Breastfeeding might not protect kids from obesity. So what?

The past few days have produced a flurry of articles on how breastfeeding may not protect against obesity. You’d think I’d be shouting an obnoxiously loud DUH or TOLD YOU SO. Instead, I want to poke my eyes out and claw at my ears until they bleed. That’s maybe slightly dramatic, but seriously – I’m at my wit’s end, here.

The truth is, there have been quite a few studies and reviews that showed negligible or conflicting results regarding the effect of infant feeding practice on later obesity (ie, this one, this one, or this one). That hasn’t stopped numerous government or health organization from urging us to support breastfeeding because it will solve the obesity epidemic, opting to focus on this convoluted claim rather than the myriad of health benefits that have been repeated consistently over metastudies and reviews (i.e., lower risk of gastrointestinal infection, lower risk of ear infections, hell, even the IQ thing is more soundly supported by the research).

I get why there’s more attention being paid to this finding – it comes from the PROBIT study, which is the closest thing we have to a randomized, controlled experiment in the infant feeding world (other than sibling studies, of which there have been exactly two- at least that I’ve been able to unearth). For those who don’t spend their free time reading the canon of breastfeeding research, let me give you the Cliff’s Notes: PROBIT was a study undertaken in Belarus, which had low breastfeeding rates at the time. They took a cohort of pregnant moms and gave one randomized group more intensive prenatal breastfeeding education and baby-friendly hospital etiquette when they delivered; the other group got the status quo by way of breastfeeding support. The thought was, the group that got better education and support would breastfeed more exclusively and for longer; the other group probably wouldn’t.

Are you confused? You should be. The thing that puzzles me (and hopefully you as well) is that while this plan might have convinced more women to initiate breastfeeding, the same pitfalls that plague all breastfeeding research still remain. Some of the women in the “breastfeeding friendly” group still – presumably – could not breastfeed for physical reasons, others may have chosen not to. All this study can really show us, after all the necessary confounders are accounted for, is whether this type of breastfeeding promotion and support can increase breastfeeding rates. Otherwise, it’s basically more of the same. There are still fundamental differences in the women who were able to breastfeed and those that couldn’t/didn’t.

But, for whatever reason (desperation?) the medical and advocacy communities have grasped onto PROBIT as the Holy Grail of irrefutable breastfeeding science. So, if PROBIT shows that breastfeeding confers no protective effect against obesity, that means something. (Incidentally, as the babies involved in PROBIT get older, I’m sure we will see a lot of headlines on the long-term effects of breastfeeding… so if you’re interested in this stuff, try and familiarize yourself with it now. Here’s some good literature on it, to get you started.)

While I believe, based on my reading of additional research into the obesity link (more on this in Bottled Up, not that I’m plugging my book or anything. I mean why would I have to, book sales being as horrible great as they are?), that there truly is little to no advantage to breastfeeding in regards to later obesity, there’s no excuse for bad science or bad reporting. And this, my friends, is a both. We are taking ONE finding from ONE study – a well-designed one, to be sure, but far from perfect or immune from the problems plaguing most infant feeding research- and proclaiming its results as absolute truth. The sad thing is, some of the biggest breastfeeding advocates are just as guilty of this as the knee-jerking media: Dr. Ruth Lawrence, one of the founders of the Academy of Breastfeeding Medicine, even admitted that she was “disappointed” about the result (although as someone so wisely pointed out on our FFF Facebook page, how freaking ridiculous is it that she is “disappointed” to find out that the vast majority of Western babies – being that they are nearly all at least partially bottle fed – are not doomed to a life of morbid obesity just because their mothers were “suboptimal” breastfeeders?? And what does this suggest about the inherent bias of breastfeeding researchers?).

The near-hysteria surrounding this finding is just further evidence of how warped our thinking is around infant feeding. Why is it such a big deal that breastfeeding doesn’t solve the obesity epidemic? Because we’ve made it a big deal. We’ve built a house of cards on top of this one health claim: it’s the basis of the First Lady’s push to support breastfeeding; Mike Bloomberg has used it to justify locking up formula in NYC hospitals; pretty much every article about breastfeeding in the past year has suggested that formula fed babies better start saving up for Lap Band surgery. The grotesque amount of fat-hating aside (because if you think formula feeders have it bad, you should see how awfully we treat overweight people in our public health discourse), it’s ridiculous that we’ve focused so much attention on this supposed benefit of breastfeeding when common sense says that our nation’s growing waistlines are due to a multitude of factors – genetics, cultural differences, lack of clean air/safe streets/room to move in our cities, processed food, sedentary lifestyles, the time we waste on the (ahem) internet….

