Disaster in the Philippines: Why overzealous breastfeeding promotion has no place in relief plans

Dear FFF,

We are based in Manila which, thankfully, was spared from the brunt of typhoon Haiyan. As you may be aware, our fellow Filipinos from the other islands of Leyte and Palawan suffered from this catastrophe. Aid has been slow in coming, and the situation is now miserable and desperate. Donations from all over the world are coming in, but the logistics of getting them to the people who need them are difficult because many of the islands are isolated and cannot be easily reached. Many have not eaten since Saturday. They also do not have clean drinking water and are living in the streets amidst rubble and dead bodies.

Which brings me to my question/issue – What is the best way to feed a baby in a crisis situation like this?

 Our Department of Health has BANNED donations of formula milk – powdered or pre-mix – because of the perils of formula and because it undermines breastfeeding.  According to the Department of Health, the best solution is to breastfeed, or if the mother is no longer breastfeeding, to give support towards re-lactation. If these are not feasible, then the next alternative is wet nursing. I do understand that this is the exact reason why formula has been deemed “dangerous – because preparation of formula in unsafe, unclean conditions (including using unclean water and bottles) can lead to diarrhea and infant mortality.  However, I also believe that the options given by the Department of Health practically require a mother to choose between death of a child by starvation and death by diarrhea.  They say re-lactation as if it was like turning on a switch. Most women who have weaned young babies likely had problems lactating in the first place. How likely is it that she would be able to re-lactate in the midst of the stress, chaos, and misery of a calamity? The Department of Health says that the solution is to provide breastfeeding support, counselling, and breastfeeding-friendly setups where breastfeeding can be encouraged.  In a situation where the most basic of necessities such as water, shelter, and medical care have not even reached the victims, it does not appear that anyone is currently equipped to provide these conditions that would foster breastfeeding in a crisis situation. Wet-nursing or donated milk is the next alternative presented. On wet-nursing, I do wonder if that is really a safe option, since it is possible to also contract disease from tainted breast milk. Again, in a calamity situation, who has the time and resources to check for infectious diseases when looking for a wet nurse?  On donated milk, I concede that this is probably the most viable option, but given the sheer number of people affected, I do not think that it is a sustainable source of nutrition for all the babies affected (given that several hundred thousand homes were affected). Babies need constant nutrition, and while donated milk may augment at the start, is it really sustainable to provide for the nutritional needs of all the victims in the coming days before they are moved to a safe and clean environment? 

And so, I think, banning pre-mix formula donations is a case of letting the principle of promoting breastfeeding defeat the principle of saving as many lives as possible.  Even the American Academy of Pediatrics concedes that pre-mixed formula is the last alternative when the other options are not feasible.  Our government, however, has taken the firm stance against formula and will refuse donations of pre-mixed formula.  Incidentally, pre-mixed is not readily available in the Philippines, but I’m sure it can be procured from other countries or even by local formula manufacturers if only it were allowed.

– S. T.

 

After receiving this email, I logged on to my computer to find several sources reiterating what the author had said. According to Gulf News,

Government and private hospitals in Manila called on nursing mothers nationwide to donate milk for babies in typhoon devastated central Philippines… Explaining the aim of the campaign, (Dr. Jessica Anne Dumalag of Manila’s Philippine General Hospital’s Human Milk Bank) said, “Milk from lactating mothers is preferred over formula milk, which is basically processed cow’s milk.”

The department of health which has been promoting breast feeding has a policy to prohibit the donation of formula milk for babies in temporary shelters, during a calamity….“Children are more exposed to allergy when they consume formula milk. We are also not sure if the water used to prepare formula milk is clean (that is why it is not recommended),” said Dumalag….Government and private hospitals including private organisations were organised to accept donations of human milk. Milk donations will be pasteurised, frozen, and kept in insulated containers before they are sent to evacuation centres in central Philippines, Dumalag said.

 

Concerns over water and sterile preparation of bottle feeds during disaster situations are valid and necessary. Several years ago, we had a lengthy debate here on FFF about this very topic; I’m well aware that if relactation or wet nursing is a possibility, it is without a doubt the safest option in natural disaster settings. Bacteria-filled water, poor sanitation, and lack of resources make formula feeding a deadly proposition; when formula feeding is seen to be “encouraged” in an at-risk population, lactation may be interrupted which can have long-term consequences (i.e., the family would then need formula on an ongoing basis, which could prove difficult if money or resources were an issue). I’m not disputing this, nor am I ignoring the fact that formula marketing in the Philippines is a hot button issue at the moment, and that breastfeeding promotion is in overdrive for reasons that I can’t fully comprehend, as a privileged Western woman.

