Erika Goyer

What is in a Symbol?

The history of the images we have used to represent infant feeding is a problematic one. In the past, pictures of baby bottles were used to represent feeding and to designate spaces where it was acceptable for parents to attend to their babies’ needs. Clearly, there was advocacy work to be done. If we were going to normalize breastfeeding, we needed a new symbol. So in 2006 Mothering Magazine sponsored a contest. The winning design for the International Breastfeeding Icon was created by Matt Daigle – a new imagining of infant feeding was born! It is now recognized universally, and it is celebrated for its affirming message. However, while the International Breastfeeding Icon’s symbolism is powerful and purposeful, it was not right for our campaign.

Members of the NPA firmly believe that breastfeeding and breast milk are the standards for newborn and infant feeding. Supporting and normalizing breastfeeding of newborns and infants is a cornerstone of NPA’s advocacy work. But because our organization is interdisciplinary and intersectional, we have always known that supporting breastfeeding requires solutions that work across different environments and in varied contexts. It is clear that there is no one way of breastfeeding that works for everyone. We need diverse solutions. So when representing breastfeeding, one symbol would not do; we would need a diverse library of images.

Reimagining

By its nature, the International Breastfeeding Icon emphasizes simplicity and clarity. The goal of NPA’s images is different. We wanted to represent infant feeding in all its modes and methods.

Because you are reading Neonatology Today, you certainly understand the issues that face infants and families in the NICU. When a baby is born early or sick, their nutritional needs are different from the typical newborn’s. And their ability to feed at the breast can be seriously delayed or impaired. They might have an immature gut. They may be unable to coordinate their abilities to suck, swallow, and breathe. They can potentially burn more calories than they can take in. Yet they need the highest quality nutritional care and nurturing that we can provide if they are going to survive and thrive.

We also understand that when a baby is born sick or early, their parent may be sick and healing too. They are certainly almost always in shock or distress over a traumatic birth. This complicates their capacity and ability to initiate breastfeeding. When we are focusing on saving lives, even the best-laid breastfeeding plan can be abandoned. So we need to put measures in place to support families’ breastfeeding goals under these challenging circumstances. These include:

• Assuring the family that their baby’snutritional needs will be met.
• Making time to talk about their feeding goals and how you will create a plan to support them.
• Describing what their babies’ feeding progression might look like.
• Delivering trauma-informed lactation support.
• Explaining different feeding modes and methods (including TPN, gavage, and tube feedings) as well as their pros and cons.
• Offering all the information parents need about feeding interventions (including formula, donor breast milk, and supplemental nutrition) so that they can make informed decisions.
• Supplying high-quality electric breast pumps and appropriate, supportive spaces to pump.
• Feeding parents and supporting their health and nutrition so that they can – in turn – nourish their baby.
• Most importantly, being responsive and flexible.

This is why NPA’s Breastfeeding Awareness library includes images of dyads using NG-tubes, G-tubes, supplemental feeding systems, and breast pumps.

Once a family’s medical needs are being met, we need to appreciate the larger context that feeding decision-making takes place in.

How Families Make Feeding Decisions

Parents and babies are not just part of a family – they are part of a community. How their community has set norms and expectations around breastfeeding will depend on their shared experience. We need to acknowledge that we have not supported communities equally and equitably – and sometimes that has understandably led to estrangement, resentment, and mistrust. If we want to truly address disparities and inequities, the medical profession needs to acknowledge this history, address our biases, and take actions that show cultural humility. We need to demonstrate respect if we are going to begin to remediate the damage and restore trust.

This is why NPA’s Breastfeeding Awareness library includes images of members of diverse communities – including Muslim, African-American, and indigenous nations – as well as larger people, young parents, and people with disabilities.

Each of us is a unique individual with unique needs. And it is important that we acknowledge that. The way that people choose to use their bodies is a deeply personal decision. We have responsibilities to support parents’ decisions, including when those are decisions that are different from the ones we want them to make.

We also have a responsibility to respect and embrace the way people define and describe themselves, their families, and their bodies. This is why NPA’s Breastfeeding Awareness library includes images of dyads that do not conform to gender norms and embraces terms like chestfeeding.