My hope is that breastfeeding advocates and health officials might learn from this; that they might take a step back and reassess the way they are promoting something that should be a basic human right as a medical necessity. But at the very least, I hope this will be a cautionary tale for those of us who strive for critical thinking to remain skeptical of absolutism, in both science and in life.


Arsenic and Old Ladies

I’ve learned a valuable lesson this week: don’t put off until tomorrow what you could do today, because tomorrow something even more aggravating might happen and then you find yourself buried in a pile of horse manure.

There are two big stories going down in the infant feeding world at the moment. First, arsenic was found in baby formula. Second, a meddling concerned grandmother decided to investigate the sugar present in formula, and discovered a sticky sweet conspiracy to hook America’s children on simple carbs from day one.

Let’s start with the arsenic scare, because it’s the least annoying story of the two, and better we should ease in to this evening’s exercise in frustration. A group of researchers hypothesized that brown rice syrup, a sweetener often used in organic foods in place of villainous high fructose corn syrup, would have high levels of arsenic. This is because organic arsenic (not the same thing as inorganic arsenic, the kind we commonly hear about in old detective novels) is often present in soil; rice tends to soak up the arsenic, and if brown rice syrup is used in a variety of foods that we eat, it could add up to potentially harmful levels. High levels of organic arsenic have been linked to cancer, heart disease and other health problems. Now, theoretically (and not-so-theoretically, as arsenic has been found in other rice products), any kind of rice-derived food could be a source of trace amounts of arsenic. But if we’re talking baby food, we’re also talking tiny humans who are far more susceptible to chemicals and such. As NPR explains, “The risk appears to be dose-related… with higher levels of arsenic increasing disease risk… Concentrated foods like rice bran or brown rice syrup, which is sometimes used as a sweetener in vegan recipes, can be very high in arsenic…”

(Just want to pause for a moment to muse about the irony of everyone turning up their noses at table sugar and HFCS as if it is poison, and yet something totally organic and supposedly better for you ends up being truly poisonous. As we’ve discussed on here quite a bit, “natural” or “organic” does not always necessarily mean “perfect”. Death is natural and organic, and so is body hair, and I really dislike both of those things and do my best to keep them out of my life.)

So, to be clear – this study was looking at products containing brown rice syrup, especially those fed to babies and children, as their relative risk is higher due to lower weights, developing bodies, and the fact that a lot of kids eat massive amounts of certain products like cereal bars, rice cereals, and yes… formula. One of the types of products tested was infant formula; out of a slew of formulas tested, only two – both organic brands- contained significantly high levels of arsenic. While the researchers would not call out the companies manufacturing these formulas by name, a bit of investigative journalism unearthed that only one company used brown rice syrup in their formulas, and that was Nature’s One, makers of Baby’s Only Organic Dairy Toddler Formula and Baby’s Only Organic Soy Toddler Formula (I say this with an arched eyebrow, as it took me all of 10 minutes to figure out that brown rice syrup was only used by one type of organic infant formula by checking the ingredients of all commercial organic formulas. And yet it took at least a day before anyone was naming names on the news… seriously, guys. It’s called Google.)

Interestingly, Nature’s One is pretty adamant about marketing these formulas as toddler formulas anyway, so they aren’t even technically “infant formulas” – semantics, but important semantics, as the news bytes made it sound like the arsenic problem was a common one, endemic to all infant formulas. Not so much.

Bottom line? The only folks who need to worry about this particular risk of formula feeding are those using Nature’s One products. And if this is you – please don’t worry too much. I might consider switching to another product if you can, at least until more research is done about the true risk of the measured levels of arsenic – but it’s highly doubtful that your baby will suffer any ill effects if s/he has been using these formulas. Talk to your physician, but remember:  all this study showed was that there are relatively high levels of arsenic in ONE relatively unpopular brand of formula – it did not show that this particular level of arsenic was harmful in any way. 

