Food security for infants and young children: an opportunity for breastfeeding policy?

Definition of food security

Concepts of food security have developed from a focus on the supply of food to its current definition, established in 1996 and confirmed in the 2009 Declaration of the World Summit on Food Security convened by the Food and Agriculture Organization of the United Nations: ‘Food security exists when all people, at all times, have physical, social and economic access to sufficient, safe and nutritious food, which meets their dietary needs and food preferences for an active and healthy life.’ ([49] p. 1). Although the importance of breastfeeding was recognised in the 1996 Rome Declaration on World Food Security [50], breastfeeding policy was developed within infant and maternal health and nutrition domains, and received limited attention in the wider ‘food security’ discourse [51-54].

Concepts of ‘food security’ and ‘nutrition security’ overlap [55]. Breastfeeding indicators are included in national and global nutrition-specific programs [56,57] and breastfeeding may be a goal or intervention within ‘nutrition security’, ‘food security’ and ‘global nutrition system’ frameworks [57-59]. In agriculture and other sectors, broader ‘nutrition-sensitive’ strategies are now called for to improve maternal and child health [60].

Availability

Food availability is further described as ‘…sufficient quantities of food of appropriate quality, supplied through domestic production or imports (including food aid).’ ([62] p. 1). Breastfeeding is simultaneously the ‘domestic production’ and supply of food of appropriate quality for infants and young children, in accordance with WHO/UNICEF guidelines [1]. These guidelines stipulate both supply and appropriateness, as follows: ‘The vast majority of mothers can and should breastfeed… Only under exceptional circumstances can a mother’s milk be considered unsuitable for her infant.’ ([1] p. 10). Appropriateness of food also includes its social context, which for infants and their mothers, differs between breastfeeding, feeding of expressed breast milk and feeding breast milk substitutes.

In terms of sufficiency, the policies and practices required to support breastfeeding in different settings are known [2,45,46,48] but wherever breastfeeding rates are suboptimal, it follows that breastfeeding and breast milk are available inequitably. The total amount of breast milk available to a population is the amount consumed by breastfed babies plus any surplus, taking into account all sources (mothers, wet-nurses and expressed breast milk via milk banks and milk sharing). Estimates of breast milk production obtained from breastfeeding rates are included in national food production statistics in Norway [63], and have been used in studies of the volume and economic value of breast milk produced in Australia, the United States [42] and Sub-Saharan Africa [64]. However, these calculations do not include surplus breast milk.

The total amount of surplus breast milk and its effect on food security for infants at national levels are not known. Expressed breast milk can sometimes fill a short- or long-term gap in the supply of breast milk if a child has difficulties feeding at the breast or following maternal death, illness, absence or use of contraindicated medicines or drugs. Most current milk banking and sharing depends on breast pump use but the relationships between pump use and milk yield and breastfeeding rates and duration are unclear [65].

The variability in daily milk yield between women breastfeeding single babies has been studied [66] but less is understood about human potential yields. Measurement of maximum potential milk yield is complicated by homeostatic regulation, in which the volume produced is largely regulated by the amount removed [67]. The capacity of well-nourished women with sufficient time and support to breastfeed exclusively two or more rarely, three babies has been documented [68]. Similarly, milk bank data and media reports suggest that a proportion of mothers are able to produce a large surplus of milk using an electric pump, with records of up to 300 litres over 8 months [69], and extreme daily yields of 3.9 and 5 litres [70,71]. However, women often perceive their milk supply to be insufficient [12,72] and this lack of confidence contributes to premature weaning and is readily exploited in marketing strategies for breast milk substitutes [73].

The occurrence of milk banking is not necessarily associated with high rates of breastfeeding, although it is consistent with the WHO/UNICEF Baby-friendly Hospital Initiative and WHO/UNICEF Global Strategy on Infant and Young Child Feeding [74], and reduces the health risks and costs associated with feeding breast milk substitutes in neonatal intensive care units [75-77]. The volume of milk dispensed is disclosed by some milk banks [36,78,79] but information about the volume collected, discarded or diverted to other uses can be difficult to obtain [80]. As an indication of the amount of breast milk provided in the context of strong Government support, in 2011 in Brazil, over 200 milk banks accepted 165,000 litres of breast milk donated from 166,000 mothers which was distributed to nearly 170,000 babies [81]. In the United States in 2012 the 16 milk banks of the Human Milk Banking Association of North America (HMBANA) dispensed 74,000 litres [36], which represented a small proportion (about 0.01%) of the estimated 526 million litres consumed in the United States by breastfed babies in 2010 [42]. The added volume of breast milk distributed privately, or more publically via the internet, is difficult to quantify. A recent study of over 500 individuals donating milk on one website in the United States showed that nearly 50% of offers over a three-month period were for volumes of three litres or more [82].

