Author Archive | Lactation Matters

by Lisa Mandell, MBA, IBCLC, Global Advocacy Adviser, ILCA

As the Global Advocacy Adviser for International Lactation Consultant Association® (ILCA®), I had the honor and privilege of attending the Global Congress on the Implementation of the International Code of Marketing of Breast-milk Substitutes in Geneva, Switzerland, 20-22 June 2023, on behalf of our association. This informative and inspiring meeting was attended by more than 400 delegates from over 100 countries, all of whom gathered to learn more about,  develop plans for, and make commitments to the implementation of the Code.

The Purpose of the Congress

The Code has been shown to improve breastfeeding rates, yet many countries have not enacted legislation (or have weak legislation). The Congress served as an opportunity to increase the knowledge and understanding of the Code, help develop national roadmaps for implementation or improvements of the Code, and develop regional networks to continue support for work on the Code.

Summary of the Congress

The Congress opened with a presentation by Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization. Dr. Tedros explained that the Code helps protect health, nutrition, and development in the first years of life, and cited that rates of exclusive breastfeeding are 20% higher in countries with legislation substantially aligned with the Code than in those without. He identified that the original concerns that prompted development of the Code were contamination of water used for formula in poor areas, but now, increased research and understanding of health impacts shows the importance of the Code in both low- and high-income countries, but that legislation has mostly been very limited in high income countries. He identified that the Code is a core obligation of countries and exclaimed that now is the time to end exploitative marketing, which is what the Code aims to do.

A series of other high-level speakers brought up many important points:

• Half of the world’s children are not exclusively breastfed
• Sophisticated marketing of commercial milk formula is impacting breastfeeding rates
• We must recognize and uphold the right of every child to good nutrition and of every family to accurate information and support
• Structural discrimination and racism impact the right to health, creating health inequities
• Commercial determinants of health are important factors to understand
• There is an important need for paid maternity leave, access to safe, clean, private places to express milk, and listening to women
• Breastfeeding thrives with skilled support

Of particular interest, Clare Patton from the School of Law at the University of Leeds spoke about breastfeeding in a human rights framework. She explained that the Convention on the Rights of the Child (CRC, article 24) and the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW, article 34) identify breastfeeding rights. She said breastfeeding should be recognized as a standalone human right, and further explained that human rights laws apply to states (countries), that the state has the duty to educate, protect citizens, and enact legislation such as the Code. The commercial milk formula industry has no responsibility to protect, promote, or support breastfeeding; rather, their responsibility is to NOT market commercial milk formula.

Katie Pereira Kotze from First Steps Nutrition Trust clarified the scope of the conflict between public health and industry by contrasting a WHO video on social media that had 10,000 views and a video from a commercial milk formula company that had over 500,000 views. She also contrasted WHO’s entire annual budget of $3.3 billion vs. the $55 billion market for commercial milk formula.

Jeanette McCulloch from the Global Breastfeeding Collective offered guidance on advocacy around the Code and reviewed the importance of establishing a strategic group including influencers, enforcers, and experts, determining concrete actions you want the target of your efforts to take, and building a network of allies. She emphasized that efforts supporting Code legislation are not about restraining individual feeding choices (and the importance of making that clear). She quoted Loretta Ross with this advice: “Don’t confuse problematic allies with your enemy.”

Marion Nestle, professor emerita, New York University, spoke compellingly about the conflicts of interest in many industries, and how industries work hard to lobby government officials, sponsor research, and hide their influence. Phillip Baker of Deakin University cited the incredible $55 million spent just on lobbying for the commercial milk formula industry in the United States over a 12-year period and identified the fundamental conflict of interest between the baby food industry and public health. He reviewed strategies for countering industry influence.