Speaking of Nature’s One, the very reason they got in this pickle in the first place offers a perfect segue into my next topic: sugar in formula. The company prided itself on being the only formula manufacturer to use brown rice syrup as a source of carbohydrate, rather than the other types of sugars typically used in formula: lactose and sucrose:

Organic lactose and evaporated cane juice are simple sugars. Simple carbohydrates are quickly digested and absorbed into the bloodstream, increasing insulin levels. A more complex carbohydrate, such as organic brown rice syrup used in Baby’s Only Organic® formulas, requires more time for digestion resulting in slower and steadier absorption of the carbohydrates into the blood stream and a more constant production of insulin…The medical community has expressed concern over using cane sugar in infant formulas because it is five times sweeter than lactose and could pose health or medical issues related to obesity or dental caries. The carbohydrates in Baby’s Only Organic® Dairy Formula consist of 35% naturally occurring lactose from the organic non-fat cow’s milk and 65% organic brown rice syrup.

Source: Nature’s One Website

In other words, Nature’s One was trying to distinguish itself from other organic formulas with its sugars. Their marketing team was on to something, although sadly for them, by the time society caught up and started freaking out about sugar in formula, it happened to coincide with the discovery that brown rice syrup may pose its own “medical issues”. Coincide as in the very same week.

This sweetener scare was started by a grandma who was troubled by her granddaughter’s rapid weight gain (four pounds in a month) after switching from breastfeeding to formula feeding. She went on a mission to find out just how much sugar was in these “baby milkshakes” her grandbaby was chugging, and was shocked to find out that some formulas contained as much as 13.4 grams of sugar per serving. But the amounts varied, with some formulas only having about 3 grams, and in the formulas with higher sugar, the sugar tended to be lactose, which is the same sugar that’s found in breastmilk (and considered to be a “good” type of sugar). These findings apparently make one pediatric dentist nervous:

Chicago pediatric dentist Kevin Boyd, who also has a Masters in nutrition and dietetics…said he has long been concerned about the sweetness of formula and the effect it has on babies. 

“We’re conditioning them to crave sweetness,” Boyd said. “I would say any formula that has sucrose, it?s super sweet, it makes the kid crave sugar. It triggers the release of dopamine in the brain, and it’s a comfort-level thing. It makes the kid want to eat more, so they become hypersensitive to sweetness.” 

While the amounts of sugar grams may be low, Boyd said the impact on babies is huge.
“They’re conditioned to just really like super sweet?. And their fat cells are saying more, more, more please.”

But color me confused, because breastmilk has around 7 grams of sugar, in the form of lactose, as well.

Formula is trying to get as close to breastmilk as it can in terms of its constituents. Because, as any breastfeeding website will gladly tell you, it’s supposed to be a substitute for breastmilk when babies can’t have the gold standard It’s not being produced as part of a nefarious plot to make the human race a bunch of sugar addicts. Babies are pre-programmed to like sweet things; this is exactly why breastmilk is so much sweeter tasting than cow’s milk. Nutrition guru Dr. Cinque explains it quite nicely:

Breast milk is loaded  with sugar!  Human breast milk has nearly  40% of its calories as sugar! Human milk is the sweetest milk on the planet, and by far.  In this whole wide world of mammals, going from the tiny pygmy shrew which weighs less than 2 grams all the way up to the blue whale, which is the largest animal that has ever lived, to every mammal in between,  none makes a milk as sweet as ours.  Nothing even comes close. Human breast milk, by weight, is over 7% sugar! In comparison, cow’s milk is only 4.8%, goat’s milk 4.4%, sheep milk 5.1%, and water buffalo milk 4.9%…

The news reports were all up in arms that formula companies weren’t listing the amounts of sugar in their products, and I can understand why people might think this was sketchy. But if you look at the back of a formula can, the nutritional information doesn’t look like a normal nutrition label. That’s because formula is not really considered a food as much as a supplement. I’m not condoning that, necessarily, but what other food has a warning on the label stating that you shouldn’t eat it because something else is so much better? (Imagine if the back of your V-8 said “Fresh fruits and vegetables are best. We recommend not drinking this in place of eating fruits and veggies.”) Most parents (and apparently most grandmothers and new reporters) don’t understand the difference between sugars – lactose and sucrose are beneficial in different ways; lactose is the sugar which is in breastmilk and thus preferable for babies, but lactose-intolerant or milk allergic children can’t tolerate this sugar, which is why hypoallergenic or sensitive formulas often use corn syrup solids or sucrose as a carbohydrate instead.