The recent expansion of milk banking and sharing practices in different settings, especially in countries with low breastfeeding rates [27,36,82,83], are the subject of intense ethical debate [39], but less frequently considered in the context of infant food availability. Concerns that milk banking might reduce the motivation of mothers to provide their own milk has not been borne out in neonatal intensive care units [75,84-86]. Alternatively, milk banking and sharing could divert resources otherwise spent on improving breastfeeding rates, entrench poor breastfeeding policies, or replace breastfeeding for healthy full term babies.

The availability of breast milk substitutes is indicated by retail sales data for baby food and estimates of consumption by infants and young children of milk from cattle, buffalo, goat and other species. Sales of standard infant formula, follow-up formula, toddler milks and special baby formula in 80 countries amounted to 2.2 million tonnes, worth US$39.7 billion in 2013 [11]. These figures indicate how the current deficit in breastfeeding is being met. Further analysis of import statistics reveals the relative contribution of domestic and overseas supplies of breast milk substitutes and the length and complexity of globalized supply chains for infant foods [87]. Infants and young children are especially vulnerable to failures in the integrity and reliability of these supply chains. In contrast, the food availability and ‘supply chain’ for a breastfed infant is based on the proximity of the mother. It can be argued that food security for infants and young children in countries like China and Australia depends, ultimately, on the capacity to breastfeed.

Accessibility

The accessibility of food is defined as ‘Access by individuals to adequate resources (entitlements) for acquiring appropriate foods for a nutritious diet. Entitlements are defined as the set of all commodity bundles over which a person can establish command given the legal, political, economic and social arrangements of the community in which they live (including traditional rights such as access to common resources).’ ([62] p. 1).

Access to breastfeeding requires access to a lactating woman –a mother, relative, friend or wet-nurse– and the infant’s ability to breastfeed. Separation of the breastfeeding dyad is entrenched in many policies and practices to do with post-natal care in hospitals, illness, maternity leave, work, childcare and sleep arrangements, and cultural and religious beliefs that influence breastfeeding in public and the age of cessation of breastfeeding [88-90].

Access to breast milk, is distinct from access to breastfeeding. The accessibility of expressed milk from a mother’s stored milk, milk banks, or social networks (including the internet), depends on appropriate equipment and transport. Breast pumps are common items in some high-income countries and research indicates that milk expression was practiced by over 70% of breastfeeding mothers of healthy full term babies in Australia and the United States [91,92]. Refrigeration and freezing extend the shelf life of breast milk [93]. Milk is usually pasteurised by milk banks, although milk that is not heat treated is used by milk banks in Norway [94] and is also shared informally elsewhere [29,32]. Alternative processing and packaging technologies are also being developed [95]. Systems for the collection and distribution of breast milk vary from mothers who transport their own expressed milk to delivery by firefighter and postal services in Brazil [96]; regional depots for milk banks in North America [26] and local delivery or postal services for milk sourced via the internet [29,32].

However, not all children qualify as recipients from milk banks, which typically prioritise premature or ill babies [26]. Donors of shared milk may also determine who obtains their milk (but have little control over its end use in practice). Donor criteria include the recipient’s need, relationship and other factors [82,83]. Access may also be determined by societal views that peer sharing of breast milk is an act of common humanity, a gift or a resource that should be shared rather than sold [28,39]. Alternatively, milk sharing may be considered an unacceptable activity that is disgusting or perverted [97]. In contrast, concepts of ‘milk kinship’ in Islamic cultures may support milk sharing but restrict access [98]. Detailed analysis of the distribution of expressed breast milk in a population has not been undertaken [82].

The complex factors that influence food distribution and access are recognised in concepts of food security. Use of milk sharing and wet-nursing allows babies to access milk from women who are better able to breastfeed by virtue of the ‘legal, political, economic and social arrangements of the communities in which they live’ ([62] p. 1). If a woman is unable to breastfeed because of insufficient support from her health system, family, workplace, child care or community, she can theoretically source breast milk from a woman who is so supported. Concepts of food security acknowledge that social inequity, and cultural and institutional barriers determine access to breastfeeding and breast milk. In contrast, popular discourses often attribute decisions to breastfeed to individual choice or agency alone [89,99].

Access to breast milk substitutes is determined by the distribution of retail outlets in most countries for other highly processed foods, pharmacies, and, less commonly, on prescription. In countries where the WHO Code [16] and resolutions [14,18] are not observed, direct supply to mothers occurs through hospitals [12,100], health professionals [101,102], the internet and government welfare programs, for example the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in the United States [103]. The safe reconstitution and feeding of breast milk substitutes also requires skill and access to supplies of energy and potable water.