Kathy Shats from UNICEF, David Clark, legal consultant formerly with UNICEF, and Fatmata Fatima Sesay from UNICEF provided lots of information on understanding the Code. Kathy later identified steps to take in pursuing Code legislation, starting with establishing baseline measurements on breastfeeding rates, companies operating in the country, current marketing practices, and more. Next, reviewing existing laws, including in other industries, and evaluating their effectiveness and how they are being monitored and enforced. Additionally, considering financing mechanisms, and what to include in legislation vs. regulations. David later presented information on ensuring effective legal enforcement. Kate Robertson from WHO provided detailed information on how to draft legislation that does not trigger concerns about restraint of trade, and how to address those concerns if they do arise. Marcus Stalhofer from WHO provided further information on monitoring and enforcement provisions, and how to strengthen them.

Elizabeth Zehner from Helen Keller International reviewed the many resources on the Code, most of which are available on the Global Breastfeeding Collective Toolkit. She and others highlighted several new resources:

• What I Should Know About ‘the Code’: A guide to implementation, compliance and identifying violations
• Clarification on Sponsorship of Health Professional and Scientific Meetings by Companies that Market Foods for Infants and Young Children
• Protecting Infant and Young Child Nutrition from Industry Interference and Conflicts of Interest

Speakers also reviewed the findings of these recent important publications:

• How the marketing of formula milk influences our decisions on infant feeding
• Scope and impact of digital marketing strategies for promoting breastmilk substitutes
• The Lancet series on breastfeeding 2023

In addition, there were several presentations from countries and from non-governmental organizations (NGOs) sharing inspiring examples of how they overcame resistance to implement or strengthen legislation on the Code. Of particular interest to me was a speaker from Timor Leste who spoke about the importance of positioning nutrition as “politics neutral.”

On the first day of the Congress, a panel of mothers was included to help illustrate the importance of Code legislation. The mothers spoke about their experiences of having their infant feeding choices impacted my manipulative marketing. One mother said “I wish breastfeeding support would be marketed as much as formula.”

Perhaps the most important work of the Congress occurred in breakout work sessions, where country delegations from a region gathered to work on understanding their Code legislation (or lack thereof), and what they can do to move forward, culminating with commitments for actions to take. I was a facilitator for the North America and Caribbean Region and was delighted to work with fellow facilitators from UNICEF and the dedicated groups of people from Canada, United States, Antigua and Barbuda, Barbados, Guyana, Haiti, Jamaica, St. Kitts and Nevis, and Trinidad and Tobago. In total, over one hundred countries’ commitments were shared visually and select countries highlighted their commitments verbally. Additionally, the countries provided information on how they might continue to work together in regional networks to continue to advance work on the Code.

Next Steps and What You Can Do

The real determination of success of this Congress will be in seeing countries fulfilling these commitments and moving forward with enacting new legislation or strengthening existing legislation. This work will depend on much support from beyond governments, including from those working with breastfeeding families. I was thrilled to see at least 20 IBCLCs in attendance at the Congress and was able to gather 15 of them together for a photo! It is important to have IBCLCs at the table when policies related to infant and young child feeding are being determined, and it is exciting to see IBCLCs in health ministries and other positions. Look for more information and opportunities to become involved and advocate for the Code in your country.

by Lisa Mandell, MBA, IBCLC and Tova Ovits, BA, IBCLC

The USA launch of the Lancet Series on Breastfeeding took place 18 April 2023 in New York, New York, USA, and was attended by representatives of the International Lactation Consultant Association® (ILCA®), including Tova Ovits, BA, IBCLC, secretary of the ILCA Board of Directors, and Lisa Mandell, MBA, IBCLC, ILCA’s Global Advocacy Adviser. ILCA Executive Director Jenn Kasowicz, MA, attended the launch virtually. Ellen Chetwynd, PhD, MPH, BSN, IBCLC, the Editor-in-Chief of the Journal of Human Lactation, was also in attendance.

The purpose of ILCA’s representation at the launch was to gain insight into how the important information within the papers was being presented in the United States, and to have the opportunity to speak with other breastfeeding supporters and to advocate for skilled lactation care.

Introductory speakers Victor Aguayo, PhD, Director of Nutrition and Child Development at UNICEF, Fatmata Fatima Sesay, Nutrition Specialist in Infant Feeding at UNICEF, and moderator Nina Martin, editor and reporter for Reveal/Center for Investigative Reporting, opened the launch, collectively stating that the enablement of breastfeeding is a collective societal responsibility, not the responsibility of individual families, and set the stage for what the findings of the Lancet series mean for breastfeeding in the United States.