As for the pediatric dentist who jumped on board this particular media circus caravan – the sugar in formula is no more likely to “program” us to like sweet things more than breastmilk, which is (at least in most cases) equally sweetTake a taste of breastmilk, and a taste of formula. Which tastes better? Why would a baby learn to crave sweet things from something that tastes kind of odd and not all that sweet in the first place? Haven’t we all read a ton of anti-formula literature that talks about how bad formula tastes, how much sweeter breastmilk is, etc.? One of the higher-sugar formulas in the study was a hypoallergenic, and this just proves to me how many holes are in this report, because the hypos most certainly do not taste sweet. (This is one of the reasons I knew how much my son was hurting on my milk when we switched from bottled breastmilk to hypoallergenic formula – if he looked so satisfied with something that tasted so god-awful, breastmilk had to have been making him feel horrible.)  From a business standpoint, what benefit would there be to a formula company to make their formula sweeter? It’s not like babies have a say in the matter; parents choose formula based on what coupons they get in the mail, what their friends or pediatricians recommend, or what ultimately works best after a lot of trial and error. How “sweet” a formula tastes does not factor in.

In terms of obesity – there’s no evidence that the sugar in formula causes obesity, as far as I know. If you watch the video about this story, you’ll notice that the baby in question isn’t at all obese, which makes me wonder what the circumstances were prior to her rapid weight gain. Why was she switched to formula? Perhaps the mom had low supply or other feeding problems which were not allowing the baby to gain properly? Without more information, we’re left with half a story. Also, FFF Siobhan caught something interesting in the video that she posted over on the FFF Facebook page – at one point, the grandmother appears to be encouraging the baby to keep drinking her bottle, even though the baby is showing no interest in doing so… “Try a little more?” she says, as milk dribbles out of the baby’s mouth. Perhaps teaching this woman better bottle-feeding techniques would help her combat her fears of baby obesity and feel a bit more proactive.

To review: sugar is not inherently bad, especially for babies; formulas use sucrose or other sugars in place of lactose because some babies can’t tolerate lactose or milk-derived ingredients. Except for a few formulas, most commercial formulas have equivalent (or in some cases less) sugar to breastmilk.

Got it? Sweet.

2012 Resolutions

My parents are in town, so we have free babysitting. Which meant movie night for me and Fearless Husband. We chose to see “Young Adult”, thinking that it would be light and funny; 90 minutes later we were about to poke our eyes out with hot coals, since that would have been less painful. Or at least less emotionally draining. Great acting, but one hell of a downer.

The film got me thinking on a myriad of levels, and one particular element of the script provoked me to come home and visit the blog (much to Fearless Husband’s chagrin, but what can you do… date night or not, I haven’t spent quality time with FFF in quite awhile. Sometimes it feels like I am in a polygamous relationship, I tell ya). Charlize Theron’s character, Mavis Gary, is unlikeable in about one thousand different ways, but you end up feeling sorry for her because she is completely delusional. At the same time, Mavis feels just as sorry for everyone else around her, because she thinks they are ignorant, small-minded simpletons. It’s a weird dynamic to experience as the moviegoer, because you aren’t sure who to identify with: if you empathize with Mavis you’re a cold-hearted egomaniac; relating to the rest of the cast makes you feel like kind of a loser. In the end, you realize that it is all a matter of perception. You can be the hero in your own story, but to everyone else you might be the villain, or even worse, just an ancillary character.

