Transcript: Breastfeeding & Infant Feeding in International Perspective with Mia Smith, RD

Jacqueline Kincer  0:37  

Welcome to the podcast, Mia, we have Mia Smith with us today. She's a registered dietitian in Cape Town, South Africa, and she's working on her IBCLC I'm so excited to have you here to bring a fresh perspective to the show. So say hi to everyone and tell us more about yourself me and tell us about what you're doing. With you're studying and you're practicing.

 

Mia Smith  1:01  

Hi, thanks so much for having me. I'm so excited to be here. Um, yeah, so I'm a registered dietitian. And I'm actually kind of specializing and plant based health. So like my practice that I work for, we see people from like, all walks of life, kind of feel like pregnancy through old age. And we kind of tried to intervene with plant based diets. So like, even if it's just people wanting to be healthy on a vegan or mostly plant based diet, or like someone who maybe was recently diagnosed with like diabetes or something, and they kind of want to treat it holistically before, you know before taking medication. So that's kind of my day job, I would say. And then I'm Yes, I'm working on my IBCLC. So I actually volunteer with an organization called the ZOE project. And doing my hours with them. They're a great like, nonprofit organization. They're kind of situated out of a clinic, where they, yeah, they help with everything from like mental health, substance abuse issues, alcohol abuse, abuse of husbands, just like wherever someone needs help on their pregnancy and like infancy journey they step in. So it's great to work with someone, or like an organization like that, where they kind of treat the mental health side as well. Because as we all know, breastfeeding is a very mental decision to us. Absolutely. Wow, you

 

Jacqueline Kincer  2:45  

have just so much wonderful, varied experience that all just gels really nicely together for ultimately helping with breastfeeding and beyond. So that's really amazing. Do you when you do your volunteer work there without and so we project? Are you doing the breastfeeding piece? Are you doing the diet piece as well? Or some other things?

 

Mia Smith  3:09  

Yeah, so what we do so it's kind of like a day hospital in conjunction with maternal and obstructed obstetrics unit. So like, low risk, women will give pregnancy or like won't get their pregnancy care. They're like antenatally. And then they give birth there. And then sometimes they're kept like postnatally. If it's like your, if it's a high risk, there'll be referred on to like, the more specialized hospitals. So what I kind of do is I give the dietary advice where it's needed, or I'll do like talk, kind of education talk and see if anything comes out of that. Like if there's someone who needs, you know, some extra help or whatever, after the talk, and then I kind of shadow a doula. So I'm like, part of the birth process. And then after that, I'll like go and kind of, there's a room where the moms are kept for 24 hours after giving birth. If they're like, something was a little bit complicated, and then for six hours, if it was just like a normal, uncomplicated pregnancy, then they stay for six hours for observation. And they are not allowed to leave until the baby latch as well. Because they are very, like, very breastfeeding, positive there. So that's nice. So I get a lot of experiences like that first kind of 48 hours and then that's also where some of the lower weight babies will come back for checkups. So they'll come like, Yeah, they'll come there and get like, checked out. explained about like the skin to skin position. And any warning signs that the mom needs to watch out for so babies that are like born maybe a little bit too early, and then I think they're seen until they are around two kilograms, which I'm not sure what that is in pounds. But yeah, like, there's kind of like a weight cut off where they, they're big enough, they're growing while they're gaining every week, then they were discharged.

 

Jacqueline Kincer  5:08  

Wow, that sounds like really amazing care that you're able to participate in there. And I just listening to you describe that I wish we had more of that happening in the US. So I know we were talking before the show, and this is how we even connected to have you come on was just that I always am able to bring the US perspective to things I talk about. But that's not the only place where breastfeeding happens. And you have this different perspective being where you are and working with these populations that you are with this organization to so breastfeeding is always something that's important and valuable. But specifically, where you are it that makes a bigger health impact when it goes well. And I'd love for you to talk a bit about that.

 

Mia Smith  5:57  

Yeah, so. So it kind of started it was like as dietitians we do this theory of breastfeeding. And because it is literally like, yeah, part of feeding. So we do kind of the nutrition for the mom and why it's optimal nutrition for the baby. And then because yeah, because I studied in Cape Town, they do put like the South African perspective on it. But like, that's all good to know and stuff. But what actually like kind of cemented it for me was when you qualify as any health professional in South Africa, you have to do a year of community service, which means that like you work at a government institution, so either clinic or hospital, and the government chooses where they send you. So I got sent to a really rural, it was a village, like in the middle of nowhere. Um, and it was in a different like province to the one that I'm living in now. So it was, it was like far away very, like sort of different than what I'm used to. Different language, everything different culture. So when I was there, it was because it was so rural, like, I was only used to like the urban side of things like I guess, Cape Town does have breastfeeding issues and all of that. But where I was in the village, it was like, it just kind of hit more home because they didn't have water for like, most of the day, their electricity was like also very spotty. So all of those things like led to kind of it made it really impossible to formula feed well. So yeah, like when I worked there, I was just kind of like, okay, breastfeeding can actually have such a big impact in these baby's lives. I saw so many, so many kids like come into the hospital with like, dehydration from diarrhea or just like malnutrition, kidney failure, liver failure. Because when like when the like struggled with the breastfeeding, the moms that often turn to formula because they were so like desperate to just get something in the baby. But it wasn't sustainable. So they could often like start, but it was too expensive to sustain like formula feeding giving them enough bottles, like per day. And then what would happen is like, the formula would get diluted. So they would either like do like one scoop per bottle, or like mix it with flour and mix it was cornmeal or something like that. So oftentimes will be like really early introduction of solids, because like cereal and stuff is cheaper than formula. So like giving the baby you know, from two weeks of age even like giving them porridge and stuff just to fill their stomachs. But, yeah, long term, it didn't always work out that great. So that's kind of where I was like, I need to learn more, so I can help more.

 

Jacqueline Kincer  8:59  

And were they were they turned out to be the formula because they just weren't able to maintain the milk production or was it more of an issue of actually getting the breastfeeding happened like the baby latching or I'm sure it was a confluence of factors, but just what what precipitated that start of the formula use.

