EPISODE 3Beyond Breast is Best: Infant Feeding in Nova Scotia & Cambodia

World Breastfeeding Week is celebrated every year from 1 to 7 August, not just to encourage breastfeeding, but to raise awareness of the different cultural and socio-economic challenges to breastfeeding that caregivers face world-wide. Nova Scotia has its own challenges. Nova Scotia has among the lowest breastfeeding rates in Canada, with less than one quarter of infants receiving Health Canada’s recommended 6 months of exclusive breastfeeding.

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Mission: Healthy People & Healthcare Systems

Rhys Waters 0:00

Welcome to Beyond Research, a podcast brought to you by Research Nova Scotia.

Stephanie Reid 0:09

Every year during the first week of August, countries around the globe participate in world breastfeeding week, not just to encourage breastfeeding, but to raise awareness of the different cultural and socio-economic challenges to breastfeeding that caregivers face worldwide. Nova Scotia has its own challenges.

Kyly Whitfield 0:27

Here in Nova Scotia, we have among the lowest breastfeeding rates in Canada. It's actually less than a quarter of infants who are exclusively breastfed to six months.

Stephanie Reid 0:35

This is Dr. Kyly Whitfield of Mount St. Vincent University. She's an assistant professor of applied human nutrition and lead researcher of the Milk and Micronutrient Assessment Lab, also known as the mama lab. Kyly's perspective is international, her research on breastfeeding practices and culture span communities in both Nova Scotia and Cambodia. Today, you'll hear how her work is contributing to a global conversation that has impact on the health and wellbeing of caregivers and babies abroad and at home. Thank you for joining us today Kyly.

Kyly Whitfield 1:05

Thank you so much for having me.

Stephanie Reid 1:07

Kyly, can you tell us a little bit about the MAMA lab at the Mount and what you do there?

Kyly Whitfield 1:12

Yeah, so I do like to talk about my research in terms of the "what" of human milk and the "how" of infant feeding. So the "what" side is looking at the milk itself and a lot of this research I actually do internationally. I'm interested in the vitamin content, specifically the thiamine content of milk. And that's because in Cambodia, we know that thiamine deficiency is prevalent among lactating moms, which can put their infants at risk of developing a potentially fatal disease called infantile beriberi. So that's international work that's really important. It's probably much less important in Canada where we know most moms are taking a prenatal vitamin through pregnancy and often during lactation. It's just not a concern. The "how" of feeding is probably much bigger of a concern and that's because the "how" happens in so many different ways in Canada. You know, I've worked a lot in Cambodia. Moms breastfeed at the breast, they do that usually for a few years and they do that baby after baby. In Canada, moms are feeding at the breast, they're supplementing with formula, they're expressing milk and feeding that out of a bottle and there's all sorts of things that go along with that, the cleaning of the bottle, the sharing of the feeding responsibility with other caregivers in the home. So understanding that "how" of infant feeding is so important, and I think it's often glossed over. We talk about breastfeeding as the provision of human milk. But it happens in many different ways. You can pump that milk and feed it from a bottle, feed it from a cup, or from a spoon, feed it from a tube, you can feed at the breast. There's so many things happening and with all of those different variations, the milk changes and the behavior around feeding changes.

Stephanie Reid 2:53

You have moms and families coming in and out of the MAMA lab all the time. Can you tell us a little bit about what you're doing with these families here in Nova Scotia and what their role is when they come into the lab?

Kyly Whitfield 3:05

One thing that we're really interested in right now is understanding what's called responsive feeding. So in an ideal circumstance, moms will be watching their babies as they feed and will be kind of looking for cues and understanding what that baby wants. Are they hungry? Are they full? Are they finished feeding? Do they want to play? And they'll be responsive to those cues.

Stephanie Reid 3:28

Wow. So like beyond the feeding itself?

Kyly Whitfield 3:31

Exactly, and we're doing this both with breastfeeding and with feeding pumped milk from a bottle.

Stephanie Reid 3:36

I was really interested to learn that Nova Scotia has among the lowest numbers of breastfeeding moms in Canada. Can you tell us a little bit about that? And have you learned why that might be?