So how does this pertain to our little infant feeding blogosphere? I think the flawed communication and general lack of empathy on the part of many involved on both sides of this debate comes from a similar egotistical P.O.V. as Charlize’s unlikeable character. Perceptions are vague and/or downright incorrect, colored by our own experiences, our own realities. I know full well that some see this blog, and all other formula feeding support, as something vicious; others, as something that should be pitied or handled with kid gloves. And on our end, it’s easy to dismiss all breastfeeding advocates as intentionally obtuse; privileged; limited in scope.
There are many gray areas to this debate, and I think that my New Years Resolution is going to be that I will strive to give that gray some much-needed color. That means more bottle-feeding research rather than simply tearing down breastfeeding studies. (Although this will be hard to do, when studies like this one pop up. Completely aside from breastfeeding, I simply cannot fathom how such a clumsy study has gotten both funding and media attention. I don’t think I need to explain the ridiculousness of what the researchers did here, but if anyone wants to discuss it we can do so on Facebook. Suffice to say – where the hell was the control group of non-exclusively breastfeeding kids who DIDN’T chug sugary drinks? And what’s with the dig about juice? How many leaps did it take to get to the conclusion that this proves anything about the link between breastfeeding and long-term obesity?…Aw, crap. Why do my resolutions never last longer than my neighbor’s Christmas tree?) More attempts to reach out to experts and pick their brains about specific subjects. More support for combo feeders.

Of course, this all can only happen if I get off my ever-growing butt and focus on the blog a little more. Considering I’m only now writing a New Year’s resolution post and it’s a few minutes before January 8th, maybe that should be resolution #1.

The FFF Quick-and-Dirty Guide to Formula Feeding: How much and how often should you feed your formula-fed baby?

There are a ton of charts and calculators online claiming to help you figure out how much you should be feeding your baby. Unfortunately, they are all missing one fundamental message: your baby is an individual. He probably doesn’t adhere to static feeding rules any more than you do. For instance, I tend to eat barely anything during the day, but I chow down like a Sumo wrestler at night. Although this runs contrary to all advice given by nutritionists (I think the breakfast like a king, lunch like a pauper, dinner like a peasant concept is pretty well-accepted across the board), this seems to work for my body and my metabolism. Likewise, there are some kids who eat more, some who eat less, some who eat a ton and then throw it all up because they have god-awful reflux, and some who comfort eat due to stomach distress. The latter two might need some medical help (or a formula switch) to remedy their issues, but my point is that not all babies play by the Baby Rulebook.

I hesitate to give a formal “guide” on how much you should feed your baby, because I believe that for the most part, parental instinct is superior to over-generalized prescriptives. But I know there’s a need for non-judgmental practical advice, so here goes.

Before talking amounts, let’s just go over some basics:

1. You cannot overfeed a newborn. You cannot make a newborn fat. Yes, I know there have been recent studies linking rapid weight gain in infants to later obesity, but come on, people… how many scrawny people do you know who were chubbilicious babies, and vice versa? Newborns do not have the brain power to binge eat. They eat when they are hungry (there is one exception to this, which I will talk about in a second, so bear with me), and when they are full, they will pull away from the bottle or, when they are teeny tiny, they may just unlatch. I’ve heard the warnings about formula feeding parents forcing their kids to finish the last few ounces while the poor babies flail and choke helplessly, but the fact is, any baby who is strong enough to to do the “breast crawl” or handle breastfeeding can make it pretty clear when they are done with a bottle. Just watch your baby – if she pulls away or suddenly doesn’t seem interested in eating, that means she’s done. Doesn’t matter that the feeding guide that came with your formula says she should be eating 3 oz in a sitting; if she acts finished after 1.7 oz, that’s all she needs at the moment. On the other hand, if she downs the 3oz you prepared and is still screaming at you or sucking desperately at the nipple, offer her another few ounces (this is where a formula pitcher or even just a salad-dressing mixer comes in handy – if you make like 10 oz at a time, you can offer smaller amounts off the bat and give only an ounce or tow more at a time, so as to avoid wasting formula.

2. As for knowing when to feed your baby, that’s a matter of learning his hunger cues. All babies have them; the most common ones are “rooting” (moving his head from side to side or opening his mouth wide like a guppy, especially when you touch his cheek or chin); shoving his hands in his mouth; sucking on whatever is in reach; crying (this is what many baby sites deem as a “too-late” hunger cue, implying that if it gets this far you must have been negligent in some way); fussing; or my favorite, sticking out his tongue.

