Why breastfeeding and work can, and should, go together

Returning to work after maternity leave rates as one of the top reasons why mothers stop breastfeeding their babies before they should. The 2017 World Breastfeeding Week runs from the 1st to the 7th of August with the aim of uniting all sectors of society in the protection, promotion and support of breastfeeding. The campaign, co-ordinated by the World Alliance for Breastfeeding Action (WABA), identifies four critical focus areas, one of which is women’s productivity and work.

ADSA_Breastfeeding ImageWorking SA mums are entitled to a minimum of four consecutive months of maternity leave. Many take at least one month of that leave prior to the birth, and then make their return to work when their infants are just around three months old. However, exclusive breastfeeding of an infant from birth to six months is what is recommended as optimal nutrition by the World Health Organisation. Therefore, the only way that working new mums can meet these important health standards is if they can breastfeed or express breast milk for some months at their workplaces.

 

The benefits of creating workplaces that are friendly to nursing mums go beyond just the physical welfare of our new generations. Cath Day, registered dietitian and spokesperson for ADSA (The Association for Dietetics in South Africa) points out: “There is a vast body of scientific research that has shown that breastfeeding, as exclusive nutrition in the first six months and then as a supplementary food for two years and beyond, also protects and benefits the physical health of the mother; while impacting positively on her emotional well-being as she forms the essential bond with her new child. It is clearly in the interests of the employers of child-bearing women to protect, promote and support them during the times when they are breastfeeding because companies need their employees to be healthy and optimally productive.”

ADSA recommends that businesses formalise their support of breastfeeding in the policies, standards and practices of their employee wellness programmes.

So what can businesses do practically to protect and support the nursing mums on their workforce?

  • Uphold the Law – Corporates must recognise and facilitate the legal rights of SA breastfeeding mothers enshrined in the Basic Conditions of Employment Act. Up until their babies are six months old, working mums are entitled to two, paid 30-minute breaks every work day for breastfeeding or expressing milk.
  • Know and promote the benefits of breastfeeding – “It helps to have employers who are knowledgeable about why breastfeeding is so important and a commitment to protecting, supporting and promoting breastfeeding in the workplace,” says Cath Day. “As part of the employee wellness programme, registered dietitians can be engaged to make presentations to all staff on the advantages of a breastfeeding-friendly work environment and how to make it happen in your company. The straightforward facts and the inarguable science go a long way to reducing the discomforts and stigmas people might attach to breastfeeding.”
  • Provide the place – Nowadays it is widely regarded as completely unacceptable for breastfeeding mums to have to lock themselves in a public toilet, or their car, to breastfeed or express milk at work because they have nowhere else to go. Many companies realise that a breastfeeding-friendly workplace means providing a secure and comfortable space for working mums to spend their 30-minute breastfeeding breaks. Preferably, this private room should have a door that locks, comfortable seating, plug points for breast pumps and a refrigerator for the safe storage of breast milk.
  • Be flexible and adaptable – Part-time, flexi-time or temporary work-from-home plans can be very effective solutions for breastfeeding mums, and should especially be employed by companies who provide no proper facilities for the legal breastfeeding breaks in their workplace.
  • Offer child-care facilities – A number of progressive companies with a clear focus on employee engagement provide workplace child care facilities for the babies and small children of their employees. This is ideal for breastfeeding mums as they can more easily and quickly breastfeed their infants and need to express less milk.

ADSA spokesperson Zelda Ackerman, whose areas of expertise include baby and child feeding, urges new working mums to know their rights and to get the support that they need from their bosses and colleagues so that going back to work doesn’t become a barrier to the continued breastfeeding of their infant. “It is really important for South Africa as a country to transform to a culture of being breastfeeding-friendly in every environment,” she says, “We have to consider the potential health burdens of being a country with exceptionally low rates of breastfeeding, and turn this trend around. From the family home to the work environment to society at large, breastfeeding mothers need support.”