But that’s not what this is about.

A policy that forbids powdered formula donations and encourages breastmilk donations is simply replacing one easily contaminated substance with another. Donated breastmilk – and this includes breastmilk procured by breastfeeding-related Facebook pages, speaking of privileged Western women – requires careful packaging, transport and refrigeration, not to mention screening for HIV and hepatitis B (the Philippines still has a low rate of HIV infection, but it’s rapidly increasing – TIME reports that every 3 hours a new case is now being diagnosed). There are still the same risks involved with sterilizing bottles, regardless of what’s filling them; nowhere in these news reports are people discussing the importance of cup feeding, for example – something that can significantly cut the chance of bacterial contamination.

There is, however, a substance that can be easily transported without refrigeration; that has a relatively stable and long shelf life; and which can be fed to babies in a perfectly sterile manner, at least in the short-term. That substance is ready-to-feed, pre-mixed formula, served in “nursette” bottles with pre-sterilized nipples (like these).

Granted, the cost of these supplies is rather high. But while I haven’t done the math, I’d venture to guess that the cost of procuring and safely distributing donor breastmilk would be just as prohibitive. And if people are ready and willing to donate RTF and pre-sterilized nipples, what would be the harm in allowing them to do so?

The answer is none. There would be no harm, except, perhaps, to the “cause” of breastfeeding promotion. That cause may be noble and important, but right now, it’s irrelevant. To put breastfeeding promotion ahead of feeding infants safely and in a timely manner is petty, short-sighted, and cruel. Think about it: would we discourage donations of processed, high-fat canned foods to disaster victims because of concerns over obesity, GMOs, or the environment? Or would we ensure that their immediate needs were met, and worry about preaching better health habits after the roads had been rebuilt and displaced families were settled into safe, warm homes?

The fact that Dr. Dumalog, quoted above, uses “allergies to formula” as a reason for forbidding RTF formula donations speaks to the irrationality of this policy. If a child is allergic to formula, there is also a chance s/he will react to something in a stranger’s milk. A breastfed baby may indeed react poorly to formula at first, but this is a case where the mom should receive plenty of assistance and encouragement to continue breastfeeding – not told to feed her baby via bottle with donated milk. With breastfeeding rates in the Philippines being what they are, it stands to reason that most of the babies without lactating mothers present are already formula fed – therefore they will probably do just fine with donated formula, even if it’s not the same brand. We’re talking about a little gas here, not a full-scale anaphylactic reaction.

Gulf News reports that “groups that promote breast-feeding in six hospitals and in several private clinics are part of the campaign.” A disaster situation is no place for “promotion” of anything but disaster relief. And the scariest thing about this is that the Filipino government isn’t alone in letting a hatred of formula get in the way of ration. The American Academy of Pediatrics also advocates for “screened human donor milk” before RTF (although they do, at least, acknowledge that this is an option). I have yet to see one study or agenda-free policy paper that actually looks at the viability of using donor milk as opposed to RTF formula with pre-sterilized nipples during disasters. If there is a logical reason behind these recommendations, I’d love to see it. All I can find are convoluted references to “breastfeeding being interrupted” (not an issue if we’re talking about babies who are already formula fed) and concerns about sterility and availability (absolutely valid, but just as valid in regards to donated milk, if not more so).

Governments must stop putting ideology above practicality. We are in desperate need of a neutral, informed, and rational voice to come up with better policies for infant feeding – policies that do not throw the cart before the horse, and end up running over its citizens in the process.

Bad medicine: Why the AAP’s new statement on breastfeeding & medication is puzzling

“The benefits of breastfeeding outweigh the risk of exposure to most therapeutic agents via human milk. Although most drugs and therapeutic agents do not pose a risk to the mother or nursing infant, careful consideration of the in- dividual risk/benefit ratio is necessary for certain agents, particularly those that are concentrated in human milk or result in exposures in the infant that may be clinically significant on the basis of relative infant dose or detect- able serum concentrations. Caution is also advised for drugs and agents with unproven benefits, with long half-lives that may lead to drug accumulation, or with known toxicity to the mother or infant. In addition, specific infants may be more vulnerable to adverse events because of immature organ function (eg, preterm infants or neonates) or underlying medical conditions.”