It is Not All about Formula

The discussion around whether or not to use a formula to feed babies instead of breast milk is an emotionally-charged one. It is a conversation that touches on personal, political, and social issues. And it has resulted in resentment and hurt feeling on nearly all sides.

It is complicated by the fact that there is broad consensus that the history of the marketing and distribution of formula has included many bad actors, dangerous practices, and irresponsible policies that undermined the choice to breastfeed. There is justification for the criticism formula companies have received.

One issue is whether that has given justification to the criticism of formula as a product or of the parents who use it. The vast majority of people who advocate for breastfeeding would want it to be known that they understand the necessity of using formula under specific circumstances. And they do not intend to shame or show contempt for families who choose it. Unfortunately, their intentions may be irrelevant. If I say something and the result is that I hurt or offend you – even if I did not mean to – that hurt is still real. We need to figure out how we will understand, accommodate, and address differing values, choices, and opinions in a way that improves outcomes and builds supportive relationships.

Ultimately, we need to honor that some families will not choose to breastfeed exclusively or use breast milk. They may choose to add formula to their babies’ diet. When they do, we need to respect that they are making the choice that is right for them. We have a responsibility to provide them with reliable information and support. We need to believe that families are sophisticated consumers who can advocate for safer and better products that are well-regulated and marketed responsibly.

This is why NPA’s Breastfeeding Awareness library includes images of dyads using donor milk, donating breast milk, and using a formula in combination feeding.

Our Responsibility to Build a Supportive Community

Whether or not a family is going to reach their feeding goals depends on multiple factors. Some of them are arguably within our control. Others are not.

We can offer families education and options. We can connect them with specialists who support lactation and infant feeding. And we can make sure they have the tools and equipment they require. But we have to acknowledge that there are other factors to be considered.

We live at a time and in a place where breastfeeding is not well supported. Very few families can access family and parental leave. Even fewer have the benefit of paid leave. Despite laws and mandates, workers are not being protected from pregnancy discrimination and their right to breastfeed and work is not adequately supported or defended. Insurance coverage is varied and unreliable. Co-pays and deductibles – even on what should be considered preventive health care – can make the costs of breastfeeding inappropriately or prohibitively high.

These structural and systematic barriers demonstrate how important provider advocacy is. It needs to be on an individual level when we do things like write letters of medical necessity for electric breast pumps and donor milk. It must be on the personal level when we reliably exercise our rights to FMLA benefits and support our colleagues’ needs as parents and nurturers. It should be on the legislative level where we help draft policies, testify in support of legislation, rally our professional organizations, and vote.

The overwhelming and enthusiastically positive response to the creation and dissemination of the NPA’s diversity in breastfeeding image library has meant so much to its creators and has affirmed our admiration for the families and providers we serve. The images have been shared thousands of times and generated respectful and meaningful conversations about how we feed our babies and how we support each other.

Please join us. www.nationalperinatal.org

The goal of the National Perinatal Association’s work (in general) and this campaign (specifically) will always be to find the intersection of promoting evidence-based, optimal feeding for newborns and infants while respecting and addressing the personal, cultural, and economic realities that parents face.

This is the foundation of our Best Milk Project, which is setting interdisciplinary guidelines for optimal nutrition during the first two years of life. As we develop and promote these guidelines we want our perinatal community to know…

No matter how you do it…

• nursing
• pumping
• hand expressing
• breastfeeding
• chestfeeding
• on your own
• with support
• with the help of a donor
• for one day
• or one year
• or maybe longer

and especially when you make the choice that is best for you and your baby.

We recognize and honor everyone who does their best to give our babies what they need. Because what babies need are people who love them, care about them, and nurture them.

References:

• National Perinatal Association http://www.nationalperinatal.org/
• Breastfeeding Awareness Month http://www.nationalperinatal.org/feeding_our_babies
• United States Breastfeeding Committee (USBC) http://www.usbreastfeeding.org/nbm19
• Mothering Magazine announces winner of International Breastfeeding Icon Design Contest https://web.archive.org/web/20080506030338/http://www.mothering.com/newsletter/pressrelease-nov06.html
• Poetry Foundation: A brief guide to Imagism https://poets.org/text/brief-guide-imagism