“Breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice.”
Thus begins the newest statement from the American Academy of Pediatrics regarding infant feeding. And consequently, thus begins the newest battle for FFFs anyone who cares about the freedom of women to choose how they feed their babies, and how they use their bodies.
The ghosts of statements past
It may seem like an overreaction, but the choice of words in this “official statement” from the preeminent child health organization of the United States, is deeply disturbing to me. To explain why, I think it may be helpful to look at the AAP’s past statements regarding breastfeeding, over the last 15 years.
Back in 1997,the AAP concluded its position paper on breastfeeding by stating that “Although economic, cultural, and political pressures often confound decisions about infant feeding, the AAP firmly adheres to the position that breastfeeding ensures the best possible health as well as the best developmental and psychosocial outcomes for the infant. Enthusiastic support and involvement of pediatricians in the promotion and practice of breastfeeding is essential to the achievement of optimal infant and child health, growth, and development.” This reads like a strong suggestion to breastfeed; a plea for pediatricians to support breastfeeding but at the same time acknowledging that sometimes there are complications which make the “preferred” choice a difficult one to carry out.
By 2005, an updated statement was released. This statement was relatively similar to the 1997 one, but contained some updated information (including an advisory statement about Vitamin D supplements in breastfed infants). The concluding statement was the same as that in the 1997 document.
Now, in 2012, we are presented with a document that’s opening paragraph puts the kibosh on personal autonomy for mothers. There is no longer any acknowledgment – however cursory – of external factors which might complicate the decision to breastfeed; the section on contraindications is worded in a way which suggests that even meth-addicted women are better off breastfeeding; and pediatricians are encouraged that their “role in advocating and supporting proper breastfeeding practices is essential and vital for the achievement of this preferred public health goal.” The concluding paragraph is in stark contrast to that of prior statements:
Research and practice in the 5 years since publication of the last AAP policy statement have reinforced the conclusion that breastfeeding and the use of human milk confer unique nutritional and nonnutritional benefits to the infant and the mother and, in turn, optimize infant, child, and adult health as well as child growth and development. Recently, published evidence-based studies have confirmed and quantitated the risks of not breastfeeding. Thus, infant feeding should not be considered as
a lifestyle choice but rather as a basic health issue. As such, the pediatrician’s role in advocating and supporting proper breastfeeding practices is essential and vital for the achievement of this preferred public health goal.
I am woman, hear me roar (unless it keeps me from breastfeeding, in which case I should shut up)
In this statement, pediatricians are called upon to visit an AAP website which will “provides a wealth of breastfeeding-related material and resources to assist and support pediatricians in their critical role as advocates of infant well-being.”
Labeling the intended audience of this paper as “advocates of infant well-being” is exactly right: pediatricians are advocates of infant well-being, not maternal well-being. Within a section on “maternal benefits” to breastfeeding, the authors claim that “a large prospective study on child abuse and neglect perpetuated by mothers found, after correcting for potential confounders, that the rate of abuse/neglect was significantly increased for mothers who did not breastfeed as opposed to those who did.” This study was the one we discussed here; if you go back and read that post, you’ll realize that this study did NOT control for the most important (and in my opinion, most obvious) confounder, which was that women who are most likely to be neglectful or abusive will not choose to breastfeed in the first place. This study was one of the weakest, most ridiculous pieces of drivel that I’ve read in the entire body of breastfeeding science, and that’s saying a lot. The fact that the AAP would stoop so low to add this to their official breastfeeding statement speaks volumes, in my opinion. (Although considering they later allude to the infamous Bartick study as an “evidence-based stud(y)” which has “confirmed and quantitated the risks of not breastfeeding”, I guess I shouldn’t be too surprised.) Insult is added to injury by their brief discussion of postpartum depression (“Prospective cohort studies have noted an increase in postpartum depression in mothers who do not breastfeed or who wean early…”).
It is one thing for pediatricians to write a strongly worded statement about the benefits of human milk to babies. If we’re going to talk about maternal benefits, I’d like to hear about that from a cancer specialist, a psychiatrist or clinical psychologist who specializes in maternal mental health, and maybe an OBGYN. Not my child’s pediatrician, who hasn’t focused on adult vaginas or brains since they graduated from medical school. “But FFF”, you’re probably saying, “it’s for the children! The children!!” Yes, it may well be. But if we’re going to discuss subjugating the needs of the mother for the needs of the child, then we are getting ourselves into a very controversial area, and one which I don’t think the AAP has the right – or the depth of knowledge – to tackle. And regardless of where you may personally stand on that issue, I fear that if we go down this path, it’s a short trek over to another road where they start sterilizing women over 40 because they have a higher risk of birth defects, or making certain reproductive technologies illegal because they aren’t the “normative standard” of how we are supposed to reproduce. Melodramatic? I sure hope so, but I don’t think it’s that far a stretch.