 

Mia Smith  9:20  

I would it would be different. So a lot of the times the case was something like the mom was going to be the primary caregiver, but she maybe got a job in a town for a way left, the baby was the grandmother, the grandmother had very outdated knowledge and like didn't really know, you know, the How to formula feed Well, other times, it would be something like I think there's a really big lack of antenatal education because there is not enough staff. So like one nurse cannot one on one educate, you know, like 50 mothers a day which is like the numbers of the clinics are kind of seeing like it's it's and it's very high turnover. And then, like postnatally most of the time, the only thing that they really focus on was like warning signs like, seeing the baby, okay? They look fine. They're breathing, you know, blood sugar's one like out. So it's not like sitting there with the wall and asking her, like, show me how to latch house, like, how's it going? How many times do they feed? I would say the only time when that kind of intervention happened was when it was too late when like, the baby was in the hospital sick, because then like, there was more care like to be given like the moms would stay in hospital with the baby. And then we would try to fix the problem then, but it was, there isn't a lot of like, preventative care happening. And that, I think, is the major issue. And it's also just like a lack of education. Like, a lot of times, it just doesn't get like the message doesn't get to them like okay, yes, this is this, like, often it's just like, okay, breast is best, but no other information like, okay, it might be difficult, it's normal for the baby to feed every hour, every two hours in the beginning, that's cluster feeding, right? That's, that's helping your supplier to regulate. Like that kind of thing. I would say the one thing that, that the nurses and hospital staff are quite good at is teaching the moms how to hand Express. So like, often because electricity is such an issue, because money is an issue. Like, y'all no one there had an electric breast pump, not even the hospital did. So it was more like, Okay, this is how you hand Express and it works really well. Like, most of the moms could do it really well. And then it's like going over the storage guidelines, like how do you store this, if you have to go back to work when your baby's two weeks old? Like, you can't take them with you. So even if there are, you know, laws and things in place to say like, Okay, this is this is what we're gonna do you have to express it work and then send it to the caregiver, like all of those things, like a lot of time to logistics doesn't work out, huh, yeah, no, that's

 

Jacqueline Kincer  12:01  

so important. I, I'm glad to hear that hand expression is being taught in that it's going well, because obviously, that's essential. And I think it's something that is missed in the US quite often where here, I feel like moms are pretty primed to just get the breast pump that's covered by insurance, or every hospital will have them. And that just they, they just expect to use it and that it will work great. And they never learned that skill of hand expressions. So it's very essential there. And it's so interesting to hear just what's happening, you know, that, that these these families, the mom has to go back to work so much sooner, or leaving them with a caregiver that maybe doesn't know, you think you brought up a really good point that, you know, they might hear breast is best, but they're doing whatever they can to get food into the baby. And often it's the wrong foods.

 

Mia Smith  12:54  

So, you know, if

 

Jacqueline Kincer  12:57  

if formulas not as available, or it's too expensive, or whatnot. You know, we hear this phrase in the US a lot about fed as best, right? But what you're saying is no, it's no, you can't just feed the baby anything, you cannot just fill the belly, and how do you work with families to try to turn that around once that's already happened?

 

Mia Smith  13:20  

Well, it's, it's difficult. Like, when I was working in the hospital, I remember like, distinctly there was a baby who came in and a little baby was super dehydrated, super malnourished, hadn't really picked up his birth weight, he was like six weeks old. So he should have like, reached his birth weight again. And the mom had stopped breastfeeding. But again, so like, I think it was maybe two weeks into the month, she would run out of money. And then the formula would become like, literally just flour mixed with water. And that's what the baby would be fed. So like, kind of No, you know, nutrition in that. And I had to help her to like, re start the process of like, like lactation. So it was a lot of skin to skin and a lot of hand expressing now so like excited when she got like colostrum out I think she got a few like, drops out. And kind of so that was one of the things like we would always try to like re introduce lactation. Other times, we would just be a lot of education. So we would be you know, we would say like, there you know, there's other ways around this. So but most of the time, you don't know is that sticks because there isn't like a good follow up program. Like if they live far away from the hospital. It's not easy. It's not like affordable for them to come back for check ins and stuff. So yeah, I would say it was really it's really different, different by case by case kind of taking it and seeing what you can do. The one thing so that the government here does have a free formula program But it's very strict because they don't want to, like, promote or be seen to, like, kind of free formula just like, you know, as, as the moms wanted, it's more like, I think the criteria is something of along the lines of like, the mom literally cannot breastfeed. So one time we had a mom who had had a mastectomy. So she was eligible for the program, because she literally could not, it wasn't her choice, like she had had breast cancer, so she couldn't choose not, you know, and then other times, it's like, if it's a baby's going into foster care or something like that, then they would provide the formula. Or if the baby had been severe, had had severe acute malnutrition, which the W H O guidelines, like, that's what they use to define severe acute malnutrition. So if the baby suffered from that, then like, it kind of had to get to that point, but you don't want to get to that point before. Like, you know, regulations would step in and say like, okay, you know, here's the, here's what you can do. So,

 

Jacqueline Kincer  15:59  

yeah, I think it's definitely less strict here to get formula through the WIC program. It's sort of kind of a choice. You're just more financially incentivized if you don't get the formula. So that's so interesting that it's, it's harder there. It makes sense. I understand what they're trying to do. But what you're saying is, decisions at a policy level might sound great, but at the ground level and real life, what's happening,

 

Mia Smith  16:25  

looking out for people, so? Yeah.

