox which her child has contracted. When it transpires that the mother had not vaccinated her child against this virus, a horde of posters descend on her and subject her to a lot of incredibly harsh, personal criticism faintly tinged with hysteria. After a while, another poster points out that there is a bit of controversy over the population-level effects of the chickenpox vaccine, which is why the British National Health Service (NHS) does not routinely offer it. The pro CP-vaccine posters, instead of admitting that the issue is somewhat nuanced, merely buzz even more angrily, all but accusing the original poster of wanting to murder immune-compromised children. 
2) A mum on a Facebook group announces that there have been a few cases of whooping cough in her state--the other side of her state from where she is living--and that she intends to avoid all unnecessary movement outside her home and stay indoors with her baby (not immune-compromised) for the immediate future. She receives responses of the "We are all praying for you!" type, as though the kid were already on its deathbed.
3) In an argument about the measles, mumps and rubella (MMR) vaccine, a poster correctly states that measles can potentially kill and cause serious complications--but cites statistics taken from developing countries, suggesting that a measles epidemic in the United States would kill up to 10% of those infected. The other posters on the discussion mostly know that this is bullshit but don't dare point this out, because this would risk giving ammunition to all the anti-vax posters who are on the same thread. (This article goes one further, claiming that more than half (!) of those infected with measles last year died of it, which if true would make measles deadlier than smallpox...!)

Okay, 1): Although the chickenpox vax is safe and effective, there's genuine concern that widespread vaccination of children against CP could be a factor behind recent increases in painful shingles among the elderly/immune-compromised in some countries (see here). Whether these things are really connected is very debatable; I personally decided to do the CP vax after weighing up the pros and cons. But "weighing up" is the key phrase here: I mean, I wouldn't spit venom at anyone who decided not to. If I had been some vaccine-hesitant parent reading through that thread, the overwhelming impression that I would have come away with would have been: "Vaccine-promoters are kinda selective with the truth and may cover up things which might call their case into question. Oh, and they also appear to be excitable and a little nuts."

Regarding 2): It's sensible and wise for parents to keep an eye on disease outbreaks in one's locality. On the other hand: if some lady announced that she was going to barricade herself in her home due to fear of child-abduction-by-strangers, I suspect that most of us would tell her ever-so-gently to "get a grip," and the risk of whooping cough multiplied by the disease's mortality rate has got to be similar. Worry about very small risks has to be balanced against the benefits of fresh air and having children spend time with friends and family.

3): Measles kills and blinds on an alarming scale in kids with Vitamin A deficiency and a heavy disease burden (chronic parasite infestations etc.). In developed countries, measles kills at a rate of perhaps 1 per several thousand cases. I know most pro-vax blogger etc. absolutely hate the "Brady Bunch" comparison, but honestly, there is some truth to the fact that by the 1960s and 1970s serious complications were rare enough that parents often didn't take measles all that seriously (hence it took quite a long time for the measles vax to catch on).

The reason why we should inoculate against measles is not because an outbreak would cause overflowing graveyards--it wouldn't. It's because nowadays we have very high standards for children's safety, so even a 1 in several thousand risk is worth eliminating, especially considering how incredibly safe this vax is. We wouldn't copy 1960s parents when it comes to car seat usage, either. And 1960s parents didn't know that measles may be connected to later illnesses in children due to "wiping clean" the body's immunity record (see below). Then you've got the issue of immune-compromised kids. There is no need for exaggerated figures when it comes to measles--the factual reality of the disease is already quietly worrying enough.

To be an activist, first be a "factivist"
As someone with a disability caused by a VPD, I feel a certain sense of urgency about the need to increase vaccination rates. If we want to do this, we need to make sure we're actually changing people's minds, not just grandstanding.

I don't know exactly what Largent says, as I haven't read his book. If he is descending into the nonsense of "let's present both sides of the argument" then he's talking out of his backside, because there is basically only one sensible argument here. But if he's talking about the need for sticking to the facts and maintaining a courteous tone in debate, then 
I'm with him.

As Andrew Maynard of the above linked blog post says "
[T]o use data that not only feel wrong, but are not backed up with evidence, only serves to undermines trust in public health experts. Anti-vaccine proponents are smart enough to realize this. Each time the data on infectious diseases and risk are spun beyond their legitimate bounds, anti-vaccine proponents are given a helping hand in winning the hearts and minds of concerned parents." When pro-vax people start to overreach--even by a little--it undermines the credibility of everything we say ever after.

