Since when does a guideline become a rigid rule?

Cross posted

More on breastfeeding, and how those silly naughty mothers are just wilfully doing the wrong thing. This time it’s an article in the NZ Herald, coming out of the “Growing up in New Zealand case study”: NZ mums ignoring breast feeding advice.

An official guideline that babies should be fed only breast milk for their first six months is being challenged after a study of almost 7000 babies found the vast majority of mothers ignore it.

The director of the study, Dr Susan Morton, runs through some of the reasons for many mothers not breast feeding exclusively for six months, including the pressures of work, and the reality that in our developed first world nation, the water supply is reliable. She points out that the directive for women to breast feed exclusively for six months sets many women up for failure.

That seems to me to be a useful way to reflect on the advice handed out so freely to new parents. Instead of always pushing the ideal, let’s think about the practical realities, and see if we can develop guidelines, and support to help parents to with achieving the goals of the guidelines.

But the Children’s Commissioner is having none of that.

But the Ministry of Health and Children’s Commissioner Dr Russell Wills are standing by the official guidelines. Dr Wills said Dr Morton’s comments reflected a classic “authority’s dilemma”.

“What should authorities advise when what good science says is best for baby is not what most parents do?” he asked.

“If you compromise and say that something is fine when it’s not, you are misrepresenting the science and selling parents short.”

Hmm… let’s focus on that word, “authorities”. Yes, people can be authorities, and experts in their field, and someone that other people turn to for advice. But the way that advice is translated into practice often turns into on-going policing of parents, and in particular, women, and instead of being a guideline, the advice becomes a rigid rule.

Let me tell you a story. When my younger daughters were tiny, my Plunket nurse kept up home visits for a long time. For people overseas, Plunket is a child-health service, designed to support new parents and babies and young children. In the first few weeks after your baby is born, a Plunket nurse will visit you in your home, and offer you advice and assistance.

My Plunket nurse was, for the most part, excellent. She was unintrusive, she quietly made some very helpful suggestions about how I could manage my infant twins, and she had her eye on my elder daughter too. Of course, I would find it all comparatively easy having a visiting nurse in my home, because I am white and middle-class, and any judgements she was making were likely to be positive. I felt assisted, not assessed.

But one thing puzzled me. By the time my little girls were about 18 months old, they were fully weaned, and drinking cows’ milk. Not a lot, because they weren’t big milk drinkers. One little girl was drinking about 400mls a day, and the other about 500mls. “You should really try to get them up to 600mls,” the Plunket nurse said. “That’s the official guideline.”

Then, “What about your elder daughter?” At that time she was aged about four, and she was drinking somewhere between 800mls and 1,000mls a day.

“Too much!” said the nurse. “She should only be drinking 600mls a day.”

So it turned out that in my Plunket nurse’s mind, what was supposed to be a guideline was in fact a rigid rule. Children should drink 600mls of milk a day, no more and no less.

This to me is a large part of the problem with the rules about breastfeeding. What is intended to be a guideline is interpreted as a rigid rule, with no flexibility for the needs of the individual baby, nor for women’s and families’ varying circumstances.

I think that the “authorities” need to engage a little more with the realities of women’s lives, instead of turning guidelines into hard and fast rules, and then wondering why women ignore them.

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4 comments on “Since when does a guideline become a rigid rule?

  1. hungrymamanz says:

    The trouble is not with the guideline, which does what in should in describing optimal practice based on the evidence we have available to us. The trouble is with doctors and midwives and plunket nurses who don’t have the knowledge or willingness to help mothers meet those guidelines and with societal expectations, maternity leave and other factors which make breastfeeding much harder than it needs to be.

    That said I much prefer the way LLL words the guideline which says exclusive breastfeeding is recommended until ” around the middle of the first year” which says the same thing but with enough wiggle room to allow for individual circumstances.

  2. Kathmandu says:

    Aside from all the societal stuff that interferes with breastfeeding… five and a half months to six and a half months is *approximately* the natural developmental threshold for becoming interested in solid food. Meaning that even for families that practice exclusive breastfeeding and baby-led weaning, a lot of five-and-a-half-month-olds will start reaching for the big-people-food. They won’t eat much of it (as in, not even a whole mouthful), but they want to try it. Treating six months as a hard cutoff puts a lot of parents in the ‘wrong’ for good parenting.

  3. artandmylife says:

    I have been giving talks on evidemce based practice recently and came across the concepts of “rigid users” and “thoughtful users” of evidence and guidelines. Seems like we need a bit more thought…

  4. Gae says:

    Oh sister, don’t I just remember the ‘guidelines’. My first born (son) was a thumping 5 kgs, and whacked on weight, relentlessly, for the first six months, exclusively breastfed. The Baby ‘Elf Centre sister wanted me to feed him Farex, from about four months, which was an exercise in futility.
    Then came our dainty little daughter, a whisker under 4 kg, a willing but moderate feeder. Breast fed to 12 months. The dramas came at the Baby ‘Elf Centre, because although she was healthy, plump, feeding and sleeping well, and a supremely contented little person, she never once managed the weekly weight gain she was ‘expected’ to. They were so focussed on the ‘guidelines’ that they never looked at the radiantly healthy, happy and active baby in front of them. Even at eight months she was not particularly interested in ‘solids’, unless it was suitable ‘real food’ as opposed to baby mush. Give the girl a cutlet bone to gum on and she loved it, give her sloppy tinned stuff, and she would let it slide right out again. Just as well she was number two, and I had had enough dealings with the sisters to take some of their ‘guidelines’ with a grain of salt, and the confidence to believe in my own observations. And admittedly, well educated enough, and middle class enough to stand up to the sisters.

    Gae, in Callala Bay

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