 

Jacqueline Kincer  16:29  

And what you said about relaxation? That's, that's amazing that, you know, you've been doing that work, I would say that's something in in the US or Australia or Canada or UK, those are, those are things that happen very rarely here. So it's, it's nice to know that you are working with people to do that. And what, I guess my, what does this translate to in the end, you know, these, these are starting out with some really poor health outcomes for these babies do you have a higher infant mortality rate there then because of these feeding

 

Mia Smith  17:07  

issues, I don't think our infant mortality is higher, but it kind of translates into like, more readmissions to hospital and those kinds of things. So like a lot of diarrhea coming back or yacht, a lot of the times what happens is the baby would have diarrhea from like, in, like inappropriate formula feeding. And then traditional medicine is was still really like a big thing in the, especially the village where I worked, it's not so much in the urban areas, but where I worked, it was it was very like, so they would give carbs, or traditional medicines that would cause kidney or liver damage or failure. So then it would really become a problem. So even if like that, that was another thing that we kind of tried to do is like, Okay, if your baby does have diarrhea, please bring them to the clinic don't give anything not prescribed by a medical doctor, because you don't know the sex that it's going to have. And then oftentimes, like they would come come in, and then there would be signs of like, ingestion of some kind of her and they wouldn't always be known to like the medical staff what it was, and then that's another issue because how do you treat it if you don't know what the baby had. So that was it kind of like makes this whole big snowball effect, like, okay, so inappropriate formula speeding, leading to diarrhea, leading to like inappropriate medicine, and then only did they come to the hospital. You know, I've had a baby that came in with that case, and it was an older baby, she was around like one and a half. But she was in the hospital for months and months, because her system was just so like, destroyed, she had to go on to like TBI, and like be said, in, you know, into her arteries and veins. And like all of those things, she kind of couldn't even her sister system couldn't even handle like, any food. So getting her rehab, and that all came from diarrhea that came that was treated like with with traditional medicine. So that's kind of one of the effects. And then I think a lot of the effects are only really seen maybe in school, if there's issues with like, you know, cognitive issues, but it's not always, it's not so easy to say that that is why it's not like okay, you know, this tall is struggling school. It's because they were, you know, it's hard to retrospectively do those kinds of studies and things. So most of the time, it's kind of lost into the system, you don't really know what happens to the child like after you get them well enough to be discharged from hospital.

 

Jacqueline Kincer  19:42  

Yeah, that's really hard to not have consistent tracking or follow up and see what can be done to improve outcomes for sure. Since we've talked so much about it too, and I find that this is true all around the world. Most people really don't know what it takes to formula feed. See Obviously, where you are, it's much more of a problem. But virtually every family I work with is is not educated. Pediatricians don't even provide the education on how to formula feed baby safely. Now, most of the time, unless someone is is, you know, you know, out of severe low economic status, they're not diluting the formula or things like that. But I still have seen that sometimes people think, Oh, it's hot out and my baby needs more hydration. So they're going to do that. You've kind of talked about some of the effects of not formula feeding properly, but how how should families be using formula properly? I think that's really important that we talk about that.

 

Mia Smith  20:37  

Yeah, so what we do is, like, there's a kind of, sort of questionnaire but we use the asbestos criteria. So it stands for acceptable, feasible, affordable, sustainable and safe. So you kind of go through that with with the family. So like acceptable. Is this something like culturally to you? That's acceptable? Like, are you okay with formula feeding your baby? If you don't want to breastfeed? And then feasible? Like, is it actually possible? You have, you kind of have to get really personal, which can get awkward? Like, I've literally had to ask people like, do you have running water in your house? If not, where is your closest source of water? Do you have electricity to boil a kettle? Do you have, you know, like, a sink or something to wash it in? Like, do you have an appropriate ball? Yeah, so that gets a bit awkward, especially if it's my first time meeting, then having to ask that, and then affordable. So then that's another one. That's kind of awkward, because you have to be like, This is what the cheapest 10 A formula costs. Your baby will use this many 10s, the beginning, by one year of age, it'll be this many a month, can can you do that? And so, and then sustainable? So like, yes, you might opt to formula we now know that you like it's hard to, to go back to breastfeeding, if you find the formula isn't working. So can you sustain this at least the first year of this baby's life? Which is how long they need milk? Either breast or formula? And then say, so like, is it Young? Is it safe? Like how are you preparing the models? How are you preparing the milk? Sometimes it's even like going into Can you read English? Like the instructions on the on the 10? As an English? Is that a problem for you? Like, a lot of a lot of moms in these communities are actually they're from from other African countries. So like, Malawi, Zimbabwe, the Congo, and they kind of like Come here, you know, as not refugees, but as immigrants, and they don't have the same access to like, education that a South African citizen would have. So that's another thing like, can you read the 10 know how to increase the bottles as the baby grows? Like, all of those things? So I go through that criteria with them. And then it's like, that's all good, then only can you say like, okay, you've been cleared to formula feed, but like, yeah, who am I to have that kind of, you know, even if I approve or disapprove, it's not necessarily that they will listen to what I say. Right? Which fair enough, like everyone has a right to decide how to feed their baby. But it has things that you have to think about. Right? You're you're kind of

 

Jacqueline Kincer  23:22  

this this figure that's put into the mix, and there's some responsibility for you to provide the education, right, and whether or not they follow it, you know, you don't have control over that you have to do your best. So that's, that's really hard. You know, and you would mention to how, you know, oh, my goodness, the, you know, just mixing formula and water. Yes, it looks white and milky, but there's no nutrition in that, or very little, obviously. So normally, the guidelines for for breastfeeding and introducing complementary foods, exclusive breastfeeding to six months, then you can introduce complementary foods, which obviously need to be something nutritious and have good quality there. I'm sure you're probably trying to promote those same guidelines where you are, but you already know that that's not realistic. So when you're talking about introducing solid or complementary foods to families, what are the main education pieces that you're trying to get across to them? Are you trying to get them to wait to six months? Are you going well, it's probably not realistic, it's okay at four months, like or or they have less access to formula so they may need to introduce it sooner, like what what's that dynamic? Like?

