Breaking news: breast is still best….

….But hey, let’s sloppily analyze the benefits again to make our cause even more newsworthy.

I was traveling home to LA from Chicago this morning, and was therefore happily oblivious to the slew of articles that popped up today referencing a study entitled “The Burden of Suboptimal Breastfeeding in the United States“. Just as my flight was about to depart, I checked my Blackberry one last time and saw an email from a friend, linking me to And by the time I got home, there were numerous emails from many of you alerting me to the same study.

So, I got home, unpacked a bit, got FC down (a minor miracle considering he was totally hyped up from a long day of planes, buses and cars, which are his three most favorite things in the world), and got online to blog a little damage control. I’m happy that The Skeptical OB beat me to it – at least there was one common sense reaction to a study that was at best a misguided and sloppy attempt to improve support for breastfeeding.

In the study summary, authors Melissa Bartick and Arnold Reinhold explain their methodology:

 …We computed current costs and compared them to the projected costs if 80% and 90% of US families could comply with the recommendation to exclusively breastfeed for 6 months. Excluding type 2 diabetes (because of insufficient data), we conducted a cost analysis for all pediatric diseases for which the Agency for Healthcare Research and Quality reported risk ratios that favored breastfeeding: necrotizing enterocolitis, otitis media, gastroenteritis, hospitalization for lower respiratory tract infections, atopic dermatitis, sudden infant death syndrome, childhood asthma, childhood leukemia, type 1 diabetes mellitus, and childhood obesity. We used 2005 Centers for Disease Control and Prevention breastfeeding rates and 2007 dollars.

This basically means that they made some estimates about how many medical bills (and more importantly – especially to the scare-mongering media – young lives) could be saved if, by breastfeeding, we helped children avoid these diseases. But let’s think about this for a minute: this only holds relevance if you agree that there is actually a risk of these diseases due to formula feeding. For instance, if you believe that it is truly the act of breastfeeding that lowers a child’s risk of obesity, then yes, calculating the health/financial cost of that future formula-caused obesity would be a valuable economic/public policy tool. If you believe that. And we all know where I stand on that one.

As for the scarier soundbite – that 911 lives could be saved by breastfeeding – I will start off by quoting the words of a much smarter woman than I, The Skeptical OB:

Using highly fanciful methods, Bartick and Reinhold “estimate” that the US could save 900 infant lives and $13 billion if 90% of US women breastfed. These numbers are grossly misleading since not even a single US infant death (let alone 900 per year) has ever been attributed to not breastfeeding and since the purported savings are primarily the “lost wages” of the 900 dead infants.

Interesting, but I also want to point out something else. According to

Bartick and her co-author Arnold Reinhold found that most of the excess costs are due to premature deaths. Nearly all, 95 percent of these deaths, are attributed to three causes: sudden infant death syndrome (SIDS); necrotizing enterocolitis, seen primarily in preterm babies and in which the lining of the intestinal wall dies; and lower respiratory infections such as pneumonia…Breastfeeding has been shown to reduce the risk of all of these and seven other illnesses studied by the study authors.

If 95% of the deaths in question are because of these 3 diseases, I think we should look at each one a little closer. Necrotizing enterocolitis is, as the article states, a condition mostly relegated to preemies. Does this make it any less important or scary? Of course not. But it does change the playing field a bit. Breastfeeding may indeed be more important for premature babies, as multiple studies have shown; however, in most cases, these infants need to be fed through some sort of artificial feeding system (as very premature infants are often unable to nurse), which means they will be drinking expressed breastmilk (which is a whole different animal to a scientist or study author than breastmilk straight-from-the-tap); often women who give birth prematurely are not producing enough milk, and may have to rely on a milk bank… again, all important and worthwhile issues, but an entirely new can of worms, and quite wiggly, convoluted worms at that. I’m not sure how much relevance a reduced risk of necrotizing enterocolitis has to the majority of otherwise healthy, full-term babies in this country.

Next up – the biggie: SIDS. Yes, there have been several studies which associate breastfeeding with a reduced risk of SIDS. especially in the first few months of life. Whether or not this is due to lifestyle factors surrounding formula feeding/breastfeeding is not entirely clear, from what I understand… for example, breastfed babies are often waking more frequently to eat (at least that’s what the reports say. My kid never went more than 3 hours without a bottle at night until about 5 months of age); also, sleeping in the same room with an infant has been shown to reduce SIDS, and perhaps breastfeeding moms are more apt to do this since they can more easily just wake up and feed (as opposed to running downstairs to make a bottle and stubbing your toe in the process on the seventeen pairs of shoes your husband insists on leaving by the landing). But regardless, I can’t really argue the numbers on this one. I did find an interesting website called Orthodox SIDS Prevention, out of New Zealand, which brought to light some noteworthy theories. (Which incidentally seem to follow a similar line of thinking to my post a few days ago….)

