WHO statement on infant feeding

[kamikazismom]

I know that the WHO recommends babies be fed in this order: (1) at the mother's breast (2) mother's expressed milk (3) donor human milk (4) formula.  But...I can't find any resources that say this.  I have been all over the WHO website and can't find anything.  Can anyone help me out with some links or something?  Thanks! 

[savithny]

I actually spent a long time looking for the source of this quote last year sometime, because it is so often used and never attributed.  And the laptop on which I did the research (and might have some of the files downloaded) recently died a sad death without me backing all that up...

As part of my job, I track down citations for numbers quoted and arguments made (in a different field) and fact check claims.   The fact that everyone says "WHO says this!" but no one ever has an actual citation (they're always citing another article, not a WHO report, and when you go to the other article, it will say "WHO says!" with no WHO citation either).    When I find this going on at work, I often find that in the end, someone actually made up the numbers, and then everyone cites those numbers around in a circle until no one remembers where they first came from.

Of course, I think I posted my results in a thread that got heated and later was deleted, but as I remember, the main citation from WHO that physically ranks them in that order is NOT recommendations for babies as a whole.  It's part of their recommendations for feeding the underweight and/or premature infant in developing countries, and the article is quite specific about that.  As in, its in training materials for people who are going to work in refugee camps, and discusses the options in terms of what is least likely to result in waterborne diseases (I think it may actually recommend wet-nursing rather than "donor human milk" for the same reason).  

I did find (and this took a LOT of digging) a 1980-ish article, available only as a scan of a print report, but it did not rank the four options in the same order as they're usually ranked, either.

And now I'm going to have to see if I can repeat my steps...

Long story short, saying that mother's expressed milk is inferior to at the breast feeding (which is the claim that was being made that I questioned) is not actually WHO's overall position.   In the case of refugee camps, it *is* their position, but it has more to do with the availability of clean pumps and bottles than anything else.

[Heba]

Ach, I can't find it either (I have read it at some point!  But I remember it did take me a while to find then, too).  I have found this, which does state that expressed milk is an alternative to be considered only when breastfeeding is not possible: http://www.who.int/nutrition/publications/gs_infant_feeding_text_eng.pdf (pg 16, point 18).

[savithny]

You'll notice, of course, that this article does not rank the alternatives to breastfeeding, and instead says that the right choice depends on circumstances:

For those few health situations where in- 

fants cannot, or should not, be breastfed, the choice of the best 

alternative – expressed breast milk from an infant’s own mother, 

breast milk from a healthy wet-nurse or a human-milk bank, or a 

breast-milk substitute fed with a cup, which is a safer method than 

a feeding bottle and teat – depends on individual circumstances.

Again, too -- the emphasis on cup feeding vs. bottle/teat feeding has to do with dealing with populations where sanitation is an issue -- it's easier to get a cup satisfactorily clean than it is a nipple (This is clarified at no. 13, on p. 8, under "safe.'

[Heba]

Oh absolutely - I was really posting it as the only place I can find where it ranks ebm below direct breastfeeding, not suggesting that it ranks the three alternatives, or anything about articifial teat vs cup.

It's still really bugging me...I am convinced that I have read it - but as with your experience, every place I've found where it is cited does not give the original source.  I will keep on it until I find it or give up :).  Misquotes or imaginary quotes do not help anyone.

[savithny]

Originally Posted by Heba 

Oh absolutely - I was really posting it as the only place I can find where it ranks ebm below direct breastfeeding, not suggesting that it ranks the three alternatives, or anything about articifial teat vs cup.

It's still really bugging me...I am convinced that I have read it - but as with your experience, every place I've found where it is cited does not give the original source.  I will keep on it until I find it or give up :).  Misquotes or imaginary quotes do not help anyone.

Last time I worked on this, it was a snowy weekend and I pretty much wasted an afternoon with not much to show for it.  As I said, I think in the end I found a badly scanned brochure from about 1980 or 1981 (it might have been in the ERIC database?) that was the closest I've seen, but was still not quite the wording everyone uses.
 

[PatioGardener]

UNICEF is quoted here

http://www.phdinparenting.com/2011/02/07/unicef-to-health-canada-formula-isnt-second-best/

nak

[Heba]

Done some more reading around, and it seems that the source of the so-called hierarchy is indeed the paragraph I linked to above (a couple of articles, linked to below, reference it).  However, although there is probably enough evidence from other WHO publications to support the four-point hierarchy for healthy term infants, it is not explicitly stated here or anywhere else that I can find.

http://www.facebook.com/note.php?note_id=190607097648059

http://www.chroniclesofanursingmom.com/2010/02/hierarchy-of-infant-feeding-choices.html

[IdentityCrisisMama]

Bumping an old thread because there was a recent spin-off of this topic here at MDC. I almost started a thread on the subject but a Google search for "WHO hierarchy of infant feeding" brought this MDC thread - how cool.  

I noticed that perhaps one of the early mentions of this phrase and concept comes from a  +10 year old article called, "Watch Your Language". One of my irks with the internet is that articles aren't dated often so I don't know when it was written but I know I read it many, many years ago and that it's popular with the progressive BFing advocacy groups. 

Here is the quote: 

Quote:

Breastfeeding is best; artificial milk is second best. Not according to the World Health Organization. Its hierarchy is: 1) breastfeeding; 2) the mother's own milk expressed and given to her child some other way; 3) the milk of another human mother; and 4) artificial milk feeds (4). We need to keep this clear in our own minds and make it clear to others. "The next best thing to mother herself" comes from a breast, not from a can. The free sample perched so enticingly on the shelf at the doctor's office is only the fourth best solution to breastfeeding problems.

The author does link her sources and cites this as the source: 4. UNICEF, WHO, UNESCO: Facts for Life: A Communication Challenge. New York: UNICEF 1989; p. 20. I'll see if I can still log onto my Uni library and look some of these up. 

[IdentityCrisisMama]

Dianne Wiessinger's article appears to be quoting the first edition of this publication (which would be interesting to find). There have been two editions following, the most recent in 2002. I think this is it: http://www.unicef.org/uzbekistan/FFL-Eng.pdf...wait, there is a fourth edition published in 2010: http://www.scribd.com/doc/29546915/Facts-for-Life-Fourth-Edition

So...here appears to be the source: 

Bottle feeding and giving a baby breastmilk substitutes such as infantformula or animal milk can threaten the baby’s health and survival. Ifa woman cannot breastfeed her infant, the baby can be fed expressedbreastmilk or, if necessary, a quality breastmilk substitute from an ordinaryclean cup.

[IdentityCrisisMama]

It would be interesting to get a copy of the edition that was referenced by Dianne Wiessinger's article to see if they used the term "hierarchy" or if it came from the source because the phrase "hierarchy of infant feeding" seems to have taken on a life of its own.  They even have a Facebook page. 

[savithny]

Yeah, I searched this one up and down and sideways a few years ago. WHO does not actually provide rankings in the cited article. I went back to 1980 and found an article that named the options but did not numerically rank in the way everyone cites them.

It reminds me of the xkcd cartoon about citation genesis. Everyone now quotes Weissinger quoting WHO, and no one goes to any original source.

[IdentityCrisisMama]

Do you have access to the edition of the publication that Weissinger cited? I'd like to see that...