3. As your baby gets older, hunger cues aren’t always so easy to read – babies lose the rooting reflex at a point, and sometimes it can be hard to tell what’s hunger-related fussiness versus plain old fussiness. This is where it’s easy to fall into the trap of giving a bottle for comfort and not hunger. It’s unfair, because one wonderful perk of breastfeeding is that you can pop a baby on the breast at the first cry and no one thinks anything of it; do the same with a bottle and you’ll be warned against obesity and blamed for your child’s emotional eating problem in 20 years. Fun times. Professionally, I know the right thing to say is that giving a bottle to calm a baby is probably not the best idea – in fact, I kind of think giving the breast to calm a baby would have many of the same negatives. But personally, as an ardent supporter of Path of Least Resistance Parenting, let’s just say I would never fault someone for giving a comfort bottle when their baby is screaming bloody murder in the car or whatever. Sometimes, you just need to calm the kid down, and if other things aren’t working… well, do what you need to do. As long as it isn’t a daily habit, I wouldn’t worry too much about it.

4. Okay, remember I mentioned there was an exception to the stuff I’ve been saying? That exception is if the baby has an underlying GI or health issue which may make eating challenging in any number of ways. For example, if your baby has an allergy or intolerance to formula, or severe reflux, the “classic” presentation is that she will refuse the bottle altogether, and show signs of failure to thrive. But sometimes this can manifest in what’s known as comfort feeding. Imagine that you’re a baby, and your stomach is constantly hurting or your esophagus feels like fire. And then imagine that when cool, smooth liquid is running down your throat, and you have that lovely sucking motion going on…. not all babies are going to make the association that it’s eating which is causing all the pain to begin with.

Reflux is tricky too, because some kids may eat a ton and throw up the majority of it; it might appear that they are over-eating, but really they’re keeping down the bare minimum of daily calories. Confusing matters further, kids who do eat too much for their little bellies will simply spit up the extraneous amounts; some might assume this is reflux – and a vicious cycle can begin. But I’ll tell you a little story: my Fearlette was consuming about 32 oz of thickened formula (fed in frequent, small amounts) a day. About 15 oz of that was getting regurgitated on a daily basis. She was the scrawniest baby you’ve ever seen, sometimes scarily so. But to read the “how much should they be eating” charts, you’d think I was doing everything wrong.

Bottom line? There are exceptions to every rule. I’ll say it again – every child is an individual. It’s far more helpful to focus on getting to know your kid- her quirks, her cues, her special needs – rather than knowing what the experts say you “should” be doing.

I know you’ve probably skimmed to the end of this novella and are probably wishing I’d get to the point – FFF, just shut up and tell me how much and how often should I feed my baby, dammit – so here you go. The basic rule of thumb for formula feeding:

For every pound your baby weighs, s/he should be eating approximately 2.5 oz of formula. So if she is 10 lbs, that’s 25oz per day. Most kids top off at 32 oz; the general consensus is that anything between 16-32 oz per day is in the realm of “normal” (god, I hate that word). In terms of how often, most sites/experts advise every 2-4 hours in the beginning, with longer stretches at night as the baby grows. Again using our 10-pounder as an example, this might mean five 5-oz bottles per day. But some kids are snackers, so this could also mean feeding a baby every 2-3 hours with 2-oz bottles. Just depends on the kid.

Let’s assume you have the most textbook child on the planet, though; in this case, your best bet would probably be to distribute those 25 oz primarily in daytime hours, assuming the 10- pounder is at least 8 weeks old and can go longer stretches at night. You might do a 5oz bottle at 9am; 12pm, 3pm, 6pm, and then top him off with 3 oz around 9pm to help him go through the night, with probably another 2oz around 5am. Figure out the schedule that works best for your baby; my point is just that many kids will only be able to handle a specific amount at a time, and at certain times they may want more than others. Many breastfed babies do what is called “cluster feeding”, meaning they have numerous short nursing sessions all clumped together in a short time period. Formula fed babies can do this too (obviously), by drinking smaller amounts every hour or so. (If she usually takes a 4oz bottle every 3 hours, you can do a 3-oz bottle an hour before bedtime and then another 2 right before she goes down.) Some claim that this allows babies to sleep longer stretches at night; kind of the equivalent of carbo-loading before a marathon. I did find with both my kids that if they did some cluster feeding around bedtime, they slept better. Could have been a fluke though.