Zelda’s top tips for breastfeeding mums returning to work include: 

  • Before your return to work, give yourself enough time to get to grips with finding the pump that works best for you and regularly expressing milk – and give your baby enough time to get used to expressed breast milk. Time and practice will help you both to establish this as a stress-free routine before the big change up ahead.
  • Also, ahead of time, build up a stock of breast milk at home – it can be refrigerated and frozen. Stored breast milk should always be dated, and you retain more nutritional quality if you refrigerate it immediately after you have expressed.
  • On your return to work, have straightforward conversations with your bosses and/or team members, as necessary, so that they are clear about your breastfeeding goals and needs. Be clear about your legal right to two, paid 30 minute breastfeeding breaks each working day, and establish with them how this is going to work best for you and what accommodations you will need.
  • If you encounter resistance or lack of support in your workplace, get help rather than give up breastfeeding. Other working mothers in your workplace and HR personnel may help to raise awareness of the importance of your continued breastfeeding. External sources of help can include breastfeeding support organisations and registered dietitians.
  • You can reduce discomfort from engorgement and pace your two breastfeeding breaks optimally at work if you arrange your workday mornings so that you give your baby a good feed that ends just before you leave for work; and then breastfeed your baby again as soon as you get home. Co-ordinate this well with your baby’s caregiver so that they don’t feed the expressed breast milk just before you get home. If you are breastfeeding a baby older than six months of age, make sure your caregiver doesn’t provide late afternoon snacks so that your child is ready for a good breastfeed when you get home from work.
  • Be patient and resilient. Our modern world doesn’t necessarily make breastfeeding easy, natural and stress-free. But it is as important as it has ever been to both you and your baby. The science is clear, the more you can; the better for you, your baby and our society at large.

Raising Superheroes – Book Review*

In the newly released book, “Raising Superheroes”, Prof Tim Noakes, Jonno Proudfoot and Bridget Surtees advocate for what could be considered broadly as a healthy, balanced diet for infants and children. Fresh and real foods are promoted, which include red meat, chicken, fish, eggs; full cream dairy; vegetables and fruit; and grains such as quinoa, oats and millet. The ‘golden rules’ of “Raising Superheroes” echo principles stated in dietary guidelines generally advocated, such as “steering clear from added sugar and highly processed starchy foods”. The book showcases recipes that include fresh ingredients and the healthier version to some old time classics. It is not a “Banting” for children book, as what might have been expected, although the book has similar branding to the “Real Meal Revolution” and uses many of the same arguments.

The revised South African (SA) paediatric food-based dietary guidelines (SA-PFBDGs) are cited (Reference 36) in the book, however, reference is also made to “national guidelines” which include other country’s guidelines (e.g. UK, USA, Canada). It is therefore not always clear which guidelines are referred to, causing confusion about statements made in the book concerning dietary guidelines in general. In reference to the SA-PFBDGs specifically, it is stated that the guidelines are “still to be tested”. It should be noted that the proposed SA-PFBDGs will be field-tested for understanding and feasibility before they can be accepted as the official infant and young child feeding (IYCF) guidelines for the country. This process is currently underway with studies being conducted by Stellenbosch University researchers in collaboration with other academics. The statement that the promotion of these guidelines has not reversed the epidemic of obesity and diabetes (p318) is therefore unsubstantiated. It is important to note that the “Raising Superheroes dietary guidelines” proposed from page 319 has not been tested in rigorous research for understanding and feasibility in the SA context and population, which is considered a major shortfall of these proposed guidelines.

Some information and advice provided in the introduction to the different chapters are based on current best practice and international guidelines; while some information and advice is considered lacking a solid evidence base and posing potential harm. In the chapter covering pregnancy to 6 months period, it is stated on page 34 that “we don’t necessarily advise that pregnant or breastfeeding women should be following a fully ketogenic Banting diet. In other words, we’re not recommending that you exclude carbohydrates from your daily intake to such a degree that your body’s energy source switches completely from glucose to ketone bodies. (The scientific evidence on a fully ketogenic diet during pregnancy is insufficient to make definitive calls, though we suspect it would be perfectly fine.)”. It is not responsible to state “we suspect it would be perfectly fine” when providing advice, especially during vulnerable periods, such as during pregnancy. In fact, ketogenic diets during pregnancy have been linked to amniotic fluid insufficiency, bone mineral loss and calcium excretion, putting both mother and baby at risk of complications and/or deficiencies. The arguments of a ketogenic diet during pregnancy and the benefits of ketones for infant brain growth are taken further in the last chapter. A statement is made that “A key benefit of breastfeeding is that it maintains a state of ketosis in the newborn baby for as longs as it continues”. This blanket statement is not evidence-based and is made out of context when considered against the reference cited.