Breastfeeding does not reduce the risk of SIDS, as the following statistics demonstrate: 

The breastfeeding rate in New Zealand has risen during recent decades and is very high by international standards (over 90% of newborns and 55% of babies aged six months). Yet up to 1995 the New Zealand SIDS rate was the highest in the world. 

In the United States, only 60% of newborns and 21% of babies aged six months are breastfed. Yet in 1996 the US SIDS rate (0.75 deaths per 1000 live births) was less than half the New Zealand rate (1.8/1000).

The United Kingdom has a low breastfeeding rate (66% of newborns, falling to 21% of babies aged six months), yet the United Kingdom SIDS rate is low (in 1999 only 0.57/1000). 

While breastfeeding is good practice for nutrition and various health reasons, it is not relevant to SIDS prevention. 

Lastly, we have respiratory infections like pneumonia. I still stand by my theory that the lowered risk of most contagious diseases in exclusively breastfed children is due to the fact that exclusively breastfed kids are, by default, not in daycare. Here’s a study that might back this completely naive theory up, if you’re interested.

It’s sort of silly that I even feel the need to go into these crazy defensive analyses, because when it comes down to it, we are making a big deal out of 911 “projected” deaths. I know that sounds heartless. We should want to prevent ALL infant deaths, obviously. But considering this is all conjecture – we do not know that breastfeeding will definitely protect those 911 kids from dying –  I think it needs to be said that there are more direct risk-benefit relationships that we can focus on. Like how about this one?

A new study appearing in the February 2009 issue of the American Journal of Public Health reports that securing small children and infants in the proper child car safety seats could save their lives. According to the study’s authors, use of child safety restraints dramatically lowers the chances that a child, three years of age or younger, will die in a serious traffic accident. 

The study found that the odds of a baby dying in an auto crash dropped by 75% with use of a child safety seat, while the mortality rate for older children dropped by 60%. These findings are important considering that motor vehicle crashes are the number one cause of accidental deaths among kids older than 1.

If we’re talking about the leading causes of death in infants, we should probably discuss “accidental injury” (including traffic accidents), which ranks #6, far above necrotizing enterocolitis. Why aren’t we asking the government for money to give to those parents whose financial hardships prevent them from buying the safest and best carseats? Maybe I’m just tunnel-visioned, but I really don’t see a fraction of the amount of focus, anger or passion directed at protecting kids from injury/death related to improper car seat use in traffic accidents, which is an undeniable risk to our children. Here is something that all parents CAN do for their kids, without feeling like it is taking a toll on their personal health, mental well-being, sense of self, job security, career track, or long-term financial stability.

I just don’t get it. I really, really don’t.

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.

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19 thoughts on “Breaking news: breast is still best….

  1. Here here. Thanks for taking that one on. I was livid after I read the CNN article.

    Here is my #1 major issue with these constant pro-breastfeeding news stories: Since when is fear a good promotion/advocacy method? Why does everyone feel the need to 'scare' mothers into breastfeeding? Support the mother, don't scare the mother. If if support means more mothers breastfeed- awesome. But if supporting the mother means herself and her child are better off with formula- awesome.

    Anyway- here here!!

  2. Yes, I saw this article in SFGate and you can only imagine all the anti-formula feeding mom comments on there. It was brutal. While breast milk is good for digestion and has a mother's antibodies, this is good to prevent some gastric and viral illnesses. HOWEVER, it completely missed the fact that preemies (who also have a high SIDS rate)and lifestyle changes are what really contribute to some of the statistics they throw out there. And well you know my standpoint on diabetes these days.

    The research should seem to point out how many more babies are alive because we now have formula or baby milk substitutes.

  3. Thanks for taking this one on. This article has really set me on edge. I've been told it's because I feel guilty because I formula feed but honestly I don't feel guilty. I know that I'm supposed to and all of the breastfeeding advocates assume that I must be racked with guilt and that I didn't breastfeed because I was ignorant or lacked support (oh poor me!). I firmly believe it was the best decision for me and my family. And guess what…I did have education and support.

    No this article ticks me off because it's so incredibly misleading and it serves no purpose. Moms who breastfeed will better about their decision to breastfeed. Moms who formula feed will either feel guilty about not breastfeeding but not be able to do anything about it or we'll dismiss it as hype.