 

Mia Smith  24:27  

No, we tried to just keep it at six months, we tried to like advocate for like, most of the time, even if it is formula feeding that like may not, you know, be going ideally, we just we still say like you know, you have to push it to at least six months. It doesn't doesn't really happen most of the time. I think like like I said, there's still a big a big thing of like, not not trusting like medical professionals so much and going to the community for Advice were like the granny or the auntie would would say like what they did. And then I'd be like, Okay, I'm gonna do that, because my Auntie has had six kids, they all turn out fine. I'm gonna listen to her versus like this random person I met at the clinic once, which makes sense, like, it's someone in your life that you know, is, is you're close to. So obviously, you're, that is kind of what happens. But as a medical, like professional, we still advocate for him for six months. And then we kind of really emphasize iron rich foods, because that is still like anemia is still a big problem. So we're like, start with iron rich foods with whether that's fortified infant cereal, or like, you know, traditional foods like maybe lover or whatever you like, have access to so sometimes it's it's fish or cultures or chicken or beans, lentils, like, that's kind of that's the basics that we do is like, just milk until six months, and then are enriched foods when you start and vegetables. So it is very, very basic information. And that's another gap, I think that will be really good to like just kind of cover is like how to actually properly start. Yeah, complimentary complementary foods.

 

Jacqueline Kincer  26:15  

Yeah, that makes sense. Just for my own curiosity, it's somehow entered my mind. Do you have issues where they're trying to feed just straight animal milks, like, from from goats or other animals to their babies? Or is that not so much an issue on time

 

Mia Smith  26:31  

sometimes, but like, cow's milk is still it's not expensive. But if you're very rural, you don't really have access to the shop with like, refrigerated cows will sometimes be online. And in South Africa, we do we have what's called the our nine on one document, which is like it was kind of adapted from the W H O is like, formula feeding standards or whatever. And it's like, kind of goes into, like, how you can market books. So all all milk looking things in South Africa have to say not suitable for infant feeding. So like coconut milk jars, or like tins would have that on or almond milk? Like, yeah, basically, anything that has the word milk associated with it will say that. Because yeah, I think, yeah, it has been an issue in the past.

 

Jacqueline Kincer  27:28  

Yeah, that's good. I've definitely had some clients who are very naturally minded, they may have their own farm animals, and they live Rowley, and they've asked me, Can I feed my baby goat's milk and pink? No whole? I mean, there are homemade formula restaurant. You know, you got to add other things into it. And that's the whole safety issue of its own. But yeah, I have I have been asked that question. And it sounds like maybe more to us than happening there. Which is, which is funny, but for anyone listening know, don't feed your baby straight animals milk until they're ready for that as a complimentary beverage or something. But yeah, that's, it's, it's so great to hear how different things are there. Because I think that we lose that perspective here in the US, when we have such easy access. I mean, I can go to the gas station down the street and go by formula. Like it's just so incredibly easy to access things or it's, it's easier here to get it for free. It sounds like from the government, and you can probably go on, you know, but there are cases where, there, there's some, there's some intersect of things for sure. But I know that, you know, you and I know from from your training and and whatnot that you know, not having good nutrition at the beginning of life can absolutely have this lifelong impact. And like you said, it's sometimes really hard to prove. I'd love to turn the conversation a bit to infectious disease. You mentioned diarrhea, which is obviously a huge issue. And of course, comes with more dangers there. Right? If they're not close to a hospital, and the baby's dehydrated, oh, my goodness, you know, where they're giving these, these herbs from, from the village person. And, you know, here that's, you know, most people are only going to have things at home that are over the counter relatively safe, sort of sort of things that they might give, they might go buy some Pedialyte, you know, that's, we're very, very, very privileged. Here, even people who are of low socioeconomic status are still generally going to have access to those things. So I you know, that coupled with HIV, which is obviously much more prominent there, what's, what's that like in that environment in terms of just with breastfeeding, because here, it's, it's still kind of a toss up in terms of like, if a mother is HIV positive, she can breastfeed. If she's on antiretroviral drugs and, you know, has, you know, meets this criteria in terms of, you know, some sort of lab work or something that's done, but most of the time that's encouraged that if the mother is HIV positive, she should just formula feed. But their formula is a huge issue. So how does that all shake out?

 

Mia Smith  30:18  

Yeah, so we, another government program that like is kind of in practice is called the Preventing mother to child transmission. So it's, um, it's like early identification, if someone is HIV positive, they like, they try to find that out as early as possible in pregnancy, sometimes more would even like know, going into a pregnancy and then it's really about like they get followed followed up more often, they get their ARV, so they have to take like, and they get their viral load tested. So it all goes like based on the viral load. And then during delivery, they take like kind of extra precautions, I think, like prolonged labor, as well as the risk factors, like premature rupture of membranes, those things so then, if they know that the mom is HIV positive, they're going to take extra precautions with that with the delivery, and then the baby gets tested at like different intervals after birth. So I think it's like right after birth, and then they wait like four weeks and six weeks to try to see. Like, if you know, it's, there's a window period in HIV where like the virus is you're infected, the virus is replicating, but it doesn't show up in your blood yet. So then they try to test the baby every few weeks until like certain Cuddles, I think is a click around three months to see like, Okay, this baby really wasn't infected so that they do all of that and all the time the babies on prophylactic medications. So they take the baby takes Irv, regardless of their like status, the mom takes her HRVs. And then exclusive breastfeeding is still advised, because formula has like much more dire consequences. And one of the really big issues is mixed feeding. So mixed feeding is like a big no. So that's what we tell the moms who have HIV. From the beginning, we say like, you can't do both. So you have to decide now and then you have to stick with it. And then again, going through the formula criteria are like, going through breastfeeding how to breastfeed and all of that. Because you're mixed feeding is like a big, big kind of like make you more prone. It basically messes with the permeability of the baby's stomach. And then it can allow the virus through that's in the breast milk because he has bread, like breast milk will have the HIV virus in it. It's not as I would say, like potent as like blood or something, you know, another bodily fluid. But yeah, so they kind of are really strict with that. And, like keeping the baby on prophylactics. And then what we kind of go through the mom does often breastfeed is we would like talk about thrush or cracked nipples or mastitis, like things that were blocked might come out of the breast, then we're like, okay, you need to hand express that side. And like this card that will only feed on one side, but express to keep up the supply on the other side, or what is also like popular, but this is like so hard to do. I don't even I don't think I've had any moms who actually do this, but like, they kind of pasteurize the breast milk. So yes, you're killing a lot of like the good, you know, the good things in the breast milk, but it's still better than formula milk. So you express and put it in like hot water, like put a container of hot water, and then you put the container of breast milk in. So it's like your, I don't know what you call that on this. You can make that on stuff too. But you basically like warm warm up and pasteurize it. So it kills the virus. And then again, like it does kill some of the immune cells and things. But yeah, that's kind of like what we do is breast, the breast feeding side. And we, like I said, Follow up often test the baby often. And then again, like the introduction of solids is really important to really delay that until six months until the baby's like stomach is more developed. So they can, can take can take the solids because solids and breast milk is like a form. It's mixed feeding technically, but when they're six months of age, it's fine. Right?