Here’s what I find interesting: the authors state that they are releasing this updated statement because “(r)ecently published research and systematic reviews have reinforced the conclusion that breastfeeding and human milk are the reference normative standards for infant feeding and nutrition. The current statement updates the evidence for this conclusion…” And yet, the main source of data is the AHRQ Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, which is also the basis for the recent Surgeon General statement on breastfeeding. This document is actually a really good read, as nearly every benefit they cite is capped with a strong warning not to get over-excited over the findings as they are bogged down by study limitations, confounding factors, etc. If you haven’t read it, I strongly suggest that you do – it will make you feel a hell of a lot better about the foreboding statements made by our government and the AAP.
If you look at the references at the bottom of the newest AAP breastfeeding statement, you’ll see that quite a few of the cited studies are indeed from after 2005, when the last AAP statement was released. In that sense, a new statement is justified. But what do these studies really tell us that the older ones haven’t? None of the “rules” have changed; it’s more of the same type of evidence, which suggests a slight benefit after adjusting for confounders (which are usually not appropriately comprehensive). As usual, I feel I must state for the record that I am in NO WAY suggesting that these findings are fundamentally incorrect – I’m only trying to remind everyone that the methods used to obtain this data are inherently flawed. Breastfeeding may indeed be so far superior to formula that it makes breastfeeding look like Lindsay Lohan circa-Parent Trap, and formula feeding resemble post-jail Lohan. But so far, the body of evidence looks more like a comparison between chubby Renee Zellwegger and skinny Renee Zellweger. The body might be a bit different, but the face is cute regardless. (And hell, she won an Oscar for the film she did when she was chubby.)
Now, there have been some studies published since 2005 that would have been interesting to include – like this one, which argues that breastfeeding problems are strongly linked to PPD, which may explain away the data that they are using to promote breastfeeding as a maternal mental health advantage. Or how about this one, which counters the claim that breastfed children are smarter than their peers. Or this one, this one, or this one, which found that breastfeeding has no correlation with future obesity risk? But no. The AAP cherry-picks the studies which support its ideologies, and ignores the ones which might offer some truly new insight. Now, whether or not we like to admit it, here on the interwebz and in scholarly debates, we all cherry-pick to some degree. (In fact, one could argue that I just did it now, by purposely finding 5 studies which supported my argument.) This is because we take sides; we fall victim to confirmation bias; or sometimes, we just don’t do our homework. But a major medical organization should be bipartisan. A major medical organization should be honest about the evidence, especially when there are conflicting studies. A major medical organization should not be cherry-picking.
The really nasty elephant in the room (or better yet, elephantitis, maybe of the testicles. It’s that disturbing.)
And lastly…Let’s pretend, for the sake of argument, that formula is so risky that it is a true health threat to our nation, and meriting this dramatic sort of action on the part of the government and the AAP. Then why the heck doesn’t anyone try to improve formula? We live in a time where we can clone sheep and create human life in a test tube – we really can’t come up with an adequate substitute for human milk? Why shouldn’t women have the ability to overcome their biology if they so desire? Whatever science has to say about modern infant formula as a product, the fact remains that sociology may see it in a different light. Formula feeding does allow a woman to choose to return to work immediately and allow a partner or caregiver – god forbid, even a male one – to care for her infant. Whether we agree or disagree with her choice, it is, and should remain, her right. If we are going to argue that not breastfeeding is as risky as other health concerns like smoking or drinking and driving, then why aren’t we rioting in the streets demanding better?
I don’t believe that the situation with formula is that dire; not be a long shot. I happen to think that formula does a pretty bang-up job of nourishing kids, and that loving, nurturing formula feeding parents do amazingly well at providing the “nonnutritive” advantages despite their lack of lactation. But I’m starting to realize that there is a hideous punchline to this debate: if people think that formula is so awful, why is the only solution to breastfeed exclusively? I believe that for most, breastfeeding would end up being the preferred way to go if all things were equal. Social inequities aside, however – there are women out there who may just not want to breastfeed. Just like there are women out there who don’t want to have a hospital birth. Or women who want to be single mothers by choice. Or pick any other choice which falls outside the “norm” or may not be accepted as kosher by mainstream society.
So, AAP, here’s what I have to say about your “amended statement”: please realize that by “advocating for children” in this manner, you are putting mothers – and fathers, for that matter – in a really stressful situation. You are doing so based on research which is no in many ways no better than it was 5, 10, or even 20 years ago. And you are certainly not helping children by aiding a system which is trying to take away a choice from their parents, a choice which has the ability to solve medical, marital, employment, and financial problems, thus making them better parents in the long term.
FAIL. Try again, please.