While 83% of birthing parents in the US initiate breastfeeding, only 24.9% of babies are being exclusively breastfed at six months of age, supporting the recurring theme that there is greater need for systems of support, including paid family leave and skilled breastfeeding support.

From the Series Authors’ Perspective

Rafael Pérez-Escamilla, PhD, professor at the Yale School of Public Health, explained that the phrase “commercial milk formula” (CMF) was used in the series rather than “breastmilk substitute” to highlight the artificial, processed nature of formula. The word “substitute” implies that formula is equivalent to human milk despite it being so different.

He discussed how commercial milk formula companies and marketers influence beliefs, values, and practices, especially by reframing normal baby behaviors (fussing, crying, spitting up) and creating opportunities that position formula as the solution. He also highlighted case studies from four countries which illustrated how investments in breastfeeding over the past decade has improved exclusive breastfeeding rates in those countries.

Cecília Tomori, PhD, Associate Professor and Director of Global Public Health and Community Health at the Johns Hopkins School of Nursing, identified that marketing of commercial milk formula has a powerful system of influence that is multifaceted, sophisticated, and well-resourced, especially with digital marketing that sells peace-of-mind while undermining parental self-efficacy. This type of product marketing differs from others as it has lifelong effects on the health, development, and rights of children.

She also shared that the WHO International Code of Marketing of Breast-milk Substitutes is oftentimes blocked, reinterpreted, circumvented, and ignored, and that the Codex Alimentarius is manipulated to establish weak standards that become a ceiling for CMF marketing regulation, instead of the minimum. Tomori emphasized that criticism of the industry’s marketing practices is not a criticism of parents’ decisions on how to feed their babies, further stating that the system targets individuals, families, society, businesses, government, and politicians to shape decisions that increase shareholder profits but at great cost. 

Katheryn Russ, PhD, Professor and Chair of Economics at the University of California – Davis, explained how the commercial milk formula industry is highly concentrated, with six highly profitable companies representing the majority of worldwide sales and provided examples of how the industry has worked to impact public policy and trade policy in the US. Inadequate paid leave makes it harder to breastfeed, and other policies make it difficult to pump milk at places of employment.

The authors also identified how racism in the US has resulted in inequities in Black and Brown communities, including breastfeeding support. 

Key Messages from the Series

• Breastfeeding success is a collective responsibility that depends on multifaceted policy and societal responses and is not the sole responsibility of individuals.
• Infant behaviors, such as sleep and crying, have normal trajectories like learning to walk or speak and can be misinterpreted as hunger or reframed as ‘abnormal’ to promote artificial solutions.
• Commercial milk formula marketing influences our beliefs, values, and practices. It has changed the infant-feeding ecosystem and its extent and power has not been fully appreciated by most in health, civil society, and government.
• There are many constraints for individuals who want to breastfeed. It is the responsibility of governments to implement structural interventions and policies to support breastfeeding and mitigate negative, undermining influences.

Additionally, the series speakers spoke about specific implications of the global Lancet series in the United States, and the many challenges facing implementation of the recommendations. Among the many important points they made, the following were most notable.  

• The US voted against adoption of the International Code of Marketing of Breastmilk Substitutes in 1981 and has continued to undermine the Code and subsequent World Health Assembly (WHA) resolutions.
• Lax privacy laws in the US allow for targeted digital marketing of CMFs and the lack of Code legislation results in rampant formula marketing of all kinds.
• US trade policy positions undermine attempts of other countries to regulate inappropriate marketing of CMFs.
• According to the Organization for Economic Cooperation and Development, the US is the only country out of 41 that lacks mandated paid parental leave.
• Systemic inequities in the US result in Black and Hispanic parents being significantly less likely than white parents to meet their breastfeeding goals. These same inequities influence Native and Indigenous families, but data is lacking. Racism is a key driver of these inequities.
• Many factors, including climate change, emergencies, water safety issues, formula contamination, racism, and more, result in a vulnerable first-food system in the US and contribute to an infant feeding crisis.
• There is extensive influence on health professionals in the US through sponsorship of conferences, associations, and research by CMF manufacturers (in violation of WHA 69.9).
• Health professionals in the US receive insufficient lactation training.
• The Baby Friendly Hospital Initiative (BFHI) has been a huge success in the US, with over a million births (almost 28% of all births) taking place in 590 BFHI-designated facilities.
• BFHI in the US still needs more investment, especially in facilities that serve communities that have not been reached, including many that serve Black and Brown communities.
• The 2022 White House National Strategy on Hunger, Nutrition, and Health recommends expanding breastfeeding support and counseling for mothers (p. 26) and recognizes some of the societal problems that need to be addressed.