 

Jacqueline Kincer  34:18  

Yeah. Because the the guts more developed 10 and not as leaky so to speak. So yeah, it's safer for sure. That's yeah, I didn't even think about the the consideration for like cracked nipples or mastitis are something potentially introducing you know, blood or more virus. So that's, that's so fascinating. Are you seeing or do you know, if you're seeing good outcomes from HIV positive moms who are breastfeeding like that their babies aren't are doing okay and not getting the virus from the mother?

 

Mia Smith  34:48  

Yeah, that's why that's why it is like in practice, because there have been good results like it's been what they I think about like maybe 10 or 15. years ago, all HIV positive mums would just get formula like from the hospital, from the government, whatever. And that did not go well, because again, like the not so healthy feeding practices would lead to a lot of diarrhea, which then would actually lead to the baby like getting HIV because it would not, there would just be like a lot of mixed feeding and other things going wrong. So now they'd really turn and it's also the WH OHS like recommendations that you can breastfeed with, you know, with having HIV. But I think a lot of like, there's been a lot of campaigns to really educate people about HIV. So people are getting better at taking their medication, because the medication can work really well to the point where like, they don't even pick up the virus in the mom's blood. So it's like, that's suppressed. And if you have a viral load, that's like, I think it's lower than the detectable limit is what we call it, then. Then it's perfectly safe to breastfeed, and most of those moms do have good outcomes babies are, are like fine, the develop well, and actually think like in a kind of bit of a twist, because they have so much more support and follow ups, they might have better breastfeeding outcomes than a mom who doesn't have HIV, who doesn't come back to the clinics often. And like hear this message so often and have, you know, people who can help her? So yeah, that's kind of one of the benefits, I guess, if you can see it like that?

 

Jacqueline Kincer  36:26  

Well, that's good, because you're, you're breaking that energetic, intergenerational sort of health outcome, right. So it's, she's not passing this on, she's actually creating a better outcome for her baby than for her. So that's, that's wonderful. So long term, it's going to be a huge improvement for that population. Hopefully, hopefully, the it's great to hear that the medications are working. So while I've been hearing about that, and, you know, that, that it's, you know, we've needed that for so long. I mean, it's, it's interesting, I was listening to a podcast about you know, everything going on with SARS, cov. Two, and, you know, this almost resentment from researchers in the HIV field going we've been working with this for 40 years, and we still don't have a good vaccine, and you guys got one for this. It's sad, but I think because that the RVs, anti retroviral therapies are really good. It's, you know, that it's working well. So

 

Mia Smith  37:26  

yeah, they have like, improved a lot in the last few years even and, like, they got the kind of the cocktail of them, right, like which ones used together, which ones don't work. And that kind of thing. I will say, actually, what, like I kind of forgot to mention is, if it's the mum has had two kind of levels of anti retrovirals. And her viral load is so high, then she's also eligible for the like, free formula program. But she has to have like, failed to first line Aragvi treatments, and still have like, a high viral load in order to get to that, because sometimes, yes, like it is, I don't know, like, resistance in a way or she, you know, she has to, like be good at like, adhering to the program of taking her RVs.

 

Jacqueline Kincer  38:13  

Got it. That makes sense. So, yeah. I like that. There's a lot of screening happening, though, to make sure that yeah, they're going well, and that they're getting the care that they that they need. Yeah, it's so important. I'm also curious, too, because you mentioned at the beginning about just your role as as, as a registered dietician, and you talked about teaching about plant based diets and whatnot, going, you know, through working with women in pregnancy, and then, you know, after the birth, so, what are you recommending in terms of diet? You mentioned diabetes, too. We know that can impact lactation and breastfeeding. I'd love to hear more about the diet piece from you, too.

 

Mia Smith  38:56  

Okay. Yeah. So I think it's worth, like explaining that. In South Africa, there's obviously still a really big socio economic gap. So my, like community service here, and my kind of volunteer work is with one and the largest section of the population. But my like, dietitian, day job is in the private sector. Where, like, money is a lot less of an issue, if I can say more bluntly, so it is it my my recommendations definitely vary a lot by what kind of population I'm working with. And a lot of dietitians in South Africa, like they either go into into private practice, like working in private hospitals with private patients, or they stick with like the public sector. So I think like, it is a unique kind of perspective for me to be still working in both because in our training, we only do the public sector, we only get exposed to that because that's like where you're needed. And then I just I like to do a bit Have both because I think it's like, it's good to see both ends of the spectrum. But yes, I definitely, even in the public sector, I will advocate for like a plant heavy diet. So I think like 80% of the time eating whole, unprocessed plant foods is the best health outcomes outcomes that you're gonna get. So that doesn't mean you have to be vegan. But yes, definitely, like most of the time eating unprocessed and foods. And that looks differently, like I said, between the two populations. So, for example, like a lot of the traditional kind of African foods is like, you know, beans, and spinach, or corn and beans and that kind of thing. And that's like, yes, it's perfectly healthy. It's like, using people's cultural foods, to advocate for them to like, you know, eat more of that. Because, y'all, we, I think it's similar to the US here where there's a lot of processed foods, and it's, it's easily accessible. And it's not always It doesn't always have the best health outcomes. So even today, at the clinic, where I was, in the, like, kind of room where the moms wait to go home, there was like biscuits and chips and things being sold, like no fruits inside. So it's like kind of thing where, like, yes, for the middle class, those foods are easy to access. It's like on every corner, because they play last longer, and they're cheap. And it's like less prep work. So if you work like a 16 hour shifts, and you have to get home, you have to take public transport, like you're going to get home, you're not going to care what you eat. So being mindful of like what population I'm working with, definitely. But in both a lot of plants, basically. Yeah, yeah, it's