 

– Source: The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics Hari Cheryl Sachs and COMMITTEE ON DRUGS. Pediatrics; originally published online August 26, 2013; DOI: 10.1542/peds.2013-1985

The preceding is the conclusion to a new report released by the American Academy of Pediatrics, which has given birth to a number of ecstatic headlines – “Most medications safe for breastfeeding moms”. “Medications of nursing mothers do not harm babies”. “Top Pediatrician’s Group Assures Most Drugs Safe While Breastfeeding”. Reading these, one might assume that a plethora of new research had been released, provoking the AAP to make a blanket statement about risk and benefits.

One should read the actual report before one gets too excited.

Other than the introduction and conclusion, which basically explain that studies are limited on most medications and how they affect a nursing infant, but that the benefits of breastfeeding outweigh the risks, the report reads like one giant warning.

Let’s start with antidepressants:

“Previous statements from the AAP categorized the effect of psychoactive drugs on the nursing infant as “unknown but may be of concern.” Although new data have been published since 2001, information on the long-term effects of these compounds is still limited. Most publications regarding psychoactive drugs describe the pharmacokinetics in small numbers of lactating women with short-term observational studies of their infants. In addition, interpretation of the effects on the infant from the small number of longer-term studies is confounded by prenatal treatment or exposure to multiple therapies. For these reasons, the long-term effect on the developing infant is still largely unknown…Because of the long half-life of some of these compounds and/or their metabolites, coupled with an infant’s immature hepatic and renal function, nursing infants may have measurable amounts of the drug or its metabolites in plasma and potentially in neural tissue. Infant plasma concentrations that exceed 10% of therapeutic maternal plasma concentrations have been reported for a number of selective serotonin reuptake inhibitors…”

As stated in the first sentence of this section, the evidence hasn’t really changed from when the last AAP statement on drugs and human milk was released, circa 2001. But the conclusion sure has. In 2001, the authors advised that “(n)ursing mothers should be informed that if they take one of these drugs, the infant will be exposed to it. Because these drugs affect neurotransmitter function in the developing central nervous system, it may not be possible to predict long-term neurodevelopmental effects.” In 2013, the author states “Mothers who desire to breastfeed their infant(s) while taking these agents should be counseled about the benefits of breastfeeding as well as the potential risk that the infant may be exposed to clinically significant levels and that the long-term effects of this exposure are unknown.”(p. e799)

This is where I start getting nervous. The last thing I ever want to do is discourage someone who needs antidepressants or another lifesaving medication from breastfeeding – especially considering I personally chose to take the small risk and feed my newborn breastmilk while I was on Zoloft (one of the many SSRIs that are categorized in both reports as “Psychoactive Drugs With Infant Serum Concentrations Exceeding 10% of Maternal Plasma Concentrations”, meaning that the levels of the drug getting into a newborn via breastmilk are clinically significant and of potential concern for a growing neonate). These are the risk/benefit scenarios we often discuss here on FFF – decisions that parents need to make (and deserve to make), armed with solid information and free from paternalistic admonishments that don’t have real world meaning. But I don’t feel that the new AAP statement – or the way that the media is reporting it – is allowing for a truly informed decision.

Notice the emphasis of the newer AAP statement – the advice given is to counsel the mother on the benefits of breastfeeding first, and then inform her of the potential risks and unknowns of nursing on her medication. Anyone with a grade-school understanding of psychology can figure out what that would sound like. (“Breastfeeding is extremely important and will save your child from every ill imaginable! But I should warn you that if you choose to nurse while on Zoloft, we can’t confirm or deny that your baby may turn into a werewolf when he reaches puberty. Your choice!”)

Maybe I’m arguing semantics here, but why couldn’t they avoid the paternalism of both the 2001 and the 2013 statement and simply advise doctors to inform parents of the risks and benefits of both feeding options, as well as the risks of nursing on medications, in an accessible, understandable way? And then help them mitigate the risks, no matter what path they choose?