Panelist Perspectives of US-Specific Issues

Sekeita Lewis-Johnson, DNP, FNP-BC, IBCLC, from the US Breastfeeding Committee’s Board of Directors, spoke about the need for greater breastfeeding support due to the coercion to give formula, lack of access to care, and lack of informed choice. She identified the important work needed to correct policy failures and to prevent them from happening again, the need for infrastructure to deal with emergencies, and the importance of centering policy decisions on the lived experience of Black and Brown families.

Ruth Petersen, MD, MPH, Director of CDC’s Division of Nutrition, Physical Activity, and Obesity, identified that although there have been improvements in breastfeeding initiation, racial disparities remain and that 60% of breastfeeding parents don’t meet their breastfeeding goals. The CDC now has county-level data that can help evaluate disparities and help local advocates focus on areas that need more support.

Stacy Davis, MPH, IBCLC, the Health Equity and Community Partnerships Manager for the National Women, Infant and Children (WIC) Association, spoke about the lack of societal support and the different needs in rural areas in accessing support. She identified that WIC is working to train staff as registered dieticians (RDs) and International Board Certified Lactation Consultants (IBCLCs) so they are more reflective of the communities they serve.

Lori Feldman-Winter, MD, MPH, Professor of Pediatrics at Cooper Medical School of Rowan University, identified the huge gap in physician education on breastfeeding as an important issue, with 55% of recent graduates reporting no training. She also discussed the lack of accountability and collaboration with other healthcare providers as well as short visits in clinical settings as contributing factors. Prenatal opportunities to discuss how to breastfeed, not just why, help increase breastfeeding initiation rates.

Camie Goldhammer, MSW, LICSW, IBCLC (Sisseton-Wahpeton Oyaté), clinical social worker and lactation consultant, founder of several organizations, and a devoted leader for Indigenous families, discussed the significant lack of diversity of IBCLCs and how breastfeeding is a traditional cultural practice. She emphasized the importance of increasing access to high-quality lactation support, especially with more peer counselors.

Tina Sherman, Senior Campaign Director for Maternal Justice at MomsRising, highlighted several achievements: the passage of the PUMP Act, Pregnant Workers Fairness Act, and the postpartum Medicaid extension. She shared that she would like to see more accomplishments in the areas of paid leave, affordable childcare, and having every parent go home with their baby.

ILCA’s Participation

As the only international association representing skilled lactation consultants, ILCA continues to support and actively participate in important advocacy-related efforts such as the Lancet Series on Breastfeeding. At the conclusion of the presentation, ILCA’s Advocacy Adviser Lisa Mandell thanked the Lancet authors and panelists, recognized the number of IBCLCs on the panel and in the audience, and asked how lactation professionals can help improve coordination of lactation care after hospital discharge.

Lori Feldman-Winter suggested that lactation consultants collaborate with and participate in dialogue with pediatricians about such cases. Sekeita Lewis-Johnson emphasized the importance of respect for the different roles of care providers, as well as the importance of dismantling the hierarchies prevalent in the healthcare field. 

What You Can Do

ILCA invites and encourages you to read the important information presented in the 2023 Lancet Series on Breastfeeding, and consider how you can use this information to advocate for improved policies and support in your community. You can also watch a recording of the USA Lancet Series on Breastfeeding launch, available in English and Spanish, here.

