A study that has nothing (and everything) to do with formula feeding

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A new study is making headlines this week. “Early full-term babies may face later school woes” warns HuffPo, explaining that in a study of 128,000 New York City public school kids,

…of the children born at 37 weeks, 2.3 percent had severely poor reading skills and 1.1 percent had at least moderate problems in math. That compares to 1.8 percent and 0.9 percent for the children born at 41 weeks…. Children born at 38 weeks faced only slightly lower risks than those born at 37 weeks… Compared with 41-weekers, children born at 37 weeks faced a 33 percent increased chance of having severe reading difficulty in third grade, and a 19 percent greater chance of having moderate problems in math.

This isn’t great news for those of us with babies born a tad early – one of my kids came at 39 weeks, and the other at 38 and change because I had an underachieving placenta in both pregnancies – and of course, the study is being used to basically blame moms for their selfish desire to hasten delivery or agree to scheduled c-sections which work in their OB’s favor. 
The study authors were more thorough than what we typically see in infant feeding research, controlling for confounding factors like smoking, lack of prenatal care, and poverty, as well as gestational weight, so on the surface, it is rather hard to explain away these results. 
And yet, since I can’t find the actual study (just the media reports), I’m unclear if the researchers factored in why the babies were delivered a bit early, and how their pregnancies were, in general. Were the moms on any medications? Did they exercise? What about prenatal stress? Depression during pregnancy? These are all factors which might be associated with preterm labor and delivery, and possibly could be affecting attention span or some other psychological or neurological characteristics. (Speaking of which – let’s remember that test taking skills have little to do with intelligence, and only matter for academic success, not lifetime success.)
But even if we take the findings as they are, and accept that being born a bit early may have an impact on your future academic success, we need to understand what this means in context. First of all, we’re talking about incremental disadvantages. 2.3 percent versus 1.8 percent. That means that even if you are in the group of kids born a few weeks early, you still only have a 2.3 percent risk of having “severely poor reading skills”. If we take 100 kids born between 37-38 weeks, this means only between 2 and 3 of those kids will be suffering from this adverse effect. 
Now, compare this to the risks shown with late-term delivery. A study back in May claimed that babies born at 42 weeks had “more than twice the risk” of developing ADHD.  Another study claims that the risk of stillbirth is 1/926 at 40 weeks,  1/826 at 41 weeks, and 1/760 at 42 weeks – in other words, with every week, the risk of fetal death increases. Ingesting meconium gets more likely the later your baby is delivered – there has been a 4-fold decrease in the amount of babies suffering from meconium aspiration syndrome since US doctors started inducing pregnancies before they went too far past-term. 
These stats are not meant to freak anyone out – I only cite them as a way of showing that we need to consider context when we look at statistics and studies. There are risks with delivering too late, and risks with delivering too early. The lesson should probably be that if you get to choose when your baby comes, your best bet is to plan for around 40 weeks, barring any medical issues that might make an earlier delivery a better choice. If baby decides to come early or doesn’t want to leave, then you and your doctor have to do some careful considering of your options, based on your individual case. Revolutionary idea, isn’t it?
Unfortunately, in the case of this study, rather than simply stating the facts and perhaps giving a bit of toned-down commentary that explained to women that inducing early may not be the best idea unless there is a medical reason to do so, the media pundits got alarmist and judgmental. A pediatrics professor/neonatologist interviewed for the HuffPo article lamented that “There are still a lot of babies who are being delivered more or less electively at 37 and 38 weeks, with people thinking, `This is no big deal – these babies are full-term.’ I think this is a big deal….I don’t want to panic moms whose babies come at 37 weeks…But those elective early deliveries really need to stop.”
This may be true. After having two babies induced early, I can attest that there are other issues that arise when a baby is forcibly evicted before the lease is up. But we also need to be careful about overstating things. A tiny little decrease in the ability to take tests is hardly a “big deal”, especially when I suspect most early deliveries are not “elective”. Many doctors do choose to induce or perform c-sections at 39 weeks, and maybe that should stop… but I don’t think it’s the moms who are making these calls. So maybe the focus should be on influencing the American Academy of Obstetricians and Gynecologists rather than engaging in subtle barbs towards these mythical moms who “can’t be bothered” to stay pregnant.
I know it seems odd that I’m posting about this, a study which has nothing at all to do with infant feeding, but think about it: you could easily sub out the term “elective early delivery” with “formula feeding” and the study would look and sound all too familiar. Without a strong understanding of relative risk and a healthy dose of perspective, it’s far too easy to use studies to scare women and create misunderstandings which will later be used to back up inflated claims. The more we learn to approach parenting science with a critical eye, the better off we will all be – no matter what our feelings about infant feeding.
A little post-script:
When I was looking for the actual study published in Pediatrics, I stumbled across another study in that same journal that we surprisingly (said with sarcasm) have not heard about in the parenting media. In the June issue of Pediatrics, researchers found that