Kyly Whitfield 3:4I

I first moved to Nova Scotia in 2016 and this was one of the first things that I noticed, and I was kind of looking around town, looking around town and I didn't see a breastfeeding mom for months. I had been living on the west coast where breastfeeding is much more prevalent. Previous to that I was living in rural Cambodia where breastfeeding is ubiquitous. You always see mums everywhere breastfeeding, and so it was a bit of a shock, and there's a few kind of things going on. In general, Canada does not have great breastfeeding rates. So typically, we measure breastfeeding rates in countries around the world by looking at the number of moms who are breastfeeding exclusively to six months. So feeding only human milk, no other foods or water. And that's the standard that we use around the world and the data that UNICEF collects. In many low and middle income countries, breastfeeding rates to six months are quite high. You know, in Rwanda, it's upwards of 90% of women who are breastfeeding exclusively to six months. When you come to high income countries, those numbers drop off, so Canada's rates are not great. About a third of women in this country will breastfeed exclusively to six months. When you go to, you know the states or the UK, these numbers are extremely low and so kind of in general high income countries are not great at meeting that standard. When you look at Canada, there's a bit of a gradient going from coast to coast. So we see the highest breastfeeding rates on the west coast and it peters off and it's lowest out here in the Atlantic provinces. And so part of the work that I'm doing right now is trying to understand why that is. And we think that it's probably got a bit to do with history and also the culture in the Atlantic provinces. So from a historical perspective, bottle feeding became very, very popular in you know, the middle of the last century. Scientific mothering was huge, of course, formula that came in a can had to be better than anything that moms could produce. So that's a bit of the historical piece. But also culturally, I think people are less likely to feel comfortable breastfeeding in public and, you know, revealing themselves as some might think of it and so I think that might also have a bit to play.

Stephanie Reid 5:55

Sure. And I've heard a lot of rationales around various stigmas, or even socio-economic factors. Are those things that you'd be looking at as well or hearing from moms?

Kyly Whitfield 6:06

Yeah so, Health Canada publishes data every few years, kind of showing these sorts of trends. So we know for example, older moms, moms who are partnered, moms with a higher socioeconomic status, who are wealthier and who are more highly educated, tend to breastfeed for longer compared to moms who are the opposite of all of those things. And so it's it's not rocket science, it kind of makes sense. Usually moms who are partnered means that they have more support at home, maybe they have another income in the house and so they don't need to return to work, less stress around poverty and food security. There's many things at play here that feed into that. But those are kind of the the major trends that we see across Canada.

Stephanie Reid 6:46

Right, so interesting. Ultimately, what are you hoping your research impacts for Nova Scotian families?

Kyly Whitfield 6:52

I did a really interesting study with one of my students, Kathleen Chan, we collected the data in 2018. And we were wondering, exactly this, what is happening in Nova Scotia that's leading to these poor breastfeeding outcomes. And we wondered, is it education and what we overwhelmingly found was that people know breast is best, that public health message is loud and clear. What seems to be missing is the supports to actually allow for breastfeeding to happen, and for not just breastfeeding, but all of these infant feeding behaviors. So the first 1000 days is a critical window for feeding of young children. We know that breastfeeding is a major part of that kind of package in the first two years. But we know that it also includes things like introducing iron rich foods starting at six months, you know, when do you start introducing cow's milk instead of just having breast milk and all of these different things. And I think that potentially, we've been focusing so much on breast is best that we haven't been getting into the nuances of this whole package of infant feeding. And also people don't really know why breast is best and they don't really know how to actually breastfeed. And so I think more than education, what I really hope to do with my research is to better understand the supports that are needed to allow for families to breastfeed and breastfeed successfully to their own goals, knowing the whole package of recommendations to two years.

Stephanie Reid 8:19

Right. It's funny, you say that as having been a new mother, you know, seven years ago now, you do know, you hear those messages loud and clear from, you know, your nurses, your doctors: breast is best. But you rarely hear beyond that first six months, or that whole notion of that first 1000 days and making sure your baby is set up for success beyond just breastfeeding. So I thought that was really, really interesting. And I think, definitely something we can build upon in our hospital settings. And I know now, given you know, we're currently in a global pandemic, you're not in your lab right now, unfortunately, but you haven't been wasting any time and your research interests have shifted to COVID-19. Do you want to tell us a little bit about that study and what you're doing right now?

Kyly Whitfield 9:09

Absolutely. So this study grew out of a conversation with my graduate students. When we were all in our own homes, we would touch base via video conference once a week. And every call, it would come up at some point, you know, how are you doing? How are you coping? And then one of the students would inevitably say, I wonder how moms are doing? And so you know, the second or third time,

Stephanie Reid 9:34

Not good Kyly, not good.