  4. I'm frustrated by your response to this study. I truly believe that it's important to have a forum where formula feeders are supported and have a voice; however, how does constantly tearing down anything remotely related to pro-breastfeeding articles/studies/etc support your cause?

    Why do you consistently feel the need to “take on” any positive news about breastfeeding? This kind of study is a *good thing*, if you really do support breastfeeding. An economic analysis like this helps to define just how impactful 911 lives can be, financially speaking. (Not to mention that preserving life is certainly a noble thing in and of itself)

    Your critique of necrotizing enterocolitis is nonsensical — since it applies to preemies more so than full-term babies you feel it should be disregarded? Why? This kind of finding allows for exactly what you are advocating: targeted intervention. If it is the case that breastmilk is “more” important for preemies, then this allows us to focus intervention dollars on families of preemies.

    Likewise, you spend an entire paragraph attacking the relationship between SIDS and breastfeeding, only to finally comment, “I can't really argue the numbers.” Then why are you doing so? To summarize with a quote about rates of breastfeeding/SIDS in different countries is completely misleading. Ecological studies (which focus on population level characteristics as your source quotes) are widely regarded as a less-accurate/less stringent type of study, as compared to the case control and cohort studies upon which the economic analysis is based.

    Finally, your theory about pneumonia is hardly evidence-based. The article you link to is about children studied in Iraq; the generalizability of this study is very limited. Even if you ignore the fact that it's not generalizable to children in the states, the one sentence that I could possible see you using as a support specifically says,

    “Regarding the parents' occupation, there was a nonsignificant relative increase of RSV infection in children with working parents compared to children with unemployed parents.”

    The term “nonsignificant” means that this increase was not statistically significant (thereby not supporting your theory).

    The bottom line is, you purport to be a support for women, both breastfeeders and formula feeders. This kind of negative tearing down of positive studies is just as bad as the anti-formula breast feeding fanatics who voice so loudly on comment sections of articles.

    I'm disappointed.

  5. As far as why there is so much focus on increasing breastfeeding rates instead of the many other things that could improve the health of young ones, well, I hope you don't think this is incredibly perverse, but… breasts are sexy. They get everyone's attention. Did you know that breast cancer is not the leading cause of death in women in the US (not by a long shot, from what i understand). Heart disease is. (Also there, are several other forms of cancer that are much more deadly than breast cancer.) But still, year after year, there are breast cancer walks, fundraisers, etc. While, yes, I do think we should definitely work to obliterate breast cancer (it is a horrible, horrible disease), I find it interesting that we aren't doing more to prevent heart disease in women instead. Or the other, more prevalent and more deadly forms of cancer. It's late… hope this analogy makes some sense… All I mean to say is that we aren't good at putting our resources where they most need to be. We put them in things that get our attention.

  6. @Fingerpuppets:

    I'm sorry you are disappointed with my response.

    I don't think I ever said that necrotizing enterocolitis should be “disregarded”. In fact, my (relevant to your critique) words were, “Does this make it any less important or scary? Of course not. But it does change the playing field a bit…I'm not sure how much relevance a reduced risk of necrotizing enterocolitis has to the majority of otherwise healthy, full-term babies in this country.” My point was that while this is certainly a worthwhile finding (albeit one that has been discussed before in several other studies concerning the benefits of breastmilk for premature infants), I felt it was misleading for the purposes of THIS study.

    That last sentence – misleading for the purposes of this study – is kind of the point altogether. How is is ever good to scare women into breastfeeding? Considering that there is nothing new in these findings- just a restatement of old facts and some theoretical numbers based on these old facts – I don't think it deserved the attention it received. And I'm sorry, but this DOES hurt formula feeding women, and those are the women I try to protect. I SUPPORT breastfeeding women, but they have other people who PROTECT them far better than I obviously could; I'm here for the formula or combo feeders. Nearly every headline I saw yesterday alluding to this study had some form of “formula feeding harms babies and costs the country money”. To me, that does not support your assertion that studies like these are a “good thing”. They are dangerous and misleading in my opinion, and grossly overstating and misrepresenting facts.

    As for the SIDS section – I meant that I – as in myself, a non-statistician, non-medical professional- could not argue the numbers, due to my lack of knowledge in this area. Not “I can't argue the numbers” in the colloquial sense. Admittedly poor writing.

