Battle vs the bottle

The survey that covered 1,153 households in 27 provinces and 10 highly urbanized cities showed one in five infants and young children, or zero to 23 months are stunted; one in 10 children are underweight; and 7.2 percent of children below two years old are wasted or the child’s weight and height are not proportionate with their age.

For pre-school children under five years old, stunting affects one in four children, one in 10 are underweight, and 5.5 percent are wasted. 

There are many factors that affect the nutritional intake of every individual but experts say improper food given to children as early as when they are in the womb until they are born have significant effects to their overall wellbeing until they become adults.

Experts say problems on undernutrition and malnutrition in the Philippines could be largely addressed if the basics on feeding are religiously practiced. This includes exclusive breastfeeding.

The same survey of the FNRI showed that in the Philippines, exclusive breastfeeding on infants under six months is high at 60.1 percent. However, numbers dropped significantly after six months with only 41.8 percent infants and young children being exclusively breastfed for two years.

A study by the Health Sciences Center of the University of the Philippines Manila showed exclusive breastfeeding in the country stands at 34 percent – a far target of the World Health Organization that by 2025, exclusive breastfeeding should be 50 to 60 percent.

Why is it that despite the benefits of breastfeeding on both mother and child, many mothers do not practice exclusive breastfeeding, choosing instead to “mix feed” or alternate breastfeeding and bottle feeding?

Galvanizing existing policies

Lactation counselor and founder of the Breastfeeding Care Center of the North Di Anne Mendoza said mothers should not be blamed for not being able to sustain breastfeeding, as there are circumstances mostly beyond their control that lead them with lesser options to choose from. 

She said while the Philippines have come a long way in educating the public about the benefits of exclusive breastfeeding, a lot more has to be done to help more mothers breastfeed exclusively at least until two years or even throughout the recommended weaning period which is supposed to be seven years old.

She said policymakers, especially at the local government level, need to craft more policies that will supplement existing laws on breastfeeding, maternal, and child health.

The mandatory setting up of lactation centers in offices and business establishments alone is a step that need to be followed up by LGUs as many establishments have yet to designate a room where mothers can either nurse their baby (for companies that allow mothers to feed their child) or express their milk.

“Marami sa mga nanay sa toilets pa rin nag-e-express ng gatas dahil walang lactation or breastfeeding station, which is hindi dapat nangyayari dahil unhygienic sa toilet,” Mendoza said, pointing out this practice is not only uncomfortable for the mother, this could also compromise a baby’s health for the moment a mother expresses her milk, bacteria present in the atmosphere can contaminate the milk or the container where the milk will be stored.

Mendoza is also pushing for local health offices to organize additional and continuous trainings for midwives, nurses, barangay health workers, and barangay nutrition action officers about proper breastfeeding, the proper way of introducing the “unang yakap” between mother and her newborn, the correct way of storing expressed milk, the proper way of feeding using a cup, instead of rubber nipples, how to determine a newborn’s cues when hungry, the right foods to eat during pregnancy and after birth, in order to entice more mothers to practice exclusive breastfeeding.

Mendoza added the advocacy on exclusive breastfeeding should not be limited to women, mothers, and health workers but should spread regardless of gender, age, and educational attainment so that the public would truly appreciate its importance.

Mendoza also intends to spread the advocacy by one day meeting with Mayor Benjamin Magalong and Rep. Marquez Go to take the initiative and make Baguio a mother and baby-friendly city.

“The global campaign for exclusive breastfeeding started in Baguio. Hindi tayo dapat nagpapahuli sa pagiging mother and child friendly locality. Look at Tublay, nagawa nila. Marami silang training for BHWs and BNAOs, dapat kaya rin ng Baguio,” she said.

Baguio as pioneer of a global crusade

Unknown to many, a Baguio-based doctor pioneered and is now recognized as a pillar of the global advocacy for exclusive breastfeeding and rooming-in of mother and child.

The late Dr. Natividad Clavano, former head of the Department of Pediatrics of the Baguio General Hospital and Medical Center, is credited globally for her contribution in saving infants from death and malnutrition attributed to the consumption of infant formula milk.

The global crusade began when in the mid-1970s during Clavano’s stint as head of the BGH Pediatrics Ward and on which time she went to London, England to pursue her post-graduate research on pediatric asthma. Her mentor however suggested for her to consider a subject that developing countries are experiencing – the high number of illnesses and mortality of children below five years old due to various forms of infection and malnutrition.

At the time, several researches have already been published pointing to a child’s lowered immunity because of the consumption of formula milk.

Clavano accepted her mentor’s suggestion so that upon her return to the BGH, she broke tradition by implementing policy changes in the department she headed.

She banned representatives of milk companies in the maternity and pediatric wards and disallowed them from giving freebies to mothers. Instead, she mandated the midwives and nurses in the hospital to assist mothers who just gave birth to breastfeed their newborn and barred them from feeding babies with infant formula dona-ted by milk companies who at the time were allowed in hospitals.

Simultaneous with the policy of exclusive breastfeeding in the hospital, Clavano also made mother and child stay in one room, instead of the western practice and adopted in developing nations then, where after birth, mother is wheeled to another room and her child stays in the nursery.

The idea of making mother and child stay together is to facilitate feeding especially on the first hour after birth where the colostrums – scientifically recognized as the very first vaccine of a child – can immediately be taken in.

Clavano later ordered the removal of posters of milk companies that were then openly displayed in the hospital and replaced these with posters showing the risks of consuming infant formula.

Clavano documented her findings in her “10,000 babies” research covering 1973 to 1977, which showed the exclusive breastfeeding policy have resulted in an increase in breastfeeding rate from 40 percent to 87 percent and reduced infant deaths by 95 percent.  