 

Jacqueline Kincer  41:45  

so important. You know, I, like you said, no matter what is going on what stage of life you're in, it is important that we get more of our nutrition from plants. And I know that there's been this big push in the US for keto. And people think that means like eating only meat or something like vegetables, and fruits, like they're still they're still keto, like, I don't know, I got I was getting my hair done. This weekend, and the two stylists were we're gonna order lunch from this Greek place. And the my stylist said that the his coworker was you know, she was doing the keto diet. And he asked her, you know, are you just are you just gonna get the chunks of meat again? And she said, Yes. And I'm like, but why couldn't you get? It's a great place. Could you not be getting like a Greek salad with that and having just like, some olive oil dressing, or, like, why are there no olives, cucumbers, lettuce, tomatoes, like, all of that could really be a part of it. And I just, you know, it's, it's just interesting to me, I think that I feel like, at least in the US, we eat way too much meat, you know, and, or eating your meal. It's not required. And I'm really glad you brought that up. Because all moms asked me all the time, you know, what kind of diet should I have? While I'm breastfeeding? You know, what foods should I include? What should I avoid? And I think that maybe I don't do as good of a job explaining the importance of plant based foods. I usually just try to say whole foods on processed foods, but I think it's really important we emphasize plants, you know, and so many of these plants are lactogenic So eating eating, eating grains, eating eating beans, eating dark green vegetables, you know, I'm you obviously have, you know, both sort of disciplines that you can draw from when you're giving this kind of advice. Those are wonderful for milk production.

 

Mia Smith  43:42  

Yeah, no, I do get people asking me like, What can I eat? And then I'm like, well, it's more just like eating enough Whole Foods because yes, you have really high calorie needs when you're breastfeeding. So you need to like up the up the intake, because people often will think like in pregnancy, you have to eat for two, you have to eat so much. But it's actually known as lactation where you have to eat a lot more like pregnancy. It's maybe like one snack in the second trimester and two snacks in the third trimester. Like it's really not a lot extra. But then when you're breastfeeding, you need to like yeah, really get enough in but it's the same here like the low carb thing is a big trend. And I don't know like if you know a lot of about South African culture, but like, all stages of life and socio economic everything here loves meat. So it's like, a big part of our culture to like, barbecue it or like you call it a bribe. And it's like a big thing to to y'all like, socially you have beats like with friends with family in the weekday, all the time. So it is hard to like get people here to just try to you know, I always tell them like start with one meal in the week like doing meat free Monday supper, not even the whole Monday. Just do like your dinner meet for and then go from there to up your plant intake because all the evidence points to like having, you know, less animal products in your diet as being the better kind of eating pattern to have. So, yeah,

 

Jacqueline Kincer  45:14  

I'm so glad you know, I'm so glad you're talking about this. I don't know if it's trickled its way down there to to some of the people who might have access to this. But here, there's this new thing called the carnivore diet. You heard about that? Yeah, I'm like, wait, we're only eating meat. And I remember watching a video a few years ago, maybe longer now of this guy who decided to eat only steaks. And he was, I don't know if it was a documentary or something. I remember it being a fairly long video that I watched at least, and him and his wife. And they were, you know, they went to the, you know, they worked out all the time. And they had these, you know, great bodies or whatever. But I've seen doctors here promoting that. And it really worries me, I had a family I worked with recently that the dad was doing the carnivore diet, and he seemed to kind of be pushing it on the breastfeeding mom. And yeah, I just, you know, maybe you could sort of reiterate why that's not a healthy diet.

 

Mia Smith  46:16  

Yeah, so basically, like, why it's popular here, at least, like the low carb kind of thing is because it does lead to weight loss. So yes, if you cut out a major group of your food, you are going to lose weight, which hopefully, this is not so much of a trend with, like breastfeeding mothers, because like, like I said, you have high calorie needs. And oftentimes, you know, you just you do burn through a lot of the pregnancy weight by breastfeeding, but just for the general population who, like always seem to want weight loss is a way to lose weight. And that's like, yes, like, like I said, you well, but it is generally quick, sorry, it's late, because you're creating a calorie deficit by cutting out a food. Yeah. Okay. Yeah, that's because you cut Oh, no, no, it's, it's, it's as simple as that, like, yes, you're eating less, so you're gonna lose weight. So that's the big thing. And then the other thing is like, you don't know what's happening on the inside. So I've had patients who've done this diet, and then they have like, sky high cholesterol, but yes, they have lost weight. So then they're like, I don't know why my doctor is concerned about my cholesterol or my heart health. And I'm like, Well, it's because you've had like, cholesterol and saturated fat as your main kind of nutrient for the past, however long. And then it's also just like, other like little basic things. Like, you know, fiber fiber is such an important part of our diet. And fiber is preventative like, you know, it prevents high blood pressure, it prevents high cholesterol and prevents certain kinds of cancers except, like, especially colorectal cancer, it's been proven to, like, be preventative, and it keeps you full and satisfied. So like cutting up a major part of like fiber out of your diets. And it's, yeah, it'll lead to like constipation, and all these other like health problems. So maybe, initially, yes, you'll feel good, because you've lost some weight. But then after a while, it's like, well, I'm constipated all the time, I feel like sluggish and slow down. And animal products are very pro inflammatory. So it kind of leads to like, you know, a lot of inflammation. And then I know that that can lead to issues, like with breastfeeding as well, or like, you know, kind of exacerbating autoimmune conditions and that kind of thing. So it's just like this whole cascade was like, yeah, why? Why more high fiber plant dense diets are better for you than than a meat, meat dense diet?

 

Jacqueline Kincer  48:44  

And on the flip side of that, what about a no meat diet? Do you see problems with that?

