The following article is presented by Valerie Wiens.

Valerie is a La Leche League leader who has been actively providing breastfeeding support to Chinese and foreign mothers in Qingdao, China since 2008. She is also a Board Certified Lactation Consultant (IBCLC). Contact Valerie at lllinqingdao@gmail.com.

When it comes to breastfeeding, China is a bit of a conundrum. Although statistics tell us that China has better breastfeeding rates than the US and Europe (http://www.llli.org/cbi/bfstats03.html), most people having a baby in a Chinese hospital will feel there is far less support and understanding about breastfeeding. Most mothers will experience a large amount of pressure to formula feed in the hospital. This is true for foreign mothers and even more true for Chinese.

Living in China you have probably noticed that formula marketing is rampant. Formula samples are given at prenatal checkups, free “breastfeeding classes” are held by formula companies, their posters are all over the walls of most hospitals. Dr.’s and hospital staff receive perks from formula companies for promoting their products. WHO and UNICEF’s Baby Friendly Hospital Initiative prohibits formula promotion or pressuring. There are over 6,000 Baby Friendly Hospitals in China compared to 105 in the US. Still I can personally attest to being in Baby Friendly Hospitals where I see at least 4 of the 10 requirements being routinely broken.

Perhaps one explanation for the difference seen between statistics and real experience is that the statistics are for the whole of China. If you look at the major metropolitan cities you see a much bleaker picture. For instance, in Shanghai, breastfeeing rates at 4 months are 22% compared to country side Chengde at 76%. The national target is 80%. (Sources: 1, 2, 3)

Still, the general attitude in China is pro-breastfeeding. In contrast to the West almost all Chinese women plan to breastfeed. Breastfeeding in public is much more acceptable in China than in the West. Since the 2008 formula scandal breastfeeding has been promoted. For most, formula feeding is not seen so much as a “choice” and women only plan to use it if they have to. Still with a lack of medically sound support, unethical marketing, and abundant family pressure few manage to exclusively breastfeed and wean long before they hoped to.

So if you plan to breastfeed what should you expect when having a baby in China?

Hospital Stay – Do not expect hospital breastfeeding support

Those foreign mothers I’ve talked to who had babies at international hospitals report receiving help with breastfeeding and less pressure to formula feed. I can’t say the same of Chinese hospitals. Of course you might get lucky and discover a local hospital that is supportive of breastfeeding! If so, use the forum on this website to promote that hospital! In any case, it is best to prepare yourself with information so you can combat any poor advice. Here are some issues to be prepared for:

• Colostrum: There is a lack of understanding in Chinese hospitals when it comes to colostrum (the special breastmilk produced the first 3-4 days). Colostrum is often ignored, babies are given formula and water, and breastfeeding is started once milk comes in (day 3-5). This is unfortunate as colostrum is of paramount importance to infants. It seals the gut to protect against pathogens, colonizes the GI tract with friendly bacteria and enzymes, and it has a laxative effect that helps prevent jaundice. Because colostrum may not be abundant and looks different than mature breastmilk (and very different from formula) many doubt it’s ability to nourish a newborn. Research (and all of human history) shows that colostrum is the perfect amount for the newborns tiny stomach and is essential to infant health. No supplements of water or formula should be given unless medically indicated. Understanding colostrum and it’s transition to mature breastmilk will help you feel confident exclusively breastfeeding. See the World Health Organization’s website for more info on why exclusive breastfeeding is so important: http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/
• Water: Chinese see breastmilk as food not drink. 吃奶 means “eat milk.” This idea along with some Chinese medicine has lead to the belief that all babies, even right after birth, need to be supplemented with water. You will probably be instructed to give your baby water. Knowing that breastmilk has water in it and knowing the risks of giving water can be helpful. Giving water to newborns worsens jaundice, makes infants more susceptible to infection and allergies, brings imbalance to blood sugar, leads to reduced caloric intake, and lowers milk supply. There is really never a medically indicated reason to do it. Every major health organization advises against any supplements (water, food, formula) until around the baby’s 6th month of life.
• Breast Massage: This is actually big business in China! Expect to have at least one visit a day from a breast massage therapist hoping to be hired. Usually they just give you their card and move along but I have observed that they can be very persistent. Even freely squeezing your breasts (without asking!) and telling you you don’t have enough milk. Although breast massage can be useful it is something any mother can learn to do herself. These services are usually offered to fix two problems, engorgement and low milk supply. Both of these problems are usually due to infrequent feeding and both can be fixed by increasing breastfeeding frequency.
• Getting Enough Milk?: In China being told your baby isn’t eating enough is common. When your baby is first born breastfeeding VERY frequently is normal. 10-12 times in 24 hours or more. As your milk comes in and your baby’s stomach grows time between feedings will lengthen. Just because your baby seems to want to constantly be at the breast it doesn’t mean you don’t have enough milk for him. It’s helpful to know accurate ways to asses adequate intake. You can know how much is going in by how much is coming out! Take this chart with you to the hospital for reference.

