WTF, AAP? The problem with the American Academy of Pediatrics’ newest statement on breastfeeding

“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.

Redundant Redundancy

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.


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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31 thoughts on “WTF, AAP? The problem with the American Academy of Pediatrics’ newest statement on breastfeeding

  1. It is amazing how there are so many assaults on the choices of women going on right now. The whole birth control debate and now this. Society is so much better when women are able to choose how and when they have kids and how the child is fed. It frustrates me that people are attacking us for the choices that our foremothers dreamed about. I will fight tooth and nail to keep these choices freely available for my baby girl.

    • Get over yourself no one is forcing you to breast feed. Of course they would encourage something natural over unnatural. It’s angry, lonely, miserable, man hating, abortion loving feminist like yourself that are ruining the world.

  2. This is pretty much what I thought when I read the new statement. Who doesn't get the message that BFing is the preferred method of feeding? If there is such a group, than the “education” (propaganda) should be aimed at them. And after a given woman understands that BFing is preferred, it's still her choice and no one can say she is “uneducated.”

    Also–public health. How does BFing affect public health? (not snarky, I really want to know.) Or maybe a better question is: what, about formula, do lactivists think is a public health risk?

  3. There is in fact lots of research into better formula — for instance on the prebiotic/probiotic immune system benefits. Too many breastfeeding advocates actually complain about these improvements to formula, because they want people to breastfeed. It is the natural, wonderful thing to do, and there is an assumption that technology could not be better than what nature “designed.”

  4. I very much agree with you. As a mother who exclusively formula-fed one baby and exclusively breastfed her second, I get really nervous about this option slowly being taken away. It saved our lives!

    However, I guess the silver lining in all this is maternity ward nurses and pediatricians will now default to supporting breastfeeding. It is frustrating when nurses offer to give your baby formula in the hospital when you truly want to give breastfeeding a good go first. Hopefully this new statement will at least force them to reconsider this outmoded method.

  5. This is what I really don't understand. The US is a first world country. Formula is just as safe as breastfeeding. In some cases, if mom is on RA or chemo or MS drugs MORE safe than mom's milk. The issue with formula in 3rd world countries is not the formula, its the water supply.

    As a breastfeeder, I honestly definitely support improvements to formula BECAUSE well, if breastmilk is the “optimum” nutrition (i'm not saying it is or isn't, but it was for US) , why not give moms who don't have the option of breastfeeding the chance to give the kid as close as possible? I really don't understand why breastfeeding advocates would be against improvements in formula, it really honestly does not make any sense. A lot of women do not feel comfortable with donor milk so why not make the most socially acceptable, most easily acquired infant feeding method as good as it can possibly be?

  6. I want to feel optimistic about this AAP statement, because I think there are good things that can come out of it. I think it can provide some much-needed pressure on pediatricians and their staff to help moms who want to breastfeed and are struggling rather than simply telling them to switch to formula. Hopefully it will remind pediatricians that for many parents, the decision to breastfeed or formula feed is not “just” a choice like what shirt to wear today or whether to get the turkey sandwich or the chili at lunch. It is a carefully thought out decision with a variety of factors involved. Hopefully it will also help them gently encourage those moms who have misconceptions about infant feeding to give breastfeeding a try if they want to rather than perpetuating misinformation through silence. Hopefully it will help to increase the availability of low-cost, screened human milk for babies who aren't sick or premature (for those of us who might be able to fully breastfeed ourselves but also don't want to use informal milk sharing networks). Hopefully it won't just turn into an officially sanctioned shame-fest for moms who don't breastfeed for whatever reason.

    What I would like to see in the statement is something that encourages pediatricians to coordinate care with an IBCLC (maybe have one on-staff in the pediatrician's office) and the mom's OB/GYN or midwife and other health care providers to do a comprehensive job of addressing underlying causes of breastfeeding problems. If breastfeeding is a “public health issue and not just a lifestyle choice” then health problems that affect breastfeeding should be treated as such. What good does it do to convince mom to breastfeed and then not try to figure out why her supply isn't adequate or why her baby isn't latching properly or why her nipples are split open and bleeding? Also, this statement should encourage pediatricians to know what resources are available in the community (LLL meetings, WIC programs, etc.). Because again it doesn't do anyone any good to get a mom all convinced to breastfeed, help her overcome a bad latch, and then have her find out that there's nowhere she can get/rent an affordable pump when it comes time to go back to work.

  7. Very well said – I really wish that LCs, for one, were covered by insurance. If BFing is public health priority, shouldn't they be? (more so than effing Viagra?)

  8. As you have pointed out, there are SO MANY ways in which they could have done this to have a hugely positive impact on breastfeeding moms as well as bottle-feeding moms. We don't need another “breast is best” bashfest on formula parents. We need SPECIFICS. We need people to figure out the HOW and the WHY and not just pile on emotional torment on top of an already emotional time. If the AAP really wants more kids to be breastfed, why not focus on SPECIFIC things pediatricians' offices can do to encourage it?