 

Mia Smith  48:51  

Um, I think that you need to, like plan well, you need to plant any diet. Well, that being said, so. I work with a lot of vegan patients, and they have no issues like they are some of the healthiest people I've seen. Even vegetarians, like who will still have some eggs or dairy. Like, I don't really see a problem with it, you do have to so I always tell my my patients like who are vegan or vegetarian, they have to check up on their B 12 levels and their iron levels. Were as you know, people who eat like an omnivore diet have to check their cholesterol or their blood pressure or whatever. So it's just like taking care of your health. But if it's well planned, like, there are great, you know, plant proteins that you can have every day with, with like, good health effects, like beans, lentils, soy, all of those things are very good for you. So I would rather opt for like a no meat diet versus a high meat diet. Because, yeah, it's definitely, I think, a healthier way to live. And there's a lot of research coming out now, like pointing to this because it ties into like the climate crisis and all of those things as well. So, yeah, like has far reaching benefits beyond just like your health? Yeah, absolutely. I think people don't like to label their diet. So it's not about putting a label on it. It's just about like, like I said, even if it's just doing one week, free day, it'll be good for you.

 

Jacqueline Kincer  50:18  

That's it. That's really good advice. Yeah. And I don't think that extremes of diets or adopting a sort of a brand name diet is is a good way to go. Because it's kind of like that criteria for formula you mentioned, it's not sustainable. And often, it's not even affordable. Why are we? Why are we giving ourselves these extreme diets? You know, it's one thing if you're an actor, and you need to lose weight for a role, but it's another trying to be a living a healthy life. Like, gosh, I just thought of a really cool question. And I lost it now. Oh, it's it's fun. It was obviously diet related. Oh, that's such a bummer. But I'm sure it'll come back to me. Yeah, what would you say? Oh, I know what it was, um, because you just see so much so much going on with with all these, you know, different populations, populations and different perspectives that you have? And

 

Mia Smith  51:16  

what is

 

Jacqueline Kincer  51:18  

I guess I should ask, Is it common for you to see issues of food intolerance or allergy? With what you're doing? And if you do, what can be done about it?

 

Mia Smith  51:28  

Yeah, so I would say like, in my more like my dietitian side of things I do, a lot of people turn to more plant based diets because of a certain issue. So a lot of them like, yes, they maybe watch the documentary or something like that they decide to go plant based. But some people it's like, Well, I've always struggled with like this condition. And like lactose seems to make it so much. Like it's so much worse when I have dairy. And then that would be like kind of the starting point and they like cut out that then cut out meat and like go from there. So I like especially in in my more like the public sector if I work there. One of the things that I kind of wish I could implement is like I see a lot of babies with eczema, especially in the light clinic like admitted with, you know, really bad severe eczema. And I wish that I could kind of use that like dairy free approach with them because dairy in, in either the baby's diet if they're like old enough to be eating, or the mom is breastfeeding, like, as a big factor in X amount. It's like, such a low risk intervention to like, Okay, cut out dairy. But it kind of has again, like, you know, goes into label reading so can doesn't want to have time to go to the shop read all the labels of other things can they afford, like Alan volver soy milk to like, replace the protein that would be lost with it cow's milk, like, you know, kind of going into all those things. So sometimes it definitely is a frustration if I can, like think of a way to, you know, to solve an intolerance or like a condition with with a dietary related thing, but I just know that it won't be feasible, like, going back to that criteria, kind of. But most of the time, it's it like the biggest one that I would say I see is dairy, there are some people who come through and then they're like, I think it might be gluten, um, but even just cutting out dairy, like, takes away a lot of those symptoms. So, yeah, I think that's the biggest

 

Jacqueline Kincer  53:30  

one. Yeah, that makes sense. It's definitely what I see here too. And I think it's still even hard to even though someone can read the labels and go to the shop, like you said, and pick something out. Sometimes the dairy is disguised, you know, in a word that they don't know me, it doesn't say milk, it says something else, right, or they sort of miss miss it. And you know, they eat the crackers or whatever in their babies, you know, it flares up again, or something. So it's, it's not easy, no matter really where you are. And then too, I find that sometimes people tend to be somewhat addicted to foods they're intolerant to and they're like, I can't without my cheese. And I'm like, Yeah, you know, you need to though, right? So it's, it's just not easy. I know, I was dairy free for a long time and kind of started with my babies who had issues and it took a long time for me to get really used to it and not even want like a little bit of a cheese on my salad or something like that. I got to a point where I thought oh, it's gross. I don't even want it. And now I do eat dairy again. But I'm also not breastfeeding and I think having a long several year break from it was was good for me. So I don't eat like a ton of but I don't want people to think oh, it's forever either. You know, I think sometimes that's that's kind of a killer. why people don't want to get rid of it and you know, they feel pressure. Yeah, yeah, it's hard and like you said it can be A great source of protein. And you mentioned soy, which I feel like soy in the US is like a bad word. Like it is a swear word. People are afraid of soy. But the more I learned about it, the more I learned that it's not anything to be afraid of, I'd love for you to chat about soy.

 

Mia Smith  55:18  

People. It is here. It is here as well, like, a lot of people who are really, really into like, research will ask me about soy, because it gets like this bad reputation because it has phyto estrogens. And then they say like, Oh, it is like estrogen and can cause like, feminizing characteristics and men or whatever. But there's no research or like evidence that proves that, like, definitively. So, I personally like love soy like tofu, and soy milk all, like all of that is great. It's a very good source of protein, especially if you're a plant based, it's a good source of calcium. And it's very low in saturated fat, no cholesterol. So like, I definitely advise my patients to have soy in their diet. And even is like, here, you get soy mints, which is like kind of dehydrated soy flakes that you can sow and use in like maybe like a bolognese sauce or something. And it's, yeah, it's quite a nice protein sources, but it's like cost effective. And so if you have to feed a big family, or if you just want some meat free days or whatever. So it definitely is something that you can safely include in your diet like, Yeah, I think the the bad reputation just really comes from the phyto estrogens. But it's actually been proven to be like protective, especially in women against certain kinds of cancers where they looked at, like, big studies of women in Asia who like, you know, they consume soy from the time that they were like little. So, yeah, there's there's actually been shown to have some benefits, not like detrimental effects. Hmm, yeah.