…maternal cigarette smoking correlated significantly with the development of NEC (P = 0.02). There was no correlation seen between maternal gestational diabetes, maternal hypertension, formula feeding, and pathologic chorioamnionitis or uteroplacental insufficiency and NEC.
 “These data identified maternal cigarette smoking as the only risk factor that is associated with the development of NEC in premature infants,” the authors write. “Our data imply that smoking delivers toxins and nicotine to the uterine microenvironment that can affect microvascular development and may predispose the fetus to future NEC.”

Huh. I thought formula feeding was the BIGGEST reason babies got NEC. So finding no correlation between formula feeding and a higher risk is actually big news. More importantly, knowing that smoking is a major risk factor could actually help prevent infant death. Seems a bit more important than testing well in grade school, but maybe that’s just my own bias….

About the Author:

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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15 comments on “A study that has nothing (and everything) to do with formula feeding”

  1. AmyM on said:

    I thought prematurity was the biggest risk factor for NEC.

    Anyway, I don't get too worked up when studies like this come out…as you say, 39-41wk seems to be ideal, but there are plenty of cases where baby needs to be taken earlier, or just comes earlier despite anything the doctors and mothers do. My twins were 36wkers which was no surprise to anyone but I had no control over it.

    I too, am curious where all these women getting these convenient inductions/c-sections are coming from. No one wants their baby to be premature. I'm going to assume (so I may be wrong) that vast a majority of preemies are so due to some complication…if that is indeed the case, then telling us mothers of preemies/early-full termers that our children are doomed, is a waste of time that accomplishes nothing.

    Parents in America seem very concerned if any hint of delay or disability pops up, and though some will deny a problem, most will try to get as much help for their children as possible. Parents of preemies are told right off the bat that their children may have developmental/cognitive delays, and possibly physical disabilities too. We watched our sons very carefully, so if they showed any signs of an issue, we would have swooped in with early intervention asap. (they are fine) I know of several women through an online multiples group whose twins/triplets came much earlier (30-34wk) and unfortunately, have an array of preemie-related issues like CP, developmental delays, speech delays, dyspraxia, ASD, etc. Those women KNOW that prematurity is not ideal and they know that their children will struggle. Many of them got EI, and hopefully, all of those children will be able to overcome their difficulties and succeed (in general.)

    It is also common for babies to come 37-38wks, naturally. For the most part those babies are fine at birth and the parents have no reason to believe their children will have any more difficulties than any other child. I agree that OBs and parents should work together to try to see a pregnancy through 39-40wks, but that is not always possible or ideal. I think it would be appropriate for OBs to tell patients that inducing/c section before 39wks is discouraged, EXCEPT when there is a medical indication. My own personal opinion would be to err on the side of slightly early….I would rather have a 37wker guaranteed to have some struggles with school than a stillborn, or worse, a dead mother and baby. And this study shows that 37wkers are NOT guaranteed to have trouble in school, they just have a slightly greater chance then their more ideal-term peers.

    I guess what I'm trying to say is: This is good to know and all, but until we come up with ways to prevent pre-term labor, it is not very helpful. There is a very small percentage of people who deliberately induce/section with no medical indication before 39wk, and it comes across as though the authors were unaware of their target audience. I haven't read the actual article though, only your summary—was this paper directed at OBs, with the assumption that OBs are delivering 37wkers willy-nilly? Or directed at OBs with the intention that the OBs should tell their patients? Was this published in a peer-reviewed journal that generally does not make its way into the hands of lay people?

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  2. Becky on said:

    Thank you for putting the numbers into perspective!

    I was induced at 38 weeks for medical reasons, and it was awful because my body was so not ready. Having been through that I would personally not put myself through it voluntarily – and in fact if I have to deliver early again for medical reasons I'm going for the dreaded elective C-section! But I'm sure some parents have good reasons for choosing to deliver early and I wish we could talk about the potential risks without blaming and shaming women. I think it's very likely most elective deliveries before 39 weeks are done based on a doctor's recommendation anyway (whether there is a good medical reason or not).