    Lastly, the reason I linked to that Iragi study was that they 1. made a point to say that breastfeeding did not confer any statistically significant benefit in the case of certain respiratory infections and 2. cited the fact that childcare might have had an impact. I agree that it was just one mere sentence and not “statistically significant”; however, the amount of pro-breastfeeding interpretation of equally non-generalizable (ahem, Belarus) and just-over-the-line-of-statistically-significant studies boggles the mind. So hey, if it's fair for everyone else… yes, maybe I should hold myself to a higher standard, but it's hard to fight fire with fairy dust.

    Regardless, I am truly saddened that you feel I am tearing down anything remotely pro-breastfeeding on a regular basis. I do tend to get ornery about these studies. It comes down to my core belief on the subject – that formula feeding is not a public health threat, and I'm sick of seeing it perceived as such. If this study were showing how breastfeeding could just save money, I'd ignore it. But reading a million and one Tweets about the “911 formula-caused deaths” by “reputable” breastfeeding advocates makes me think that these types of studies are dangerous and misguided.

    So, I guess you could say I'm disappointed too. I'm disappointed that people are tearing down someone as smart, brave and ethical as Rebecca Goldin for speaking up against the study. I'm disappointed that no one has brought up the blatant bias of the study's lead author, who is the chair of the Massachusetts Breastfeeding Coalition. I'm disappointed that a new generation of mothers will be made to feel even more pressured and guilty about their failure to breastfeed or their very personal decision to formula feed.

    Yeah, I'm disappointed too.

  7. @FFF

    I have a lot floating around in my head – and I hope this response doesn’t turn out to be too horribly long and unmanageable. I’ll split my comment in two sections for clarity’s sake. A few point by point comments:

    The reason why this kind of study is good is because it puts a new perspective on benefits of breastfeeding. By taking “old facts” from multiple places and synthesizing it in a new way, it allows people to estimate the significance of the impact of low rates of breastfeeding in different ways. As I've mentioned before, this can allow for targeted intervention. Especially with the current administration, proposed interventions must show a basis in evidence.

    You're right, I was too liberal with my words when I said you implied that necrotizing enterocolitis should be disregarded, but I absolutely disagree with your assertion that it is misleading for this study. This study isn't about breastfeeding and full-term infants, it's about breastfeeding and all infants. Including preemies.

    I did misread your SIDS paragraph; I wasn't try to critique your writing (I like your writing). I stand by my point about ecological vs. other types of studies.

    I do think that it's unreasonable for you to grasp for straws (such as the non-significant finding in the Iraq study), when it's the very thing you critique. It's not about being fair, it's about using evidence-based facts (and I mean that for EVERYONE, not just you).

    Unfortunately, not-breastfeeding absolutely can be a public health threat, even in the United States. The evidence shows that while the effects may be small, there *are* protective effects to breastfeeding. Feel what you may about the significance of those effects, but they have been demonstrated over and over (in more generalizable studies than the Belarus study). That doesn't mean that formula feeding should be vilified, at all. In the US it's a completely acceptable alternative, and in fact I'm sure has saved lives. I know my son would not have been able to get enough nutrition to start without it.

    But what about in countries where there isn't clean water? What about the thousands of children who die world-wide because their families thought that formula feeding was just as good and/or better than breastfeeding? It's much faster and cheaper to educate women about breastfeeding than to clean the world's water. (Which is not to say that we shouldn’t *also* work on the issue of clean water, so that eventually women in developing nations will have a more balanced choice as well). What about in impoverished situations (happens in the US, also) where uneducated women thin out formula to make it last?

    In US/developed nations we are fortunately to have clean water and a perfectly acceptable alternative. So let's encourage (as you generally seem to believe) open support of women's choices, regardless of what they choose. Let's support targeted intervention which can provide enough information to women so they *can* make an educated choice. Let's encourage open communication and support of each other.

    This brings me to my more general comments…

  8. The more general comments…

    I think my frustration with your “equally militant” approach to protecting formula feeders (again, I’m not saying that you shouldn’t protect all feeders – my issue is with the militant approach described in your 10-9-09 post), is that it supports the false dichotomy promoted by those bf fanatics you fight against. And I suppose this boils down to a difference in opinion as to what approach is most effective…

    It's my perspective that it's more meaningful to try to break down that false dichotomy of either/or. Let's educate women not just about the benefits of breastfeeding, but about how to formula feed correctly so that women *don't* thin out the formula because they don't know better. Why can't we support both options, and research about both options?

    And yes, let's read studies critically — because god knows that people mis-interpret results. It is important to note peoples' biases, you're absolutely right — but it's also important to acknowledge that the publication process is generally stringent in well-respected peer reviewed journals. If you want to honestly critique the researchers methodology – then go for it — but not by using “fairy dust.” I'd love to see a thorough critique that wasn't just framed around your anger at how the media presented it. Realize how much the headlines and news articles are influencing your opinion of the study. Criticize the news sources who focus on “sexy” aspects of the study (to quote a pp).