Kyly Whitfield 9:36

So, the second or third time that this question came up, like I wonder how families are doing right now? We thought, well, let's ask them. And we were so lucky to receive funding to actually do this study really well. And so we collected data from families. It was an online survey that was open for four weeks, kind of at the heat of the pandemic and so we collected data from mid April through mid May, and we just asked moms, okay, what are you feeding your babies? Has what you've been feeding changed? Have you changed the frequency or the amount that you're feeding? Are we talking just about milk? Are we talking about solids? And we pose these questions in a very open ended way to caregivers who were taking care of a child that was younger than six months. We're just going through and still analyzing the heaps of data right now. But I think the main takeaway from what we've learned right to date is that moms are extremely resilient and extremely flexible. There's some really interesting cases of you know, some moms are pumping less because why would they pump in, put tons of milk in their freezer, they're not leaving, they have nowhere to go. Other moms are pumping more because they want to stockpile in case they get COVID-19 and they need to be away from their baby. Some formula feeding mums are stockpiling formula, other formula feeding moms are trying to access supports to relactate, to try and have have a supply that's not reliant on going out to the grocery store or ordering online. It's really all over the map. But moms are being really flexible with trying to deal with this pandemic.

Stephanie Reid 11:15

I can't imagine adding that on top of what we're all dealing with already. And moms are resilient, I guess it'll take more than a global pandemic to get us. But that's really fascinating, things I wouldn't have necessarily thought that people were thinking about it.

Kyly Whitfield 11:30

It's interesting, the support piece is huge. And that's something that Shawn threw in the data that we've been able to analyze so far. There is some concern about regular health care. And so moms were reporting concerns about not getting their regular postpartum visits and being a bit unsure about how they were doing. Their regularly scheduled baby visits were canceled. So they don't you know, there's a bit of anxiety around: is my baby gaining enough weight? Those sorts of things. At the same time, moms are saying, Yeah, so I'm meeting with moms online now, instead of you know, in the local community center, that's fine. And so really, there's the whole spectrum of dealing with this new reality.

Stephanie Reid 12:09

That's so funny, because there are all these little things that you take for granted as a new mom, you just know that you're going to go basically every week or two for some sort of a checkup, or public health is going to call you for some sort of a question or a follow up visit. And thinking back like that would be really intimidating as a new mother and not to have that support mechanism in place.

Kyly Whitfield 12:31

I will say I feel that part of the reason why breastfeeding rates are so high in Cambodia, in part really is because you see breastfeeding, it's normalized culturally, but you also see the mechanics of how the baby goes to the breast and what a good latch looks like. In Canada, we don't see women breastfeeding. And so I feel that there's a challenge here with really understanding what a good latch looks like, what how do you hold your baby in a comfortable way? And I think that that's exacerbated during the pandemic, because the normal supports, you know, public health nurses coming into your home or going to see public health nurses that mom and baby groups, you're not seeing other women breastfeeding. And if you don't have someone in your family bubble, who has experienced or can say, Oh, just you know, shift them a little bit to the left. Oh, yeah, that that looks great. You're missing that piece, which, again, brings it back to we need supports, we need a better culture of breastfeeding support in public so that women are breastfeeding in public so that kids see moms breastfeeding in public, it's a it's a real cycle. And I think the more we see breastfeeding, the easier it's going to become.

Stephanie Reid 13:37

The more we normalize it, and I think, unfortunately, usually when we do hear or see these stories of breastfeeding in public, it's negative. And I would imagine this could be quite deterring for new mothers, and have you heard that from new mothers as one of the reasons why they struggle with breastfeeding?

Kyly Whitfield 13:54

In the COVID survey that we did that was one piece. Interestingly, again, we had a flip side to that. I remember one mom said, I feel the guilt is off my shoulders, I don't have to leave the house. I can lock myself in my room with this baby and we can figure out breastfeeding together and there's no expectation that I leave, which is that's really interesting, right? And so I think, I think we really collected some rich data that's unique to this emergency, but has implications for wider learning as we're trying to understand infant feeding in Nova Scotia. Very interesting.

Stephanie Reid 14:32

Have you studied male caregivers? And have you looked at the differences when men are feeding their infants versus moms?

Kyly Whitfield 14:40

We have a little bit and we've opened it up to have other caregivers provide input, but we haven't had the same uptake. So in the COVID study, we asked for any primary caregiver of an infant under six months. 99% of our respondents in that study were mothers, we only had 1% that were legal guardians, dads or other parents. And so we didn't have much feedback to take in that study most, you know, literally 99% of the responses came from moms.

Stephanie Reid 15:06

And I imagine for families who have infants, who maybe there isn't a mother in this scenario, like you said before, you hear all of these things about breast is best, breast is best. But if breastfeeding isn't even on the table, then how do you reframe that first 1000 days in a way that you still feel like you're giving your baby the very best?