Affordability

Affordability is a key component of access to food that depends on a household’s economic circumstances. Countries and states vary in their regulation of donation and payment for breast milk, reflecting prevailing societal values [104-106]. However, breastfeeding provides much more than the production and transfer of food, and includes less tangible associations with mental and emotional health of the child and mother [107,108].

Donation-only models for breast milk are based on principles of gifting human blood and tissues [109] and raise ethical challenges of supply, cost and risk management [110] but may not fully account for breast milk as a food. Concerns about exploitation are similar to those applied to wet-nursing, namely that women might produce and sell milk against their own best interests or those of their child. These concerns need to be viewed in the light of societal expectations that mothers breastfeed without recognition of or recompense for the time, labour and opportunity costs of doing so [111].

Currently, access to banked breast milk requires payment to a milk bank or hospital and its affordability for families depends on cost sharing arrangements between health systems and insurers [36]. Payment is not accepted by most peer milk sharing networks and compensation (for example, providing containers for milk) is discretionary. Payment of donor mothers by the first milk banks in the United States in 1909 and the United Kingdom (from 1939 until 1985) was necessary to secure supplies of milk and followed the historical practice of payment of wet-nurses [112]. With the resurgence of non-profit milk banking in the latter part of the 20^th century, donors were not paid but questions about the supply and affordability of human milk remain [37]. Currently, milk provided by milk banks in the United States and Norway costs US$101-$228 per litre to cover the costs of screening donors and milk testing and processing [42,113], while milk banks in Denmark pay donors and do not charge recipients [104]. Information on prices for wet-nursing services is limited [32,42].

The cost of expressed breast milk obtained from unregulated sources is often prohibitive for households unless it is donated. Health assessment and testing of donors may be arranged by recipients, depending on their knowledge, perceptions of risk and the level of relationship or trust established with the donor [114]. Prices (excluding shipping) for expressed breast milk sold online of US$34-$101 per litre (US$1-$3 per oz.) in the United States appear stable over recent years, while in the United Kingdom breast milk is more expensive (US$112-$170 per litre), possibly reflecting the smaller size of the market [32,42,95]. The cost to hygienically prepare feeds, including that of access to clean water, must be added to the costs of both expressed breast milk and breast milk substitutes.

In contrast, the price of breast milk substitutes for babies 0–12 months old in the United States was US$1.50-US$7.00 per litre for reconstituted powder and US$7-$27 per litre for ready to use (liquid) infant formula. Prices increased to US$20-$35 per litre for products labelled as ‘organic’ or for ‘special needs’ and US$104 per litre for products labelled ‘hypoallergenic’ [115]. In China, foreign-owned brands comprise about half the market for infant formula, with prices two to three times higher than in the United States, Europe and Australia [87].

Breastfeeding may be unaffordable if the household cannot afford to lose the mother’s income, or the mother cannot provide the time and labour to breastfeed [111], express milk, or obtain adequate workplace and child care support to do so [12,116,117]. Maternity protection and anti-discrimination legislation, where these are implemented, may not effectively mitigate these costs or the loss of the mother’s future earning capacity [118]. An earlier return to the paid workforce after the birth of a child is associated with a shorter duration of breastfeeding [119,120]. Irrespective of the cause of premature weaning, its occurrence requires households to accommodate the cost of breast milk substitutes and associated short- and long-term health costs to the child and mother.

The affordability of breastfeeding also includes the cost to workplaces of supporting breastfeeding employees by providing facilities, time and flexible work arrangements [119,121]. Distribution of this cost between employers, employees and wider society, reflects the extent to which breastfeeding is normalised and protected in that society or remains a source of gender inequity. Tools are available to assess the national costs of implementing effective measures to protect, promote and support breastfeeding [122,123].

Utilization

The definition of food security includes ‘Utilization of food through adequate diet, clean water, sanitation and health care to reach a state of nutritional well-being where all physiological needs are met. This brings out the importance of non-food inputs in food security’ ([62] p. 1). Breast milk fed by breastfeeding or wet nursing meets all the criteria of utilization. Utilization of expressed milk is more contentious. Expressed breast milk that fails to meet safety and quality standards for milk banks and milk sharing recipients may be lost to the food chain. Screening of donors and testing and pasteurisation of milk reduce some of this wastage [36]. A proportion of expressed breast milk is also lost during collection, storage and feeding.

