In our original blog ‘Talking about the WHO Code’, we cover the basic principles of the WHO code and dishonesty within the infant feeding industry, mainly in relation to formula promotion. In ‘Talking about the WHO Code Part Two’, we will be looking at the code as it relates to bottles and how bottles are promoted.
It is not the intention of this blog to come across as ‘anti-bottles’. Expressing and bottle-feeding that milk is a very normal part of many mums’ breastfeeding journeys, including many of the admin team here at BfSI. We fully appreciate that many mums reading this will be expressing and bottle-feeding that expressed breastmilk (referred to from now on as EBM) whether occasionally or exclusively, and we wouldn’t want to make anyone feel bad about their choices. We just want to help ensure that bottle feeding is conducted in a way that is protective of breastfeeding for mum and baby, rather than for it to be skewed to be advantageous to bottle manufacturing companies.
As detailed in part one of the blog, the World Health Organisation (along with UNICEF, scientific bodies and other agencies) designed a code of ethics in 1981, mainly in response to babies’ deaths and declining breastfeeding rates worldwide. It’s a stark fact that the UK has some of the world’s worst breastfeeding rates. Although 81% of mothers try to establish breastfeeding, by six weeks only 55% are still breastfeeding (and only 24% exclusively). Only 34% are still breastfeeding at six months (and only 1% exclusively) and by 12 months, only 0.5% are still breastfeeding at all. For further details on these statistics, see here, and in addition, the Lancet ran a great series on breastfeeding.
There is by no means one single cause or influence for declining breastfeeding rates. However, countries that enforce the WHO code in its entirety tend towards higher breastfeeding rates. In this country, only the part that relates to first-stage formula is enshrined within our legislation.
There may not be a single cause, but what doesn’t help is the fact that bottles have become the normal symbol to represent a baby. Bottles are everywhere, and right from the very beginning of a small child’s life, they are taught that babies are fed with bottles; it’s in books and on television as well as all around them day to day. In the pictures above, you can see examples from children’s books that show not only the feeding of a baby with a bottle, but an insect feeding its young with a bottle – even rewriting nature to fit bottles in as the normal method of feeding! We can also see how the bottle is used as the symbol for a baby in the pictures below – on a nappy, on a changing-room door, and even from the NHS and RCN! All of this subliminally programs our minds to accept bottle feeding as the norm, and on every occasion shown here, it was totally unnecessary! The NHS, RCN (and the door and nappy) could have just used a picture of an actual baby to represent a baby.
The WHO code says that there should be no advertising of products that fall within the scope of the code, which includes bottles and teats. So any companies that market their bottles in any way are in violation of the WHO code of marketing (that does not make it unlawful, only unethical). These products are often targeted at newborns.
The direct marketing of bottles as a product can make them seem like a necessity. Mums-to-be could be very easily led to believe that they need a whole host of equipment in order to breastfeed, as you can buy ‘breastfeeding starter packs’ with a pump and bottles, making you think that you have to pump and bottle feed as part of breastfeeding. However, despite what these companies would have you believe, you don’t really need much at all breastfeed see here for more details.
Whilst you don’t have to pump at all, for many mums these days, pumping and bottle feeding becomes a regular part of breastfeeding. For some mums this is part of their return to work (for support with this see here), or there are other reasons that they may need to leave their baby – this could be due to the health of baby, being in an NICU for example, or the health of mum, particularly where there are post partum complications. there may be other reasons for separation, or a need for EBM without separation – perhaps weight concerns or milk transfer issues leading to top ups being medically necessary. There is nothing wrong with bottle feeding EBM being a part of your breastfeeding journey, but it is helpful to understand that it can lead to difficulties, because understanding that potential helps you understand how best to prevent it from happening.
Some mums feel that expressing and bottle feeding is necessary in order to help their partner be involved – it’s definitely worth exploring other ways dad can help before considering this. Other mums may feel it will help them get more sleep, although again, there are other options which may be more helpful (see here). Whilst the majority of mums do not need to express and bottle feed to get adequate sleep and the majority of dads do not need to bottle feed EBM in order to bond with their child, it is not unusual for bottle manufacturers to imply that this is necessary in order to market their products, as shown above. This is a subtle form of undermining breastfeeding that is missed by many mums. It is seen as helpful – caring even – but companies don’t really care, they are marketing a product – using a mum’s vulnerabilities, her worries and concerns to make her doubt her own ability to feed exclusively at the breast.