A portion of her research published in The Lancet, the globally recognized medical journal, stated incidence of oral thrush, diarrhea, and clinical sepsis have also drastically been reduced.

Clavano’s research have been used by breastfeeding advocates, clinicians, doctors, and other medical experts to reinforce their campaign that as opposed to the marketing campaign companies producing infant formula, breastmilk is the best source of food and nutrition for babies.

The increasing global disapproval about the marketing strategies of milk companies plus the researches about infant formula have resulted in the United States Senate launching an inquiry into the marketing strategy of milk companies in 1978. One of the resource persons then was Baguio’s very own, Dr. Clavano.

As offshoot, the World Health Organization and the Unicef, in 1981 passed the International Code on the Marketing of Breastmilk Substitutes and Other Related Products, out of which was borne Executive Order 51 or the Philippine Milk Code of 1986, signed by then President Corazon Aquino.

The Milk Code bars the advertising or promotion in any form of breastmilk substitutes; giving of samples supplies or gifts of breastmilk substitutes to the public, their families and even to healthcare personnel; point-of-sale advertising, giving of samples or any other promotion devices to induce sales directly to the consumers at the retail level, such as special displays, discount coupons, premiums, special sales, bonus and tie-in sales; distribution to pregnant women or mothers of infants any gifts or articles or utensils which may promote the use of breastmilk substitutes or bottle feeding, nor shall any other groups, institutions or individuals distribute such gifts, utensils or products.

Several laws have later on been passed complimenting the Milk Code such as the Expanded Breastfeeding Promotion Act, Expanded Maternity Leave Act, Rooming-in Act, and the Kalusugan at Nutrisyon ng Mag-Nanay Act, which gives premium to giving adequate nutrition for a child especially on their first 1,000 days.

Continuing fight against Goliaths

The campaign for exclusive breastfeeding is a continuing one. Mendoza said Clavano may no longer be around to see how far her advocacy have gone but many have taken on her cause and just like their mentor, are undaunted to face milk production companies that are able to spend billions on adverti-sing.

While admitting the claims in advertisements about the supposed benefits of infant formula and the breastmilk substitutes have impacted the buying choices of the public, she said nothing beats going to the grassroots and explaining undisputed facts about the benefits of breastfeeding.

“Hindi naman ipinagbabawal pero binabantayan (ng batas – Milk Code) ang mga milk company lalo na mga false and exaggerated claims nila,” Mendoza said, reiterating that breastmilk is the most nutritious first food for babies complimented with a variety of nutritious food beginning from six months.

“Ang totoong pampatalino ay breastmilk, hindi cow’s milk,” Mendoza said, who herself experienced difficulty in breastfeeding and which resulted in her almost losing her newborn then due to hunger and dehydration if not for the tutorial she learned also from a lactation counselor.

At some point, Mendoza found herself battling giants when in 2021, at the height of the Covid-19 pandemic, she submitted a position paper to the city council opposing the resolution asking milk companies to donate milk products to be included in the Covid-19 relief packs.

The city council subsequently recalled the assailed resolution. Mendoza said if not for the timely intervention of her group, cow’s milk would have easily found its way to households especially exposing vulnerable children.

How the public can become a breastfeeding advocate

Promoting or just simply supporting exclusive breastfeeding can be done by anybody by accepting that breastfeeding is a biological way of mothers tending to their newborn.

“Hanggang ngayon hindi pa rin nano-normalize ang breastfeeding in public because the breasts are being sexualized,” Mendoza said.

She cited a case in a mall where a mother was breastfeeding her mother in a food court. She said the mall’s guard called out the mother and instructed her to proceed to the building’s breastfeeding station.

Mendoza said this should not have happened if the public is more aware that while there should be breastfeeding stations at establishments, a mother should not be prevented from breastfeeding her child in public.  

“All mothers want to breastfeed but there are circumstances that do not support them,” Mendoza said citing “internal” and “external” reasons.

“Internal” is when friends, family members, or close acquaintances immediately turn to infant formula when a mother could not “produce” milk.

“Ang instinct agad nila bibili ng bote at gatas. Mali,” Mendoza said, reiterating that if only mothers have a “breastfriend” who can assist her the proper way to breastfeed, use of infant formula can be prevented at the onset.

She also said more milk banks should be established to help feed babies that are not able to nurse from their mothers, as she debunked misconception that use of infant formula is mostly availed by those who are financially capable.

Mendoza had clients who, because of their desire to help add to the family income, return to work immediately after birth and use breastmilk substitutes such as am, sweetened milk, adult’s milk, or broth, which, like formula milk are not supposed to be fed to newborns yet to protect their “virgin gut.”

A virgin gut has antibodies that protect an infant from different kinds of infections.

“External” are circumstances beyond the control of the mother.

She cited the Expanded Maternity Act, which extended to 30 days the 60 days maternity leave. Mendoza said this may have been a remarkable legislation the Philippines but other countries in Southeast Asia, they offer up to six months paid maternity leave and in developed countries, up to one year of paid maternity leave.

“Hindi mo masisisi ang nanay na mag-mix feed kasi pagkatapos ng tatlong buwan kailangan na niyang bumalik sa trabaho. Tapos sa trabaho wala namang lactation station para sana makapag-express ng gatas,” Mendoza lamented but is hopeful that lawmakers would consider again expanding the maternity leave to allow more mothers to stay at home longer and breastfeed.

Many counties around the world recognize the long term benefits of investing on proper nutrition beginning from infancy, yet in the Philippines, this, among many other programs, take a backseat. “(Exclusive) breastfeeding is a social issue and a human rights issue because the right of the mother to breastfeed and a child’s right to receive proper nutrition are disrupted due to circumstances outside their control,” Mendoza said, which is why its promotion requires a holistic approach as it cannot be done by one sector alone.