    Instead of issuing a statement every so often, it'd be so much more helpful for the AAP to make more frequent, targeted statements on what pediatricians can be doing–things like what Jennifer said–to make it really happen, instead of making people feel forced to make it happen and then devastated when it doesn't.

    Our pediatrician is a very practical person. When I told her why we were on formula, she said hey, breastfeeding is not going to work for everyone, that's fine. She said there's the ideal, and then there's the reality. A lot of times, they don't match. She has a basket of coupons on her desk for formula, nursing pads, bottles, baby painkillers, lotions, vitamins, etc. Her wall has flyers for the local LLL group and another local breastfeeding support group. She has breastfeeding “how to” pamphlets sitting out, and formula samples if you need them. I've seen her receptionist give referrals to lactation consultants to other patients. She also uses a combination of remedies: natural ones as well as things like painkillers and antibiotics. I love this doc because there's no bashing of any form of medicine or infant feeding, just a simple “what works best here?” analysis.

  9. I know there are some hospitals where this happens, and it's ridiculous. Ours was very pro-breastfeeding. All I had to say was “I plan to breastfeed, so please no pacifiers, sugar water, bottles, or formula.” No problem. No one even batted an eye.

    I would have preferred the AAP release a separate statement to address what you said, Jenna–that parents have the right to decide how they want their kids fed, and if you've got a parent who's giving breastfeeding a go, here are some things not to do unless specifically directed by the parent, or unless the child is in danger of starvation, dehydration, etc.

  10. Add this to the current contraception debate, and anyone can see there truly is a war against women being waged right now…

  11. Answer: if you go by the “evidence” proclaimed by “evidence-based” folks, formula-fed kids are the reason for everything from diabetes to obesity to lower IQ to poor socioeconomic status to allergies and asthma to global warming. I'm only semi-joking about that last part, I'm sure they could make the case that since formula-fed people are unhealthy they have to drive to the doctor more and thus contribute to pollution more.

    If you go by the evidence as it is examined by folks who pay attention to things like how the studies were conducted, what was controlled for as best as possible, and how much the conclusions match up with reality (e.g. plenty of breastfed kids have food allergies, get ear infections, have lower IQ, are fat, and have chronic conditions like diabetes and asthma)–formula-fed kids are about as healthy, smart, and thin as breastfed kids. In the aggregate there may be a greater chance for ear infections and GI infections, but it's not a lot–one more ear infection and one more GI infection in the aggregate. Individuals can vary wildly.

    Curiously, no one seems to factor in the health risk of the intense pressure to breastfeed on new moms into that overall cost to society that formula supposedly creates…

  12. Teri, one of my friends was told that all the formula cans she was buying were bad for the environment…can we spin that as a global warming contributor? 🙂

  13. Oh, ok, I have certainly heard all of those things (and like you think for the most part they are total bs), so perhaps I am misinterpreting the term “public health.” I was thinking of it in terms of vaccination, like we need solid herd immunity for public health–to keep the general public safe. Asthma, diabetes, obesity, etc are not contagious, so I didn't associate them with public health.

    So by public health, the AAP (or lactivists?) are referring to the average/general health of the population as a whole? I can see the AAP being concerned with that, but why would the average American care what the rate of obesity (etc) is? The average American will care if it affects him/her/his or her offspring. And even if the rate of obesity (just for an example) is ridiculous and all the other countries are laughing at us, so what? I think obesity is an individual health concern for sure, but I think we really need more information on healthy nutrition, as well as access to relatively inexpensive healthy food, among other things, not cherry picking various “evils” to blame.

    Oh, and the mental health should surely be included, so it's too bad that (as Teri mentioned) it isn't factored in.

  14. I have had two friends whose babies were in full blown failure to thrive due to insufficient milk and were still being told to “just keep at it!” I would like to see a study on the long term health of babies whose mothers couldn't produce enough milk but weren't supplimenting.

  15. I really think they ought to first look at the public health cost of not treating individual patients as just that–individuals. How about the cost of unethical health care–when patients are treated with nothing but an eye for reaching statistical goals like improving breastfeeding rates, whether those goals are appropriate for the patient or not? Our pediatricians #1 and #2 certainly cost us a fair bit of money and sanity, one with me on a wild goose chase to get breastfeeding to work despite the fact that it was killing my health, and #2 because his colleagues were so whacked out on the idea of unpasteurized goat milk formula that they couldn't be bothered to do normal things like give me some advice when my daughter started teething.

  16. I think the idea behind things like obesity, asthma, and diabetes being public health concerns is twofold. First, to the extent that a significant part of the public has less than ideal access to health care, it's the public health system that ends up addressing these things with people. It's the local health department that has to educate people about health risks from these things. It's the county hospital that sees the people with no insurance whose blood sugar is out of control and who are having problems with their eyes or their feet. It's the free clinics and community health centers and whatnot that end up seeing these folks who have lots of risk factors and have to educate and treat them. Second, there's the public cost of ill health. The expenses when someone who has inadequate health insurance gets sick, the expenses from lost time/productivity at work, and costs of providing disability insurance or other public benefits. That being said, I'm not looking to get into a political discussion on any of these issues. Everything I have just stated above is my understanding of what those ideas are, it is not my personal opinion on any of it (except to the extent that I would like to see people have access to high quality health care regardless of their income or ability to pay).