  *   Day One: 1 wet, 1+ meconium (dark tarry) stool
  *   Day Two: 2-3 wet, 1+ meconium stools
  *   Day Three: 4-6 wet, transitional stools
  *   Day Four: 4-6 wet, transitional stools
  *   Day Five: 6+ wet, 3-4 yellow stools

  (Taken from “Core Curiculum for Lactation Consultant Practice, 2nd Edition,” Mannel, Martens, and Walker)

Breastfeeding Issues after Discharge

• Well Baby Checks: Unless you’re going through an International style clinic or hospital you may not have scheduled well baby checks. Well baby checks are important to the breastfeeding mother because your baby can be weighed, measured, and you can be assured that he/she is getting enough milk. Also most serious cases of jaundice present AFTER discharge. Especially if your baby still appears jaundice after you leave the hospital schedule a check up soon. One of the easiest solutions parents have found is to look online to find the normal schedule for check-ups and vaccines from their country and try their best to follow it.
• Growth Charts: In China there is an outdated growth chart in use in most hospitals and clinics. In the West there is a slow transition to using growth charts based on breastfed babies instead of formula fed babies. The WHO chart is the one to use for breastfed or mostly breastfed babies http://www.who.int/childgrowth/standards/en/. Take it with you whenever your baby will be weighed and measured. Many mothers have been told to wean or supplement with formula because their baby is in the lower percentile on a faulty chart. Whatever you hear at a check up you can take home and look up. Some families have found it useful to purchase a digital baby scale so they can keep track of weight themselves. Scales in hospitals also seem to vary greatly so it’s good to use the same one consistently.
• Nutrients: Breastfed babies often have lower iron levels and I’ve heard of many mothers being told their babies are anemic. Breastmilk iron is unique and is extremely well absorbed. 50%-70% compared to 1%-12% in formula. So breastfed babies who may test low in blood iron levels may be thriving just fine. Anemia is a serious condition so don’t take it lightly. But do consider a second opinion, preferably from a pediatrician who is familiar with breastfed babies. Research has shown that babies who are exclusively breastfed for the first 6-7 months are at a lower risk of becoming anemic than formula fed babies. (Pisacane in 1995) Breastfed babies are often also told they are calcium deficient. This again is based on the high levels of calcium in formula that are not bioavailable to the baby. Always take your baby’s blood work home and do a little research for yourself before you get scared by statements like “you’re milk is bad quality” (very unlikely), “your baby is deficient in ______”, or “your baby is underweight.” Chart of normal iron levels: http://www.kellymom.com/nutrition/vitamins/iron.html Iron rich foods for babies starting solids: http://www.llli.org/faq/firstfoods.html

*“Stop Breastfeeding”: Of the many breastfeeding mothers, foreign and Chinese, I interact with here in China almost all have been told to “stop breastfeeding” at least once by a well meaning health professional. Unfortunately, weaning is often advised here with problems such as mastitis, slow weight gain, sore nipples, or even a cold. In all of these situations abrupt weaning will only cause many more problems for both mom and baby. That being said don’t just “tough out” breastfeeding difficulties! Get good support and help.

• Milk Increasing Foods: The Chinese have many traditional galactogogues (food or herbs that increase milk supply). Soup, especially fish soup, is said to increase milk supply. Scientifically, we know that breastmilk production is regulated by a “supply and demand” system. No amount of special food will be able to save the milk supply of a mother who is not allowing her baby to drive her supply by frequent breastfeeding. That being said some Chinese galactogogues may have a cause a slight rise in prolactin (milk making hormone) levels. Fish soup is a great source of calcium, important for a culture that doesn’t consume much dairy. Except for anything typically high in toxins (like shellfish), there’s no reason not to try the “more milk” foods your ayi makes for you!

Resources and Support for the Breastfeeding Family

• Lactation Consultants: In China there is no real concept of lactation consultant practice. This is not true of other Asian nations. South Korea has a very large number of International Board Certified Lactation Consultants (IBCLCs) as do Japan and Thailand. Lactation Consultants hold an official certification and are often employed by hospitals or pediatric offices in developed nations. In China, advice about breastfeeding is left to nurses (who usually have very little training), Yue Zao (the ayis hired to help a mother during her “sit month”), breast massage therapists, and mostly family members. Contacting a lactation consultant in your home country by phone or email may be possible. There are a few in China who are understandably overworked.
• Support Groups: La Leche League International is active in China with Leaders in the following cities: Shanghai, Beijing, Hong Kong, Qingdao, Kunming, and Suzhou. La Leche League groups are fun to attend and are a great place to find support and encouragement. If you wish to know about a La Leche League group in your area see www.muruhui.org. This site is in Chinese. You may contact me if you cannot find the information you are looking for there. No LLL group in your area? Start your own support group! Just get together with some other moms and start sharing what you’re learning. As all of us expats know, friendship and encouragement are important ways to avoid feeling alone.
• Online Resources: Find the answer to almost any breastfeeding question you have on the following comprehensive and respected websites. These sites also include online help forums you can use.
  • La Leche League International: http://www.llli.org/
  • The Australian Breastfeeding Association: http://www.breastfeeding.asn.au/
  • Kelly Mom: http://www.kellymom.com/