Moving on… painkillers. The AAP is now agreeing with what I freaked out about in Bottled Up – Vicodin and newly postpartum, breastfeeding women are not a match made in heaven. And before you post-C-section mamas beg for the Darvocet, that won’t fly, either. Turns out that infants whose mothers used these commonly prescribed drugs  for managing postpartum pain have popped up with cases of unexplained apnea, bradycardia, cyanosis, sedation, and hypotonia; one infant died from a Vicodin overdose after ingesting the drug through mother’s milk. But hey- you can take (moderate) doses of Tylenol and Advil to manage that post-surgical pain, so no worries.

Are you starting to see why “Medications of nursing moms do not harm babies” might not be the most accurate headline?

Ummm…. Herbal remedies! Those have to be okay, right? They’re natural, after all!

Not so fast, sugar.

“Despite the frequent use of herbal products in breastfeeding women (up to 43% of lactating mothers in a 2004 survey), reliable information on the safety of many herbal products is lacking…The use of several herbal products may be harmful, including kava and yohimbe. For example, the FDA has issued a warning that links kava supplementation to severe liver damage. Breastfeeding mothers should not use yohimbe because of reports of associated fatalities in children…Safety data are lacking for many herbs commonly used during breastfeeding, such as chamomile,black cohosh, blue cohosh, chastetree, echina- cea, ginseng, gingko, Hypericum (St John’s wort), and valerian. Adverse events have been reported in both breastfeeding infants and mothers. For example, St John’s wort may cause colic, drowsiness, or lethargy in the breastfed infant…Prolonged use of fenugreek may require monitoring of coagulation status and serum glucose concentrations. For these reasons, these aforementioned herbal products are not recommended for use by nursing women.”

Wait. It gets worse. You know those galactagogues you were prescribed to increase your milk supply? Flush them down the toilet, says the AAP. The safety of Domperidone, for example, “has not been established.”

“The FDA issued a warning in June 2004 regarding use of domperidone in breast- feeding women because of safety concerns based on published reports of arrhythmia, cardiac arrest, and sudden death associated with intravenous therapy. Furthermore, treatment with oral domperidone is associated with QT prolongation in children and infants.”

The authors aren’t overly enthusiastic about other galactagogues, either, and instead encourage moms struggling with supply to “use non-pharmacologic measures to increase milk supply, such as ensuring proper technique, using massage therapy, increasing the frequency of milk expression, prolonging the duration of pumping, and maximizing emotional support.”

I’ve read the report 10 times now, trying to see where they could possibly come to the conclusion that this is a game changer; that it is at all newsworthy; that this is what counts as progress. To my untrained eye, it appears to be little more than a re-framing of old information to fit in better with the “breast is best at all costs” mantra, rather than a landmark “update” of an antiquated policy paper. Based on this report, how are pediatricians supposed to tell patients, in good conscience, that there is adequate evidence that it’s safe to breastfeed on “nearly all” medications?

For most of the meds in question, it probably is safe- similarly to how the risks of infant formula are scary on paper and far less daunting in real life, I honestly believe that we’d be seeing a lot of seriously messed-up kids if your absolute risk of nursing while on antidepressants was high. Just like many of us have made carefully weighed decisions to formula feed, feeling the weight of misery in one hand and balancing that with an increased risk of ear infections in the other, so shall we handle questions of breastfeeding and medications. The problem is not with moms making choices based on the facts we have- the problem is when respected, policy-creating organizations create false narratives that render us unable to make those choices in a truly informed way.

The report leans heavily on the work of Thomas Hale and LactMed, fantastic resources for research on these issues. I’m grateful there are people dedicated to focusing on this research – research that matters so much more than yet another associative study attempting to show that breastfed babies are smarter than formula fed ones. We desperately need more research on how commonly prescribed medications affect breastfeeding infants, not so that we can “forbid” women from breastfeeding, but so that we can help them reach their breastfeeding goals. This might mean timing medications so that they are mostly metabolized prior to nursing, or pumping for some feeds, or even -god forbid- using a little formula or donor milk for the feeds that have a higher amount of the drug coming through milk (these are tough things to figure out, sometimes, as people metabolize differently, as do babies, but it’s a good goal to have on the horizon). Maybe it means finding better medications. Or it might just mean allowing parents to ponder their own risk/benefit scenarios and respecting their decisions, whatever those may be.

Before we can do that, though, someone has to remind the AAP that they are doctors first, breastfeeding advocates second. Let the science speak, not the zealotry, and maybe we can start helping parents make truly “informed” choices.

 

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.

 

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