"Courtesy" is important too--not frosty politeness through gritted teeth, but genuinely empathizing with people's worries. And for the love of God, please stop the aggressive dogpiling of people on discussion threads (I'm sure I've been guilty of participating in these in the past, too). Most people who hesitate about vaccination are not hardened anti-vax types, but worried parents who don't know who to trust. If we can talk to them as if we genuinely care about them and their kids, we might be surprised at how willing they are to listen.

Further reading:

A heretic in the academy: What if not all parents who question vaccines are foolish and anti-science? (Alice Dreger)  (Dreger's book, Galileo's Middle Finger, is worth a read too.)
Vaccine (Mark Largent): The subject of this post, but I haven't read this one yet, myself.
In which pro-vaccine advocates are inappropriately portrayed as frenzied, self-righteous “zealots” (Respectful Insolence): The counter-argument
Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality (Science)
What is the risk of dying if you catch measles? (2020 Science)
Shingles & Chickenpox: What's the Link? Simple discussion
Why is measles still endemic in Japan? (The Lancet)

Thursday, May 7, 2015

What to expect when you wean your child at the age of 4.2 years

When I had my baby, I didn't quite expect that I'd be breastfeeding her for longer than 12 months. If you'd suggested to me that the duration of our nursing "relationship" might be reckoned in years rather than months, I'd have laughed and told you to stop talking nonsense.

And yet it wasn't until a few months ago that I nursed my child for the last time. She was just past her 4th birthday--actually, not so far from the famous "4.2 years" which is sometimes bandied about as the global average for the duration of breastfeeding (not true, as I pointed out in another post). Well, it may not be the global average, but it was the average for my children--or child, rather, since I have just the one child and there probably won't be any more of them.

I carried on nursing for this long mostly because I was simply taking the path of least resistance--I didn't mind nursing her and had no particular reason to stop. I stopped nursing her for pretty much the  same reason. She had been losing interest for the last year or so, and I have other ways to relate to my child. She's old enough to do fun things with, now--we can chuck a ball around, we draw together and sound out simple words, she is developing a keen interest in baking and crafts, especially trying to "make" dresses for her dolls out of tissues and play-dough. I can see she will be into knitting and needlework in a few years' time.

After I had realized that she had basically stopped nursing, I was happy enough but felt slightly bothered, somehow, that I couldn't remember when the "last time" was. So when (a couple of weeks later, shortly after her 4th birthday) she asked to nurse again, I agreed and let her, simply because I wanted that sense of closure. I said to her "This is the last time, though, because you're a big girl now." She said "Yes, Mummy," very calmly and demurely. And we nursed that one last time. And that was it.

That was now several weeks ago. No weird hormonal changes or breast oddities so far. In fact, not-nursing-a-preschooler is pretty much exactly the same as nursing-a-preschooler (it had been so sporadic for that last year, after all). I haven't even stopped producing milk. I can still squeeze a drop or two out, even now--a couple of months later. Sometimes I wonder if that will ever go away.

And I'm still interested in infant feeding politics, and I can't see that changing any time in the future either. That interest has to compete with other sources of interest these days, of course--education-related stuff is the new obsession, and my interest in politics has picked up a lot as well in the past year. But I'll still be keeping the blog going, and in fact I'm aiming to get my act together and start posting a bit more regularly. Some time in the next couple of weeks or so, I will be putting a post together on "the real advantage of nursing a child past 12 months." Watch this space.

Thursday, February 5, 2015

Pumping cultures, nursing cultures: Japan, Britain and the United States

I am a British blogger, who lives in Japan... and I follow a lot of motherhood-related stuff in the States, because a lot of my favorite blogs and parenting groups/forums are US-based. There are lots of differences in breastfeeding culture between the three countries that one could potentially talk about--differences in attitudes to supplementation, newborn procedures, cultural oddities like beliefs about alcohol and diet while nursing--but one aspect where one sees big differences is attitudes towards pumping and bottlefeeding expressed milk.

Breastfeeding advocacy has always had an ambiguous, push-me-push-me attitude towards expressing--is it a "good" thing that replaces formula in bottles, or is it a "bad" thing that competes with the act of nursing directly at the breast? You might imagine that cultures which make it easy to nurse your baby directly will also be places that make it easy to pump and bottlefeed your breastmilk. In fact, that's often not the case, as we shall see. A quick disclaimer--the following discussion is mostly based on my personal experiences of these breastfeeding cultures both online and in real life, so this time I don't have a lot of data to back me up. If anyone does have any data that disproves anything here, speak up!