Utilization of breast milk raises potential human rights issues. Lactating women may have limited control over the end use of their milk, for example through a lack of transparency by milks banks or other recipients of donated milk or requirements in marital, divorce or surrogacy arrangements to supply breast milk [124-126]. There is limited understanding of how much breast milk women would produce and make available for different users for altruistic or financial reasons and if protected from exploitation. Studies of not-for-profit (donation-only) milk sharing sites and breast milk banks show that most of their donors are strongly motivated by altruism [127,128]. However, in locations where it is possible to choose between selling and donating breast milk, the amounts sold and donated have not been compared. Financial incentives are likely to appeal most to unemployed or poor women, without adequate support or maternity protection. Recently, shopping vouchers were offered to disadvantaged women who breastfeed in the United Kingdom [129], and limited access to maternity leave was a rationale for payment by a breast milk cooperative in the United States [95]. These strategies, and the debates surrounding them, are unique to the cultural, legal, political and economic settings in which they arise [37,38,130].

The efficiency of breastfeeding compared with other methods of feeding infants is of fundamental importance to food security. Utilization includes concepts of efficiency of resource use from processes of production through to consumption. Wastage from artificial feeding occurs through the use of land, fertilizer, water, energy and materials to make and use breast milk substitutes, teats and bottles. The environmental impacts of these processes include pollution of natural resources, transport and disposal of wastes, effluent and packaging [131,132], which are also relevant, in part, to storing and feeding expressed breast milk. Life cycle analyses show that the dairy sector consumes large amounts of water [133] and contributes about 2.7% of global anthropogenic greenhouse gas emissions [134], most of which occur on farms. Research on the stability of global agricultural production and food supply under a range of resource-limited scenarios needs to be linked to policies for infant and young child feeding.

Stability of supply

The vulnerability and growth needs of infants and young children give them little capacity to tolerate unstable supplies of food. ‘To be food secure, a population, household or individual must have access to adequate food at all times. They should not risk losing access to food as a consequence of sudden shocks (e.g. an economic or climatic crisis) or cyclical events (e.g. seasonal food insecurity). The concept of stability can therefore refer to both the availability and access dimensions of food security.’ ([62] p. 1).

A household’s supply of breast milk is not stable unless a woman is able, motivated and supported to breastfeed, or she can access milk from another lactating woman. Separation of the mother from her child may be managed if distance and time permit access to breastfeed, or carers use stored breast milk. Outside the regulated childcare sector, some mothers arrange for their child to be cross-nursed.

Temporal and geographic variation in supply to breast milk banks and milk sharing sites are not well understood [82] and may include fluctuations in the time available to express milk, awareness of milk banking and sharing, skill in expressing milk, factors that influence weaning, the donor’s use of medicines or herbal preparations, the age of her baby and guidelines on milk storage [26,135]. The breast milk supply chain to milk banks and sharing networks depends on constant recruitment of donors from a population with adequate breastfeeding rates. Shortages of milk are reported frequently by milk banks [36]. In the first years after human immunodeficiency virus appeared, recommendations for infected women to use breast milk substitutes or pasteurise their milk [136] reduced breastfeeding rates in some countries and closed milk banks in others [137].

The supply of breast milk substitutes can be destabilised by disruptions to manufacturing processes and supply pipelines, distribution and marketing systems, food safety recalls and changes to food regulations and corporate decisions. Instability in a household’s supply of breast milk substitutes may occur because of their high cost relative to income or economic shocks, for example sudden unemployment.

Emergencies, natural disasters and civil unrest challenge all aspects of food security. A key responsibility of international aid agencies and governments is to plan for infant feeding in these situations [138,139]. Breastfed infants and young children are food secure if their mother or another lactating woman is accessible and well enough [140], with little additional food, shelter and social support [141]. In emergency situations the food security of artificially fed infants and young children can change abruptly due to disruption to the supply and affordability of breast milk substitutes [142] or a lack of resources and equipment to feed powdered infant formula safely [143]. Guidelines have been developed for international aid agencies to support breastfeeding mothers in emergencies and prevent the donation and distribution of breast milk substitutes that destabilize breastfeeding practices [139,143]. However these guidelines were not observed in the aftermath of earthquakes in the Asia Pacific region (Yogyakarta and Central Java in 2006, Sichuan Province in 2008 and the north-east Japan earthquake and tsunami in 2009) [142], Cyclone Nargis in Myanmar in 2008 [144] and the Haiti earthquake in 2010 when large amounts of infant formula were distributed despite the use of baby tents to maintain breastfeeding in the latter [145,146]. Outbreaks of Ebola virus in West Africa in 2014 present new challenges to breastfeeding [147].