  17. Geez, glad you found a sane pediatrician! I agree…while statistics can be helpful, they don't necessarily apply on an individual level.

  18. No, this really helps…I had not thought of things that way. Certainly I have heard enough people say how they don't want their tax dollars paying for “XYZ” and that those people (who need XYZ) should either pay for it themselves or not need XYZ. Ultimately, that's a problem inherent to our (US) healthcare system, and though I believe everyone feels it should be reformed, there is disagreement on the best way to do it.

    Stuff like this AAP statement doesn't help though, if the evidence the statement is based on is: 1)non existent 2)biased or 3)ambiguous. I think anyone would say that breastfeeding is ideal, but there is little strong evidence that not breastfeeding is dangerous (assuming you have access to clean water, etc).

    If the AAP truly believes that BFing is in everyone's best interests, then they should do the things (you?) mentioned below—providing actual help, realistic information and helping with formula should that be the way things fall out. I fear that those who believe that breastmilk is the magic panacea for everything and everyone will just take this as a bolster, and that doesn't help anyone either.

  19. Have there been any studies done on infants in developing countries? If they have no access to formula, and breastmilk is inadequate either an inappropriate substitute will be used, or the baby will be malnourished or even starve to death. (or dehydrate more likely)

    Now, what about infants who were malnourished but survived to adulthood? I'm pretty sure their growth will be stunted, and they may have problems related to lack of various vitamins/minerals. I know nothing about how malnourishment affects brain development, but I'm guessing it can't be good.

    I can't remember where I heard/read this, but (I think) there are 3 major growth spurts in a human's life: last trimester in utero, birth to 1yr, and puberty. If the malnourishment is occurring during one of those stages, I doubt it has any positive effects on health. 🙂

  20. And don't forget, we lazy FFers also fill up landfills with disposable diapers. And throw our trash out the window instead of finding an appropriate receptacle. We suck.

  21. I find myself agreeing with you once again, Teri. The AAP could have written all sorts of things to assist healthcare providers and parents in feeding babies. Instead they just tried to shove BFing down everybody's throats. *Gag*

    Sure, BFing deserves support. Some practical advice on that front would be great. But as FFF mentioned, the AAP could have acknowledged that sometimes formula is called for– for any number of reasons. And some moms don't want to BF. It's their body and their baby. Health care providers are going to encounter plenty of parents who make decisions they don't agree with. As long as they're not abusing/neglecting/endangering their children, you need to respect their choices. So no giving parents a hard time for BFing, FFing, combo feeding or pumping. And it's the child's health care provider's responsibility to advise parents on how to feed them properly, whichever method they're using. The professionals don't always seem to know exactly how to instruct parents on infant feeding. Maybe the AAP could help them out there. But then babies might actually get fed better.

    Your pediatrician sounds awesome. The AAP could take some lessons from her 😉

    I won't be having any kiddos for a while. Just hoping the AAP changes their tune before then. What I do with my boobs might viewed as a “public health issue”? Excuse me while I barf.

  22. India has an incredibly high percentage of malnourished children and women *do* tend to either BF or use non-formula alternatives (wet nursing/sharing, diluted milk with water, sugar water) – I really wish formula were cheaper and clean water more readily available in rural-poor areas for this reason.

  23. Heehee, I feel like we all deserve her after the hell of the prior two pediatricians. After pediatrician #1, the only reason I was even willing to try to trust another pediatrician was because my own pediatrician as a child was not only a tremendous force of good in my life, but saved my life on several occasions. I feel like we had to kiss some frogs till we found our princess. 😛

  24. My understanding is that the problem with 3rd world countries and formula is that it has LESS to do with the water supply (after all, you can always boil water, and most people even in the worst conditions are aware of this) and MORE to do with the fact that a family in a 3rd world country is:
    a) less likely to have the resources to afford formula, which logically means they will dilute the formula more and stretch out feedings, thus depriving their child of vital nutrients,
    b) more likely to only have access to old formula, damaged formula, recalled (in Western nations) formula, etc. which increases the risk of problems in the formula itself,
    c) less likely to be literate in the language that is on the formula cans, therefore more likely to not have access to adequate information on appropriate quantities needed and the consequences of feeding diluted formula, concentrated formula, or spacing feedings out too much.

  25. It's a combination of all of these factors. Water is only part of it, true; but water supply problems affect everybody, not just pre-weaned infants, so I think it naturally gets more focus.

  26. All true, but also don't underestimate the challenge of boiling water – you need fuel to do so, and you have to cool it down after. It takes a lot of time and effort even in relatively well-off families and waterborne diseases are common in poorer areas for this very reason (i.e. the effort/time/cost of boiling and cooling water for everyone, not just infants, makes people skip the step esp when their lives are busy just making ends meet)

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