International Lactation Consultant Association® (ILCA®) recently sat down with Hannah Rice, MPH, IBCLC, Chair of the 2023 Conference Program Task Force (CPTF) for a behind-the-scenes look at program-planning for the ILCA 2023 Annual Conference, taking place 13-15 August 2023 at the Hilton Lake Las Vegas Resort and Spa in Las Vegas, Nevada, USA.

With a number of innovative and thought-provoking sessions planned for this year, we wanted to give the lactation community a sneak peek of just some of what can be expected at this year’s conference before full session details are made available in May. Read the Q&A to learn about Hannah’s role, gain insight into some of this year’s session topics, what she is most excited about, and why this year’s conference is one not to miss!

Q&A with Hannah Rice, MPH, IBCL

Q: Please share a bit about your professional background and what brought you to ILCA.
A: My academic and professional background is in education and public health. I received my MPH in Global Health at UNC Gillings School of Global Public Health, where I attended the Mary Rose Tully Training Initiative to become a lactation consultant. I now work at Duke University as an IBCLC in pediatric outpatient services. I was drawn to ILCA as it provided me the opportunity to combine my passion for education, research, and lactation care. I love being a part of this collaborative and supportive community of lactation professionals!

Q: What excited you about the opportunity to serve on the Conference Program Task Force?
A: I truly believe that it is our duty as lactation professionals to continually learn and grow in our practice. The ILCA Annual Conference is an exciting opportunity to stay informed on cutting-edge research to better support families and communities in their breastfeeding goals. It is an honor to be part of the CPTF team.

Q: Abstract submission numbers are higher this year than they have been the past two years; as your team reviewed the submissions, what were some of the big/recurring themes you saw across all submissions?
A: There were a lot of great submissions sent in this year! One of the particularly exciting aspects of the many submissions we received were the new and innovative perspectives on common challenges we face in the lactation field. Many of the authors presented novel approaches to understanding and practicing key elements of lactation care.

Q: What did the CPTF look for when reviewing submissions for concurrent sessions?
A: With so many great submissions, it was difficult to select only a few for the concurrent sessions. The CPTF focused on identifying submissions with strong evidence-based research and content that was inclusive of our diverse ILCA community.

Q: Without giving away too much, is there any accepted content that you are excited about this year? 
A: I am most excited about the wide range of topics that are covered in this year’s sessions. There will be speakers addressing policy, research, programmatic, clinical, and advocacy topics, providing interdisciplinary perspectives on key issues in the lactation field. Some of the highlights will be presentations on postpartum mood disorders, microbiota, and equity in lactation training and practice.

Q: Why should someone attend this year’s Annual Conference?
A: This is a special year as we can finally join together again and learn with one another in person. What is also really great is that anyone who registers for the in-person conference will get access to all the virtual and recorded sessions as well. This means more opportunities to access the interesting and exciting content from our speakers.

Learn More

Visit the ILCA 2023 Annual Conference website for event details. Additional information will be posted online as it becomes available.

by Lisa Mandell, ILCA Global Advocacy Advisor and Zoe Faulkner, ILCA Board of Directors

The Lancet published a powerful 2023 Series on Breastfeeding during an in-person event held 8 February 2023 in London, United Kingdom.

International Lactation Consultant Association® (ILCA®) Board Member Zoe Faulkner, who is also Chair of Lactation Consultants of Great Britain, attended the in-person launch and shared, “It was a real privilege to be in person at an event that was being live-streamed internationally. There was an incredible atmosphere in the room, with a sense of hope and excitement that these papers may play a part in enabling positive change.”

During the Series’ Q&A portion, she asked if now was the time to also focus attention on the workforce that is so vital to counseling and supporting breastfeeding families.

“It appears that the lack of understanding of the importance of breastfeeding for public health is also reflected in a lack of understanding of the infant feeding workforce, inclusive of the knowledge, skills, and the range of roles that provide the support services that mothers and lactating individuals need. This workforce is inclusive of peer supporters, breastfeeding counselors, International Board Certified Lactation Consultants, midwives, and health visitors such as community public health nurses – all of whom collectively play a role in providing vital support.”