Kyly Whitfield 15:27

Absolutely. And there's all sorts of reasons why people might choose not to breastfeed or might not be able to breastfeed. And so I think, you know, the breast is best has been the slogan for so many years, I think it might need a bit of an update. There's a lot of shame and stigma associated with infant feeding. On one side, you know, there's potential stigma associated with breastfeeding in public and exposing yourself, when we know that when you're breastfeeding, we really can't see much. So there's the thing. But there's also shaming happening when you pull out a bottle.

Stephanie Reid 16:04

I was on the receiving end of that. My daughter ended up in the NICU, and that was just the reality, and I didn't see her for the first couple of days, because that was what my situation was. So by the time we met, she had already been bottle feeding and I just assumed that that's what I needed them to do. But I still remember being in mall food courts and getting those stares from moms who are breastfeeding, or, you know, in the mommy groups, because there is that stigma. And I felt ashamed to pull out a bottle more often than not when I wasn't in my own living room.

Kyly Whitfield 16:37

Exactly. So you're shamed, you feel stress around this and you don't feel adequate if you're breastfeeding, if you're bottle feeding. Some moms will pull out a bottle of pumped milk, but then make it very clear like this is breast. Why are we, right? Why are we doing this?

Stephanie Reid 16:54

It's hard enough to be a new mother and we do it to each other. And it would be just so wonderful to see that go away and everybody just support each other.

Kyly Whitfield 17:02

Exactly. I think all of this research for me is to bring it back to supporting families to do what they want to do. We know that breastfeeding initiation rates are extremely high, more than 90% of moms across Canada and actually around the world will start breastfeeding. But then they fall off before they reach that six month kind of milestone of exclusive breastfeeding. So what is happening between you know, day one, and month six? And what can we do to support moms? That if they want to continue, how do we support them? If moms want to transition to bottles, how do we support them? So one study that I'm working on is trying to understand responsive feeding in different cultures. In the Halifax area, I'm video recording moms who are breastfeeding their babies, but also feeding their babies pumped milk from a bottle. And I'm also moving to Cambodia and videotaping moms in Cambodia, who are breastfeeding their babies. And so we're going to do this cross cultural analysis. And this is really for bi directional lessons learned. Is there something that Cambodian moms are doing that's really great, you know, the mom's really sensitive to her infant cues, or she's really great at picking up on when the baby's full and she stops feeding. Is that happening in Canada, maybe there's some way that responsiveness is shining through among Canadian mother infant pairs, that could be really helpful, and we could bring those lessons to Cambodia. And one really interesting thing is that we've learned that this tool that we're using to code the videos is definitely a North American tool. And so there's certain things that you're supposed to look for: gentle touch, eye contact, things like that. In Cambodia, that's just not a cultural norm. You know, moms will caress their babies in very different ways. And it was interesting, because I had to kind of say, oh, okay, so the way that she's kind of slapping her baby right now, that's normal, that's showing love. Oh, that way that that moms kind of whispering weirdly to Canadian, and that's normal, that's the way that she's showing love. And what I thought was going to be this kind of very easy, bi directional lessons learned between Cambodia and Canada is actually more of just a cultural awareness piece that I think might be really helpful in supporting newcomer moms in Canada. Because if breastfeeding is shown and responsiveness and kind of love during feeding is shown in different ways in different cultures, then health care workers and support workers in Canada need to understand that and need to kind of ask moms, what's normal? How do you do this with your baby? What would you do at home? What did your mom do with you, things like that, to try and support their breastfeeding culture here in Canada. So I think the research that I do, I try to take a really pragmatic look at what do people want and what can we do to provide evidence to support them in the best way possible.

Stephanie Reid 19:54

Thank you so much, Kyly, for joining us today and sharing a little bit about your research and all the important work going on at the MAMA lab. So thank you so much.

Kyly Whitfield 20:04

Thank you.

Rhys Waters 20:06

To find out more about this podcast and the research featured in this episode, visit researchns.ca. My name is Rhys Walters and we will see you next time.

Featured Guest:

Dr. Kyly Whitfield, Assistant Professor of Applied Human Nutrition at Mount Saint Vincent University. Dr. Whitfield is the lead researcher of the Milk and Micronutrient Assessment Lab, also known as the MAMA Lab where her and her team are working on a cross-cultural analysis of breastfeeding in Nova Scotia and Cambodia that goes beyond “breast is best” to focus on the supports required to achieve optimal health in both mama and baby.