United States
My "main" mums' board when Baby Seal was tiny was predominantly American, and one thing that stood out was the amount of time spent talking about pumping. The United States is almost unique among developed countries in that maternity leave is still not considered standard; unless you are exiting the workforce for a bit, you will probably be back at work about six to eight weeks after giving birth. For US breastfeeders, therefore, pumping is a continual source of conversation, commiseration, competition and anxiety, and US-centric breastfeeding blogs and pages tend to spend a lot of time talking about women's pumping rights at work.

To a certain extent, the normalization of pumping and bottle-feeding EBM has bled over into the experiences of stay-at-home mothers in the US, who often sock away quite substantial amounts of milk in the freezer "just in case," or with the hope of donating it at some point. The custom of carrying bottles of expressed milk around in public for feeding the baby with also seems to be commoner in the US than elsewhere, probably because public breastfeeders are more likely to get hassled (although, like everything else American, this is very regional). Exclusive pumping seems to be commoner in America too--on British fora like Mumsnet, women who want to feed their babies this way are often advised to look on American fora and Facebook pages for advice. Perhaps widespread car ownership also tends to make exclusive pumping a bit more doable in the US than elsewhere, because you can pump in the car and because a car makes it easier to tote bottles, ice packs and heavy-duty breast pumps around with you. A few women even opt for exclusive pumping due to personal choice.

Complete contrast here. Although you won't actually see many women nursing publicly in Japan, Japanese culture seems to be far more accepting of the "nursing relationship" than the States. But while Japanese culture is fairly nursing-friendly, this does not extend to pumping. You can get breastpumps in Japan, of course, and increasing numbers of women use them. But relatively few women work outside the home when their babies are small, due to maternity leave and the fact that so many women leave the workforce for many years or permanently once they have children. Using babysitters also seems to be relatively uncommon.

As a result, the culture of pumping and bottle-feeding EBM has not become rooted in Japanese culture in the way it has in the States. Quite a lot of women do give the odd bottle, but more often than not there will be formula in the bottle--a fact facilitated by the fact that Japanese mothers seem less likely to place a strong premium on breastfeeding exclusively. It's the same story with the pumping side. If you are one of the minority of women who goes back to work early, don't expect much provision or understanding for your pumping needs if you want to pump. I mostly work from home, but was asked to take on an on-site once-a-week position when my daughter was six months old. When I nervously broached the subject of pumping, they were nice enough but said that there was nowhere in the company where I could express milk. Given that the company in question consisted of a 37-storey megablock, I found that hard to believe--but it was clear that my prospective employers were having difficulty envisaging what I was asking for, because they had never received such a request. In the end, I turned down that particular job for unrelated reasons, but it was an awkward moment.

And then there's the question of getting milk into the baby. Like many things in Japan, the process of sending EBM to daycare is based on lots of silly rules and the most unbelievable inefficiency. In theory, public daycares are supposed to accept EBM; in practice, many of them outright refuse, or put enormous pressure on parents to send formula. If they do accept EBM, the majority insist on the milk being frozen first. Some daycares further stipulate that the milk has to be frozen BUT also pumped within the last week (which means that you basically have to pump, freeze the milk, and then almost immediately dig it out of the freezer to thaw it in the fridge). Apparently, even NICUs often insist on using frozen EBM rather than fresh. I have no idea why the Japanese are so obsessed with freezing EBM--are they under the impression that the freezing process "kills germs" or something? It doesn't, of course (and thawed frozen breastmilk is actually more prone to spoilage than milk that's never been frozen, because the freezing process zaps some of the natural microbicidal compounds). Given the critical shortage of daycare spots in big cities in Japan, it's unlikely that we'll see women demanding that daycares change these ridiculous rules any time soon--most women who have got a spot are too busy feeling relieved and grateful to raise many complaints, and content themselves with writing fake dates on their bags of frozen milk.