The 2023 Lancet Series on Breastfeeding builds on the 2016 Lancet Series on Breastfeeding and explores how the value of breastfeeding is undervalued and underinvested in by governments and public health, and how the vulnerabilities of women and children are exploited by the Commercial Milk Formula industry. The three-paper series is structured around the following themes, as outlined at the launch:

1. How baby behaviors, such as sleep and crying, are misunderstood and misconstrued to undermine breastfeeding, but multi-sectoral interventions can protect the extensive health impacts of breastfeeding
   • Unsettled infant behaviors such as crying, fussiness, posseting/spitting up, and short night-time sleep duration are common and normal
   • These behaviors often result in parents changing from breastfeeding to commercial milk formula (CMF) or from one CMF to another or to a specialized CMF that claims (without evidence) to resolve the issue
2. How the formula marketing ‘playbook’ targets parents, health professionals, and politicians, and undermines the health and rights of children and mothers
   • CMF sales worldwide have grown from $1.5 billion USD in 1978 to $55.6 billion USD in 2018 (a 3,700% increase in 41 years)
   • Health professionals are targeted by CMF companies due to their capacity to encourage sales
   • CMF companies are large and powerful. The four largest companies together generated $187 billion USD in revenue in 2022These four CMF companies employed more than 535,000 people globally in 2018, which is greater than the entire health workforce of South Africa, Zimbabwe and Lesotho combined
   • “CMF marketing impinges on the human rights of women and children, harms their health, and adversely affects society”
3. How power imbalances and political and economic structures determine feeding practices, women’s rights, and health outcomes
   • Breastfeeding and breastmilk are not included in most countries’ gross domestic product (GDP), so improving breastfeeding rates does not impact GDP, while increasing CMF sales does
   • The monetary value of the milk produced by breastfeeding women globally is estimated to be about $3.6 trillion USD
   • Unpaid care work, including breastfeeding, is primarily performed by women; not including the value of this unpaid care work shifts policy priorities away from it and exacerbates gender inequities
   • The CMF industry exacerbates economic disparities and health inequalities; the harms associated with CMF concentrate in low and middle income countries, while the shareholders of CMF companies who increase their wealth through increased CMF sales are almost exclusively in high-income countries

A number of critical points were made throughout the series, with the following quotes being especially relevant to the role of lactation consultants and International Board Certified Lactation Consultants (IBCLCs):

“…universal access to improved breastfeeding-supportive maternity care, evidence-based breastfeeding counselling, and public and health worker education are crucial for preventing common early lactation problems, avoiding attempts to address common behaviors of infant development by introducing CMFs, and helping mothers improve their breastmilk production and self-efficacy.”

“Skilled counselling and support should be provided prenatally and post-partum to all mothers to prevent and address self-reported insufficient milk and avert the introduction of prelacteal feeds or CMF early on…”

“Health professionals, mothers, families, and communities must be provided with better educational support and skill development, free from commercial influence…”

Key Takeaway

“Breastfeeding success is a collective responsibility that depends on multifaceted policy and societal responses. Fact-based information on feeding infants and young children that is free from commercial influence is a human right that must be made available to all.”

What You Can Do

The Series offers excellent, well-researched support for any policy decisions related to breastfeeding and supporting new families, and highlights the importance of regulation and the legal protections governments can and should provide. ILCA encourages all involved in infant and young child feeding to read these papers, amplify the messages, and act on the recommendations they provide. Lactation consultants, especially IBCLCs, should be part of every solution, from providing training for health professionals, helping to make policy decisions, and providing care to breastfeeding families.

ILCA is committed to providing the latest, quality education free from commercial influence, and upholds the WHO International Code of Marketing of Breast-milk Substitutes and subsequent resolutions. ILCA strives to support and empower all lactation consultants and IBCLCs to advocate locally, nationally, and globally for breastfeeding and for the policies that promote, protect and support breastfeeding.

The USA launch of the 2023 Lancet Series on Breastfeeding will be held on 18 April in New York, NY. Learn more about it and register for the livestream here.