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  3. Underthegrace on said:

    Hi, I'm new to your blog, and I'm actually a happily breastfeeding mom, but I ran across the title of your blog and wanted to check it out… I know there are a lot of reasons why someone might have problems breastfeeding, or choose not to… but I wonder how you feel about the movement to make human milk (from other moms) more available, (I strongly believe it to be a far better option, also, I think feeding babies should be free, or very close to it, formula companies making money off of it confuses the issue at the very least)… also what you think about the idea of using a Supplemental Nursing System… or do you advocate for skin to skin contact with babies in other ways, seeing as we know it to be so powerful, and normally a lot of it happens incidentally through breastfeeding? Also, why do you think breastfeeding is so political right now? Who stands to gain from more women breastfeeding? I guess because I'm on the “other side” so to speak, I've always just been really cynical about big formula companies pushing their wares… it's so obvious that they stand to gain financially that yes, their offers of samples, etc, seem very manipulative to me. In my experience, breastfeeding has been far more than just a method of feeding, and though it has had it's struggles, I'm just thankful that I found wonderful non-judgemental & definitely not militant ladies that supported me… It's just interesting I guess how the tables have really turned… just a generation ago you wouldn't have admitted to breastfeeding… let alone done it in public… don't you think it's good that more women are breastfeeding?

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  4. AmyM on said:

    Are you directing this at the whole population of this board? I can give you my personal take on it, which doesn't represent everyone's here.

    1)yes, BFing is good. It has benefits. It is great that more women are breastfeeding. It has become political because the benefits are overstated, for one thing. From my POV, people who stand to gain from militant lactivism are: extreme sanctimommies who need to put other women down to feel accomplished, a mysogynistic subset of the population who feel that women should be pushed out of the workforce and back home. Other groups that gain from BFing are any company that sells BFing related products (pumps, pillows, bras, tops, nursing covers, nipple cream, nipple shields, breast pads, lactation counseling).

    2)I don't think anyone here has any issues with SNS and skin to skin. I used an SNS, ultimately, it didn't help, but I was certainly willing to try it. And feeding a baby a bottle can be just as intimate as nursing—you can even bottle feed skin-to-skin! And so can Dad,which I see as an advantage.

    3)I think if human milk were properly screened, then making it available to mothers of healthy babies/full term infants would be great. As it is, milk banks (with screening) generally only give the milk to preemies in the NICU, since they need it most. Buying milk from a stranger online can be expensive (if they charge per/oz, or for shipping) and it can be dangerous, since you have no idea whose milk that is, what drugs she takes, what diseases she may have. Milk is a bodily fluid like blood, and should be treated as such, for everyone's safety.

    4)As for formula companies, I see them like any other company. Big businesses want to earn a profit. Many, like formula companies, do so by selling something that helps people. Formula isn't poison, it is an adequate diet for a full term healthy infant, and clearly there is a high demand. We don't tell Target that they aren't allowed to advertise for their products, why should formula companies be the only exception? Also, the target consumers of formula are parents—formula is not being hawked to children and getting them addicted. It's not being sold to senior citizens with some skeevy commercial about ED. I've never seen a formula commercial on tv. I have seen them in print ads in parenting magazines, and if a picture of a box of formula undermines your breastfeeding relationship, that's on you, not the formula company. Most people are able to ignore/skip ads that do not apply or appeal to them.

    As for samples, I think most women are smart enough and mature enough to decide for themselves if they want to take/use a sample or not. I got several different samples, one or two of which did not agree with my children, so I didn't use those (after we figured out the issue). I was not brainwashed…I chose whether to use samples and which ones, and we should be able to trust any mother to make her own decisions.

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  5. JoM on said:

    I personally would never give my child another woman's milk no matter how screened. I like AmyM's examples of how much money is made by companies for breastfeeding supplies.

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  6. Becky on said:

    You can bottle feed skin to skin! I did with my baby when she was a newborn and I would definitely recommend it to other bottle feeding parents. I took off her shirt and lifted up my shirt and cuddled her while I gave her the bottle, and I got that blissed out oxytocin rush you are supposed to get from breastfeeding but I never did (because I was too stressed about feeding issues). Definitely a very special experience.

    It is interesting how the tables have turned. When my sister told her MIL I was having trouble breastfeeding, the MIL sent me an email offering support and with links to BFing support groups, and included the line: :”I know how hard it is to BF when nobody supports your decision and everybody just tells you to give the baby formula.” I found that fascinating because I was having just the opposite experience! My grandma was the only one telling me to give my baby formula, everyone else was encouraging me to BF and I had practical support as well in the form of lactation consultants paid for by our universal health care system. I think maybe that's something older lactivists don't understand – things have really changed a lot (at least here in Canada and some parts of the US) as far as support for the idea of breastfeeding.

    As far as samples – it's interesting, the moms in my mommy group who signed up for samples are still BFing and have offered the samples to me because they are not using them. I never signed up for any because I was so sure I would BF and here I am. My doctor did give me samples – but not until I told her I had switched to formula.