 

Jacqueline Kincer  56:56  

Thank you for clarifying that. No, I think I think there's a difference between soy based additives and processed foods and like actual soy foods, right. So sometimes I go, Oh, well, this has, you know, soy this in it or whatever. And I'm like, Well, yeah, but that's processed food. Like, it's obviously not good for you no matter what. Exactly. Tofu or, like one of my favorite things to get is miso soup, like oh, so delicious. You know, there's a lot of great alternatives. Like you said, the meet you. And I don't know, maybe you know, this, this is going to be me just going I don't know the answer to this. But there are some herbs that work really well for, you know, supporting and increasing milk production that are phyto estrogenic. Does soy help with that at all? Do you know of any research on that or evidence? Or have you seen it even just an experience that soy helps?

 

Mia Smith  57:48  

That's interesting. I haven't I haven't like seen any. Yeah, I haven't specifically seen any, the only one that I really like, like know of is is oats and basil soy, but I mean, like, that's the big one that I recommend. Because it's affordable and easy to find in shops. And when people do ask me I'm like, well, it's not like 100% proven it's more like anecdotal evidence, but it doesn't do you any harm to have oats in your diet. So just Yeah, it's yeah, no, I don't actually know it's soy be an interesting story. Because

 

Jacqueline Kincer  58:18  

now we're gonna don't anybody go out and just eat a ton of soy? We're just speculating. Yeah, it gives you protein and you know, health benefits. You know, I can't see it hurting supply. So yeah, yeah,

 

Mia Smith  58:32  

exactly. Um, that's a good it's a good research question, actually. Like, I'm not gonna go and do some research on that now.

 

Jacqueline Kincer  58:40  

Yeah. Any any professionals listening who want to research and like, you know, send send me an email or something. Let me know what you find or anything that would be really cool to hear. So yeah, yeah, absolutely. Or Yeah, someone wants to do a study? Well, gosh, I just, I love hearing about your experience, and how things are going in a different part of the world. And you're doing some incredible work that is helping so many people and will make a ripple effect, for sure to come. So I just want to say thank you, Mia, for everything that you're doing. And I look forward to you finally, getting your full IBCLC I think that'll be just really amazing for you because you do have this awesome international perspective, like you said, Is there anything else just final thoughts, anything that you want to share or impart or anything that you want to talk about before

 

Mia Smith  59:37  

we go? I'm not really like I said, it is like a big, big difference between the two sectors where I work so baby care, health care, prenatal antenatal all those things are like much different in our private sector, which probably like is another hour long of talking because it is just very different. So it's not like a question. The border that every single person in South Africa like, doesn't have running water or electricity, like, it is a big part of our population. But it's not everyone. And it's also like, it's different in other African countries. So Malawi, actually, is a much like socio economically poorer countries than South Africa. But they have great breastfeeding rates, because they advocate for it in their, like communities. And it's just like, accepted as the norm there. So it's not like every single Yeah, I think it's easy to kind of generalize, you know, Africa, they don't breastfeed, but it's actually like, you know, there's individual countries and cities and populations, and it's different for every single one of them. So I think that's also important to remember, like, I'm speaking from my perspective, and it's like, anecdotal, and it's, you know, it is a good chunk of our population, but it's not everyone. So, like, like I said, like the middle class and up, like, have very different healthcare experiences to like our public sector, basically.

 

Jacqueline Kincer  1:01:03  

That's such a good point. Very good point. I know that I've heard from i, we were chatting before this, my husband grew up and in South Africa as well, obviously, you know, grew up well off and whatnot. But there's a frustration from anybody who lives in any country or city in Africa that they're sort of lumped into being Africans. Like, there's always tribes, languages, and every country is different. South Africa is sometimes very different from other countries. And so it's really, really important that we remember that. And I think that, you know, it's, it's something that the rest of the world really needs to get on board with. And I love that you mentioned, you know, Malawi, and how different that is. And it's really cool that you that you know that that you get to experience that and share that with us. So it's just been wonderful to hear just what you have to share. And I hope that for everyone listening that they got something out of this. For me, I think a couple of things that are my takeaways are just, you know, how really important breastfeeding is for health. How important it is that we give support, and that education, you said, that's really such a huge issue is, is the education, the follow up the consistency with things? That sounds like funding and all of that as well. So it's just been really, really great to to hear this message and not just, you know, breast is best, and everyone should be like, that's not very helpful.

 

Mia Smith  1:02:33  

Yeah, exactly. And I think, yeah, like, thank you so much for your resource as well. Because like I said, it's so hard to find, like, supportive resources for doing your IBCLC. So it's so nice to have one that's like, you know, so comprehensive.

 

Jacqueline Kincer  1:02:49  

Oh, yeah, for sure. Yeah, it's, it's not easy. And I know that because it's an international certification in every country is different in terms of their access to testing. And they even have different fee schedules, depending on where you live. And I get questions all the time, even people in the US for like, so I've been on the website, but I still don't understand how to become an IBCLC. And it's, for anyone who is listening to this, who's considering it, there's a really good Facebook group called want to be an IBCLC. And I would recommend that you join that group because it's led by some IBCLCs. Who can, they helped me along my journey, and they can help you and just some of the nuanced things and get support as you're going through the process. And that is not just for people in the US, I'd be anywhere in the world. So if you're not a part of it, Mia, you should point to

 

Mia Smith  1:03:34  

Yeah, no, I did not before I started this whole process, because I was like, I don't website is like not very helpful in terms of like, how to actually do it. It's like, it's very good to tell you like what you're going to be, but I'm like, how do I actually get there? Yeah, yeah.

 

Jacqueline Kincer  1:03:49  

Yeah. Well, thank you for again for joining us, Mia. I appreciate it. Nia is very active on Instagram. I'll link that up in the show notes. If anybody wants to get in touch with her, I would highly recommend that you follow her? She shares some wonderful information, and I'll talk to you all on the next episode.