Furthermore, the advice provided in the section on foods to avoid during pregnancy, states that mothers should “Watch out for – Alcohol.” Furthermore, “the safest option is to abstain from drinking, though recent research appears to show that a very limited intake is fine.” No guide is provided to indicate what is meant with a “very limited intake” of alcohol. The one reference cited was written in the context specific to the United Kingdom and can therefore not be extrapolated to SA. Moreover, this advice is contradictory to what is advocated in SA by various authorities, including Department of Health. To refer very casually and jokingly to drinking during pregnancy as “not getting drunk” (page 39) is an irresponsible and insensitive statement in a country such as SA with the highest prevalence of Foetal Alcohol Spectrum (FAS) disorder in the world.

The guideline on breastfeeding rightly states that “breastfeeding is the gold standard of nutrition for your child, and it comes with a range of health benefits, as we cover elsewhere”. The benefits of exclusive and continued breastfeeding are reiterated, in summary, in the book. However, the actual detail provided on breastfeeding in the mentioned chapter, states that “From a purely nutritional point of view, you should be aiming to exclusively breastfeed until 4-6 months, and continue breastfeeding in combination with solid foods for longer – until two years, at least.” The guideline advocated by the World Health Organisation and which has been adopted by the SA Department of Health (DOH) states very clearly: “As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.” The guideline on 4-6 months of exclusive breastfeeding is outdated and confusing in the SA context where the 6-month message is being strongly promoted. In a country where very poor breastfeeding practices are evident, especially in as far as the exclusivity is concerned, it is unacceptable and irresponsible to state this outdated recommendation. There is good evidence as to why exclusive breastfeeding for 0-6 months should be promoted, protected and supported and why the 4-6 month guideline should not be advocated as a broad public health message.

Furthermore, poor breastfeeding practices have a knock-on effect which leads to poor complementary feeding practices. The battle is therefore lost if a sound foundation of appropriate breastfeeding practices is not established. This fact is not emphasised sufficiently in the “Raising Superheroes” book. In the detailed section on breastfeeding, breastfeeding is described in negative words and language (including: first biggest challenge; intimidating; many experience a plethora of problems; common problems; for many women breastfeeding is difficult and can be extremely disheartening; hurdles; painful; incorrect; problem; insufficient), and this does not encourage breastfeeding as the most natural and healthful first food for infants and young children.

The paragraph to end the breastfeeding section disappointingly states: “But if you’ve done everything you can to breastfeed and it’s just not working, or if your lifestyle prevents you from breastfeeding for as long as you ideally might, then take heart; there are alternatives.” The need for strengthening the Mother Baby Friendly Initiative; breastfeeding friendly communities; maternity benefits; breastfeeding policies in the workplace which supports mothers to continue breastfeeding and/or express breastmilk; are not mentioned. Instead, what follows is a jump from the most healthful first food (breastmilk and breastfeeding) to an ultra-processed product (UPP) i.e. formula milk which is described as “practical and viable” and suggested as an alternative to breastfeeding. This is in stark contrast to statements elsewhere in the book that warn against “ultra-processed products” and promote real food. Formula milk should not be seen as an alternative to breastfeeding/breastmilk; it can only be considered a substitute if a mother chooses to formula feed.

In the ‘Science’ section at the end of the book, the following remarks are made: “Breastfeeding is nutritionally superior to formula feeding, a point that may not be sufficiently stressed in major feeding guidelines” (pg. 319) and “They [current national feeding guidelines] fail to stress the importance of continuing breastfeeding beyond six months” (Pg 344). These statements are inaccurate within the South African context. The SA paediatric food-based dietary guideline (Reference 36) for complementary feeding contains as its first message: ‘From six months of age, start giving your baby small amounts of complementary foods, while continuing to breastfeed for up to two years and beyond’ as does the first paper in the series. Furthermore, the SA DOH’s Infant and Young Child Feeding Policy (2013) states as a key component ‘continued breastfeeding for two years and beyond’, a recommendation provided in many other national policies.