    I read the article on CNN a few days ago, and immediately thought of you — I was hoping that you provide a fair, balanced critique. I think what you do is important…

    …which is why I was disappointed.

  9. I believe the problem some of us on here have with this article is the wording in itself. I doubt FFF and other people in this group have a problem with pro-breastfeeding articles, it's when the articles start to insinuate that ffing moms are a burden to our health care cost and using terms like “saving young lives”. The title reads “The Burden of Suboptimal Breastfeeding in the United States”, now wouldn't it have just been as appropriate to say the “The Effects of Suboptimal Breastfeeding in the United States”? Right from the beginning the reader has to see negative words like “burden” and when this article got tossed around through all the news sites it generated a lot of negative comments about formula feeding mothers and got people so wound up as to say breastfeeding should be mandatory and what not. I think that breastfeeding needs to be supported and positive things should be published about it, but it can be done without the alarmist quality the author and like many others in the past have projected to the reader.

  10. Well put, Michelle K! I have no problem with trying to detail the benefits of breastfeeding, or supporting breastfeeding. I actually think most areas of the country still have atrocious breastfeeding support (my own area included). However, I take issue with anything that seeks to promote breastfeeding by scaring people and I don't agree with anything that displays formula feeders as public menaces. My daughter is beautiful, healthy and very smart. I'm far enough removed from the new baby thing to not get too upset by the breast vs bottle stuff, but these types of negative articles can throw a new mom who couldn't make breastfeeding work out very depressed. We should be supporting all mothers, regardless of how they feed their children!

  11. First of all, @fingerpuppet , I just need to say that I totally disagree with your comment that FFF is militant or doesn't support both options.

    Secondly, I totally agree with Michelle and Fifi that the issue is Breastfeeding should not be promoted by scaring Mom's into fearing formula. Breastfeeding needs to be promoted by looking at how better to support Mom's.

    Can I just say that I really think that by presenting formula feeding a serious public health risk, this puts additional stress on a new Mom that the stakes for not succeeding in breastfeeding are super high. And stress is not a good thing when you are trying to breastfeed. Perhaps less focus on the risks of formula feeding would allow Mom's to relax and focus on trying to make breastfeeding successful, rather then fearing the alternative. Just a thought.

  12. i saw this when it hit CNN here:

    There's a very strange statemtn halfway through:
    “Researchers also included the direct costs of health care and parent's time missed from work.”

    At which i pause and say, HANG ON… Are we including the costs of parent's missed time from work if they're 100% breastfeeding, cos that's gotta be an order of magnitude more than the missed work from looking after a baby who is home from daycare because of the common cold.

  13. btw: some anecdata to go with the New Zealand statistics. Our daughter is about 80% breastfeed. Through the last 3 encounters when the places recording these statistic they consistently recorded her as 100% BF. The first 2 times without asking, the 3rd time dispite my husband making a point that she isn't.. It was only on the 4th encounter that he insisted it was corrected.

    Hence, throw some doubt in with the NZ stats. They're very very forceful with the Breast Is Best message, and it is near impossible to get help or support with pumping let alone formula within NZ's otherwise very comprehensive and supportive system for parents and children.

  14. @Kathleen – I quoted FFF's own words when I used the term “militant” — and I said multiple times that I understand that she says she supports both sides, but that her tearing down these studies doesn't indicate that to me.

    More generally – I completely agree with you and the other posters that it's better to promote breastfeeding with support of moms, than with fear.

    My point is, it is much more difficult to get federal funding to support such programs without have studies to provide evidence that there is a *reason* to support breastfeeding moms. If there are no benefits to breastfeeding, then why support moms? Why not tell them not to bother and hand them some formula?

    Plus if we can pinpoint for which target groups it makes the most difference, then we know where we can target interventions.

    There *are* differences, and it should be up to each woman to make her own educated choice. And there should be support of all legitimate feeding options (ie., breastfeeding, formula, and/or mixed feeding).

  15. Excellent point, Brenda.

    I also suppose they didn't include the cost of lost productivity that must inevitably occur when mothers spend a good part of their day at work pumping. That's got to cost something. Or aren't we supposed to notice?

  16. Has everyone read the Skeptical OB's post about this study, it was also very good. Thank you FFF for supporting all of us Mommas who have made careful, tough decisions about feeding our babies in the way that works best for our families (no matter what that decision turned out to be)!

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