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  7. Abbi on said:

    It is very frustrating that society (as shown through articles, media, etc) makes the assumption that babies born before 40-ish weeks were born at that time because the mothers wanted it. My water broke at 37 weeks and my body was definitely not ready. I ended up having an emergency c-section because after 18 hours my blood pressure was dangerously low, I developed a fever, and my son's heart rate was all over the place. Definitely not elective anything. And now I need to worry that my incredibly awesome toddler may have problems with reading or math? If he does, it's because there's a family history of dyslexia and learning challenges, not because he was born at 37 weeks. Great point, FFF, about control groups and all of that. And really, why was research money wasted on this?

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  8. wave412 on said:

    I'd be interested to see a graph of where the kids with poor reading skills fell in relation to neighbor. Reading proficiency is not something that's always governed by intelligence or physiological development; rather, good school instruction coupled with early exposure to reading materials is key to reading mastery. I wouldn't be surprised if many of the students with problems were concentrated in a few areas with low SES or low school funding. In that case, early full term delivery may not so much be a cause but a result of cultural and SES circumstances (e.g. stress, secondhand smoke, working physical jobs, etc). The incidence of specific learning disabilities that affect reading and math performance might be more telling.

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  9. Katie Spencer White on said:

    In England all children born between 1 September in Year Y and 31 August in Year Z are in the same year group – studies consistently demonstrate that summer babies have more learning delays than autumn babies.

    I have an August baby and he's a genius (seriously, he is).

    The long and short of it is that most kids turn out just fine – and studies such as this are simply risk assessments.

    I'm not gonna let this one make me sweat.

    Katiespencerwhite.com

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  10. Adavis6278 on said:

    My older daughter was born at 39w1d and has been moved into the 3 year old class at preschool already because she started reading, spontaneously, on her own. She can also identify shapes that most third graders can't: octagon, hexagon, ellipse, parabola, and trapezoid. So I don't think that 6 days early thing has affected her intelligence one iota.

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  11. Antigone on said:

    Here is my take on your questions.

    Human milk – milk banks are great, but the process of screening and storing the milk is expensive. Unless there is some kind of subsidy for this, this option is out of reach for many. Preemies should be prioritized. I am against using donor milk from a stranger that has not gone through a milk bank. I cannot trust that the milk does not have diseases or substances that might be harmful.

    SNS – I think the SNS is a very useful tool for someone who needs to temporarily supplement. However, I think using the SNS long term instead of bottles for formula fed babies is quite difficult and impractical.

    Who benefits – Among many people, breastfeeding has become like a religion or political position that they are intent on promoting. Most breastfeeding advocates probably don't benefit financially but it's an ideological thing. The pro-breastfeeding side can certainly be manipulative as well.

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  12. Abigail on said:

    That's funny. Except for my mother who still mentions occasionally that I have poisoned my children, my friends did the same thing. When they saw that I had hit my breast feeding wall they all signed up for free cans of what I was using and gave it to me. None of them stopped breastfeeding.

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  13. Becky05 on said:

    I just want to say that it is likely that if you were induce again that it would go MUCH more smoothly than your first induciton. Multiparas have easier inductions, and easier labors in general.

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  14. Kati on said:

    I can attest to that. I've had two inductions. The first one sucked, but the second went very smoothly. I'm scheduled for my third induction next Friday so I'm hoping that the trend continues and I have an easier labor and delivery.

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  15. Kathleen Roose Goelz on said:

    I am a regular reader of your blog, and adore your posts about 95% of the time. I feel this one is off from your usual good work, though. The idea behind the recent research and policy changes regarding elective early full-term deliveries is that, *all things being equal*, it's better not to induce before 39 weeks. These policies and studies aren't about situations where there are good reasons to intervene earlier, nor are they about babies spontaneously born early full-term. I think it's important to listen to these studies, not only because they may contain important information about the best choices for ourselves and our babies, but because I find them a really refreshing departure from the rationales usually used to support “natural” ideology. There are solid statistics behind these policies that back up what healthcare providers have known for a long time. When I was in nursing school years ago, my instructors taught me to keep a closer eye on the babies who came at 36-38 weeks, that even though they were technically full term, it was their experience that those babies more frequently had (often surprising) problems when they were small (infection, breathing difficulties). These were old-school nurses who had been practicing for decades (way before natural pregnancy and birth was en vogue). This was before these studies were becoming well known, and way before hospitals began adopting more restrictive policies on time tables for elective induction. I'm glad that this potential risk factor is getting attention.

    I totally support the decisions women make with their healthcare providers about how and when to enact their deliveries, but I think the science supports fact that delivery prior to 39 weeks is only indicated when the benefits outweigh the risks.

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