Of course, as we’ve said, there is absolutely nothing wrong with choosing to express and give bottles. But that doesn’t mean that it’s acceptable for mums to be made to feel that they have to in order to meet some societal expectation.
Aside from the above issue, there is the marketing of various types of ‘breastfeeding bottles’. There are several different well-known brands that currently market themselves as breastfeeding-friendly, mimicking the style of breastfeeding, a bottle for bottle-refusing breastfed babies, a bottle that doesn’t cause nipple confusion or make various other kinds of dubious claims.
Let’s take a look at the mechanics of feeding. During breastfeeding an initial suck draws the nipple in and then the tongue is used in an undulating motion to remove milk from the breast. When feeding from a bottle, a baby uses more of a continual sucking motion rather than using the tongue. Also, during breastfeeding there are periodic milk ejections, often known as let-downs, and the milk gets gradually thicker throughout the feed, both of which vary the flow of milk and the baby’s required response. This is very different to bottle feeding.
So regardless of the claims made, none of these bottles are the same as breastfeeding. No matter what shape they are and what sort teat they have, they use different mechanics to get the milk out. No bottle will replicate the way a breast works. These claims may seem like fun and harmless marketing but in actual fact they are damaging – they lead mums to believe that giving bottles while breastfeeding is risk-free, whereas actually there are risks associated with giving bottles regularly, even when those bottles contain EBM. Knowing how to counteract and manage those risks is a really important part of bottle feeding EBM, so stating that a bottle is breastfeeding-friendly and risk-free can be incredibly damaging.
Whilst a bottle cannot replicate breastfeeding, the style of using a bottle can. So, rather than claiming that a bottle doesn’t cause nipple confusion or flow preference, it would be far more useful to direct parents to resources around paced bottle feeding, a technique which is more likely to help guard against these issues (although there are no guarantees, unfortunately).
Paced bottled feeding is a method of feeding a baby that is slower, more responsive, and is more closely matched to the style and pace of breastfeeding. It’s suggested that all babies who have bottles are fed in this way as it helps prevent overfeeding and is more protective of breastfeeding because it means that the bottle isn’t an ‘easier win’. There is a great demonstration of paced feeding in this video, and a helpful and detailed explanation here.
We have come across mums whose babies appear to show signs of bottle preference who haven’t been using paced feeding because they didn’t think they needed to if they were using a special bottle. That is how damaging those unethical marketing techniques can be – they really can damage a mum’s breastfeeding journey by causing her not to exercise caution when using bottles. Many mums do combine bottles and breastfeeding with no issues; putting in limitations around frequency is likely to be helpful in making this work.
There are also the claims that this is the magic bottle that will enable a ‘bottle-refusing’ baby to take a bottle. It is true that some breastfed babies sometimes refuse bottles. They may do this from the first time they are offered one, or they may originally take one and then refuse. However, there is no such thing as a magic bottle, despite some mums’ perceptions that bottle x or bottle y saved them. There will usually be one bottle that a baby prefers, yes – just like how if you put six cuddly toys in front of a baby, one of them will tend to appeal to them more than the others. In reality, the heavily-advertised magic ‘bottle x’ is no more likely to be appealing to your baby than the bottle from your local pound shop – it really is all just clever marketing. I found a more detailed read about this here should you be interested in the subject.
If you are struggling with your baby not taking a bottle then there are ways to encourage them without spending lots of money on different bottles; in fact, playing around with different techniques and circumstances are far more likely to work. There are several ideas in the relevant section in this blog, and some further ideas here.
In terms of protecting breastfeeding, using the paced-feeding technique detailed above is incredibly helpful. In addition, trying to limit the frequency of bottles as far as practicable can be helpful. It is also helpful to wait until your baby is over six weeks old before expressing to allow breastfeeding time to establish and your milk supply to settle. You will always find that some mums give bottles earlier than that, or with high frequency, and their baby has no problem – but every breastfeeding dyad is different, and what is right for you and your baby may not work for someone else. If you ever find yourself in the position where your baby is struggling to feed at the breast, fussing, or showing any signs of bottle/flow preference or nipple confusion then seeking support is important, face to face preferably, but if that’s not possible then via the national helplines detailed below or online with BfSI.
Blog written by Ali Thomas on behalf of Breastfeeding Support and Information UK