In Britain, as in America, it would be pretty much unthinkable for a daycare to refuse to handle expressed breastmilk. On the other hand, British women, like their Japanese counterparts, tend not to work full time when their babies are young because most take maternity leave. So pumping has never made quite the inroads into British culture that it has in the States (which is perhaps why the slightly awkward word "express" seems to be the commoner verb to use), although the majority of breastfeeders do own a pump and use it now and again. On British (and Australian) discussion fora, quite a lot of breastfeeding advocates encourage women not to make any use of pumping and bottlefeeding at all, on the grounds that conveying milk this way is unnecessary, might mess up the mother's supply and/or create a preference for artificial teats in the baby, and is less healthy/optimal than direct breastfeeding. I think it would be a rare American lactivist who was so negative about pumping and bottlefeeding; so many American breastfeeders work full-time that she would risk alienating a large percentage of her target audience, and if you overemphasize the difficulties of maintaining breastfeeding through pumping and bottlefeeding to mothers who are going to WOH anyway, they might just give up and decide to use formula instead.

Pumping breastmilk to avoid breastfeeding in public is also far less common in the UK than in the US, because although breastfeeding rates in the UK are low, breastfeeding in public seems to be more acceptable than in the States. In any case, the reality is that when you are with your baby and breastfeeding him or her round the clock, it is really difficult to fit "pumping a bottle and feeding it to the baby" into the routine, and if a baby does not get a bottle regularly--several times a week, at minimum--there is a high chance that he or she will eventually reject bottles altogether (as I discovered to my cost). Consequently, it seems that a large percentage of breastfed babies in the UK will not drink from bottles, and this seems to have contributed towards a general feeling on British parenting boards that breastfed babies "can't be left" for any length of time.

Living in Japan, it's certainly easy for me to be irritated by aspects of the culture which are interconnected with the difficulties of expressing and bottling breastmilk. Japanese culture tends to emphasize the importance of the mother-child bond; this can be liberating in some ways (very few people here will look down on you for breastfeeding a toddler or even letting them share your bed), but it's also connected with the fact that Japan has been very slow to get women into the workplace--something which is now a big problem for Japan given its shrinking workforce and its resistance to accepting large-scale immigration. The cultural squeamishness towards breastmilk that's been separated from the mother's body and the lack of legal protection for pumping at work means that many women are not able to pump their milk or feed it to their babies if they want, which deprives them of choice; others (as outlined above) are forced to go through unnecessary and time-consuming procedures which add to their burden. While maternity leave provision is a good thing, I think we should also recognize the fact that some women want to return to work while their babies are small--and they have every right to do so and leave pumped milk if they wish. I don't think that the cultural resistance towards using babysitters does Japanese marriages any good, and I'm not a fan of seeing cranky babies being toted around to smoky restaurants late at night, as is frequently seen here in Tokyo.

On the other hand, normalization of pumping can also become a trap in its own way. There is a danger that each technological innovation can become something that merely shifts the goalposts of what mothers are expected to be able to achieve. Since breastpumps have been invented, women have increasingly been expected to combine breastfeeding and working outside the home (whereas their mother's generation, if they worked outside the home when their babies were small, just shrugged their shoulders and used formula); more efficient breastpumps have raised the bar higher, with working women increasingly expected not only to "breastfeed" but to "breastfeed exclusively without formula supplementation"; with bigger freezers, better designed storage containers and more affordable double-electric pumps, even women who are not working outside the home may increasingly feel that it is expected and normal to pump "just-in-case" stashes or donate milk. And writers like Olivia Campbell may have a point when they suggest that this technological fix (ever higher-performing breastpumps) has enabled American society to avoid confronting the issue of maternity leave, opting instead to place a double burden (working and pumping) on the shoulders of fragile postpartum mothers. Similarly, because most people in the US are aware that pumping and bottle-feeding EBM is a "thing," this can lead to more pressure on mothers to carry bottles of pumped milk around with them, and can become an excuse for negativity towards women who are trying to nurse their babies in public ("Come on, lady--they invented breastpumps for a reason!! Why don't you just pump a bottle before you leave the house??").

Considering each of the above countries in turn, I think my own country--the UK--probably represents the best overall balance for respecting women's right both to feed at the breast and to pump when they need or want to--although I do wish that there was a bit more awareness in the UK of the fact that bottles are not the only way to get breastmilk into a bottle-refusing baby. I hope that each of these countries can work towards achieving a cultural consensus that will allow women and babies to take advantage of the best aspects of both direct nursing and pumping/bottlefeeding--without either becoming something that places unnecessary burdens on women or restricts their freedom.

Further reading

Baby Food: If breast is best, why are women bottling their milk? (Jill Lepore, New Yorker)
Why I pump and why you shouldn't feel bad for me (Healthy Tipping Point)
The Unseen Consequences of Pumping Breast Milk (Olivia Campbell)