The ‘Raising Superheroes’ book refers to complementary foods (or the introduction of solids) as “weaning” throughout the book. This is an outdated term, which implies and is interpreted as the cessation of breastfeeding. The term is therefore not used in the literature globally, when optimal infant and young child feeding is discussed. The authors clearly criticise the use of baby cereals or grains for children when complementary foods are introduced. It needs to be acknowledged that South Africa is a country with high levels of household food insecurity. Often, families cannot afford or access animal protein and vegetables or fruit daily. In such situations, grains such as oats and millet, appropriately fortified staples, such as maize and brown bread, and commercially produced enriched complementary foods, such as infant cereals, may provide cost-effective food options.

In the chapter for 1-3 years of age, nothing is mentioned about the continuation of breastfeeding up to two years of age and beyond, although it is mentioned in the last chapter. The importance of continued breastfeeding during the introduction of complementary foods is also omitted. The protective effect of breastfeeding against food allergies, in particular is not mentioned. It is also not explained that food allergies are related to certain proteins in foods (e.g. protein in cow’s milk, fish, peanuts, egg white, soy and gluten) and that elimination diets (including the elimination of carbohydrates) are not routinely recommended for infants and young children, as they can negatively affect a child’s growth.

Furthermore, it is not appropriate to introduce a culture of ‘dieting’ or being placed on a diet in childhood. Fostering a healthy relationship with food during childhood is important, and balance, variety and moderation are important components that contribute to this relationship. In addition, many families in South Africa would struggle to sustain the recommendations made in this book, from a practical and cost point of view.

Several sections of the ‘Science’ chapter of the book are written from the point of view of the authors and, in particular, Prof Tim Noakes’ personal opinion and experience. Expert opinion and personal experience can be valuable when backed up by a solid evidence base and tested in rigorous research. In the case of this book, however, Prof Noakes often expresses his own views and opinions in a colloquial way and makes statements that have not been tested.

To summarize, this book provides many ideas for parents to incorporate fresh ingredients, an array of vegetables and fruit, incorporate various protein rich foods; and to cut down on sugar (with some clever party food ideas). Drawbacks of this book include conflicting messages about the inclusion of certain foods, e.g. whole grains and legumes or ‘unrefined carbohydrates’ are stated as being acceptable, but rarely used in recipes; the use of ‘fresh’ and ‘real’ food are often referred to while numerous recipes include high salt ‘processed’ and ‘cured’ meat such as bacon and ham. Furthermore, even though the evidence-based guidelines refer to grains and legumes as being acceptable, very few recipes include these ingredients. Although vegetables and fruit are recommended, the authors state that “The message of five or more vegetables a day has been overplayed by official guidelines” which is inaccurate. There is substantial evidence to support the recommendation of five-a-day and recent research suggests that it may not be enough.

In general, the target market of the book is vague. It is mentioned that a real meal revolution was started in SA and the intention is to take it to the rest of the world. The last statement in the book reads: “In summary, if the parents of newborn and young South Africans were all to follow the advice in this book we would revolutionise the long-term health of all South Africans. And that continues to be the goal of our eating revolution.” The stated aims of the “Real meal revolution” and “Raising Superheroes” point to a broad public health approach. However, the guidelines and advice, as well as recipes provided do not take into consideration the public health problems and issues of SA, and specifically those related to infant and young child nutrition. Culture, availability of foods and income are factors which should be taken into consideration when formulating broad guidelines intended for a population. Cost of food, in particular is considered a major barrier to following dietary advice. The advice and recipes in the book are clearly not targeted at the average South African, but rather the higher income market, which does not align with a public health approach. There appears to be a constant conflict between these approaches (individual VS population) in the book, which raise many unanswered questions from a public health nutrition perspective.

*This review was compiled by Lisanne du Plessis, with inputs from Catherine Day, Maryke Gallagher, Catherine Pereira, Sasha Watkins and Marlene Ellmer (Registered Dietitians and ADSA spokespeople).

References:

Department of Health. Infant and young child feeding policy. Pretoria: Department of Health; 2013.

Department of Health. Regulation R991: Regulations relating to foodstuffs for infants and young children. Pretoria: Government Gazette (Department of Health); 2012.

Department of Health. Roadmap for nutrition in South Africa for 2012-2016. Pretoria: Department of Health; 2012.

Department of Health. Strategic plan for maternal, newborn, child and women’s health and nutrition in South Africa, 2012-2016. Department of Health [homepage on the Internet]. 2012. Available from: http://www.doh.gov.za/docs/stratdocs/2012/MNCWHstratplan.pdf

Department of Health. Framework for accelerating community-based maternal, neonatal, child and women’s health and nutrition interventions. National Department of Health [homepage on the Internet]. 2012. Available from: http://www.cindi.org.za/files/eNews/enews24/Framework_Final.pdf

Department of Health. The Tshwane declaration of support for breastfeeding in South Africa. S Afr J Clin Nutr. 2011;24(4):214.

Department of Health. Landscape analysis on countries’ readiness to accelerate action to reduce maternal and child undernutrition: nationwide country assessment in South Africa. Pretoria: Department of Health; 2010.

Department of Health. Infant and young child feeding policy. Department of Health [homepage on the Internet]. 2007. c2012. Available from: URL: http://www.doh.gov.za/docs/policy/infantfeed.pdf

Du Plessis LM & Pereira C. Commitment and capacity for the support of breastfeeding in South Africa. S Afr J Clin Nutr 2013:3, S120-S128.

Du Plessis LM, Kruger HS, Sweet L. Complementary feeding: a critical window of opportunity from six months onwards. S Afr J Clin Nutr 2013:3, S129-S140.

Fisher JO & Birth LL. Restricting Access to Foods and Children’s Eating. Appetite 1999: 32: 405-419

Heinig MJ, Dobme K. Weighing the Risks: the Use of Low-Carbohydrate Diets During Lactation. J Hum Lact 2004:20, 283

Jacobs L & Steyn NP. If you drink alcohol, drink sensibly.” Is this guideline still appropriate? S Afr J Clin Nutr 2013:3, S114-S119.

May P, Hamrick KJ, Corbina KD, Haskena JM, Maraisd AS, Brookee LE, Blankenship J, Hoymef HE, Phillip J. Dietary intake, nutrition, and fetal alcohol spectrum disorders in the Western Cape Province of South Africa. Reproductive Toxicology 2014: 46, 31-39

Meyer R, De Koker C, Dziubak R, Venter C, Dominguez-Ortega G, Cutts R, Yerlett N, Skrapak AK, Fox AT, Shah N. Malnutrition in children with food allergies in the UK. Journal of Human Nutrition and Dietetics 2013, 27: 227-235

Onyeije CI, Divon MY. The impact of maternal ketonuria on foetal test results in the setting of post term pregnancy. Am J Obstet Gynecol. 2001:184(4):713-8

United Nations. Global strategy for women’s and children’s health. United Nations [homepage on the Internet]. 2010. C2012. Available from: http://www.who.int/pmnch/topics/maternal/201009_globalstrategy_wch/en/index.html

The United Nations Children’s Fund. Programming guide: infant and young child feeding. UNICEF [homepage on the Internet]. 2011. Available from: http://www.unicef.org/nutrition/files/Final_IYCF_programming_guide_2011.pdf

The United Nations Children’s Fund/World Health Organization. Baby-Friendly Hospital Initiative, revised, updated and expanded for integrated care. Section 1: Background and implementation. New York: UNICEF; 2009.

World Health Organization. Global strategy for infant and young child feeding. World Health Organization [homepage on the Internet]. 2003. c2013. Available from: http://whqlibdoc.who.int/publications/2003/9241562218.pdf

World Health Organization. Guidelines on HIV and infant feeding: principles and recommendations for infant feeding in the context of HIV and a summary of evidence. WHO [homepage on the Internet]. 2010. c2012. Available from: http://whqlibdoc.who.int/publications/2010/9789241599535_eng.pdf

World Health Organization. International code of marketing of breastmilk substitutes. Frequently asked questions. WHO [homepage on the Internet]. 2006. c2012. Available from: http://whqlibdoc.who.int/publications/2008/9789241594295_eng.pdf

World Health Organization. Infant and young child feeding. Model Chapter for textbooks for medical students and allied health professionals. Geneva: WHO; 2009.

World Health Organization. Baby and young child nutrition. Geneva: WHO; 2009.

World Health Organisation. Guiding principles for complementary feeding of the breastfed child. Geneva: WHO; 2003.