During growth spurts, you may find that your typical amount isn’t enough. I think that as long as you have spent time getting to know your baby’s hunger cues, you can feel pretty safe just feeding on demand. But also keep in mind that kids can get might ornery during these growth spurts, so it is possible that they will cry a lot and it won’t necessarily mean they are hungry. Do whatever it is you do to comfort them, and if it doesn’t work, let them eat. Babies don’t play mind-games: if something else is wrong, your baby will probably keep freaking out despite your sacrificial offering of Enfamil. If she’s hungry, she’ll eat and hopefully sleep… well, you know.

Like a baby.

Whatever the hell that means.

Fun and games with Kaiser’s new breastfeeding policy

This image was used in conjunction with this story, about how Kaiser Permanente (an American health system which prides itself on being Baby Friendly) is now promoting breastfeeding as a means to fight obesity.

For our first game, I’ll give you two guesses as to where I am heading with this one.

The article states that “The breastfeeding-obesity link is now recognized by key government agencies such as the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP).” True dat, as they say. The LINK between reduced chance of obesity and breastfeeding is certainly recognized by the CDC and AAP (although last I checked, the AAP was not a “government agency”, but rather an independent association of pediatric physicians). But, um, a link is not a cause or cure. It’s a link.

The CDC’s own document on the breastfeeding/obesity link states:

…Breastfeeding is associated with a reduced odds of pediatric overweight; it also appears to have an inverse dose-response association with overweight (longer duration, less chance of overweight). While more research is needed, exclusive breastfeeding appears to have a stronger effect than combined breast and formula feeding, and the inverse association between breastfeeding and overweight appears to remain with increasing age of the child. The three meta-analyses reported in these review articles suggest a 15% to 30% reduction in odds of overweight from breastfeeding.

If you read the entire report, you’ll see that several of the studies in question reported a reduced risk of obesity with breastfeeding initiation – meaning that if women just breastfed in the hospital, there was less of a chance that the child would be overweight. And all studies were observational in nature, as the report authors go on to explain:

There are several possible explanations for why breastfeeding appears to reduce the risk for overweight, but conclusive evidence is not yet available. The studies presented in this brief are limited in that they are based on observational studies and cannot demonstrate causality. One possible explanation for why the literature indicates that breastfeeding reduces the risk of overweight is that the findings are not true but instead are the result of confounding. It may be that mothers who breastfeed choose a healthier lifestyle, including a healthy diet and adequate physical activity for themselves and their children. This healthier lifestyle could result in a spurious relationship between breastfeeding and reduced risk of overweight. The results of Arenz et al. and Owen et al.,however, suggest a true relationship between breastfeeding and reduced risk of overweight, because after adjusting for potential confounding variables, significant inverse associations remained. For example, Arenz et al.reported a significant adjusted OR of 0.78 (95% CI: 0.71, 0.85) among nine studies that adjusted for at least three of the following confounding or interacting factors: birth weight, parental overweight, parental smoking, dietary factors, physical activity, and socioeconomic status/parental education. Similarly, when Owen et al.30 conducted a subanalysis of six studies that controlled for possible lifestyle confounders, the significant inverse association between breastfeeding and pediatric overweight remained, but it was smaller than in the unadjusted analysis. While randomized clinical trials are required to adequately test this relationship, it is unethical to randomize infants to a group with no breastfeeding because of breastfeeding’s known health benefits…

Fair enough. But then the paper launches into a slew of hypotheses about why breastfeeding confers a protective effect against obesity (none of them proven, or even studied, in some cases) and continues with a lengthy discussion about how to improve breastfeeding rates. So what can we gather from this paper?

1. Breastfeeding is associated with a lower risk of obesity.
2. We don’t know why.
3. Breastfeeding rates are low.

Hardly evidence-based proof that we should be promoting breastfeeding as a means of reducing obesity, and yet, here we are again, beating the same dead horse. Somebody should probably call PETA.

Time for the next game… going back to the image at the top of this post… can you spot the misleading or outright false claims?
First of all, breastfeeding does not “prevent” asthma. In fact, several studies (like this one and this one) have suggested that longer breastfeeding may increase the risk of asthma in babies whose mothers have the disease. One meta-study recommended that short-term breastfeeding (4-6 months) was optimal for asthma prevention, but that breastfeeding longer than that may have a reverse effect; another, published in 2011, “(did) not provide evidence that breast feeding is protective against wheezing illness in children aged 5 years and over.”
Breastfeeding also does not “prevent” postpartum depression; this particular claim is outright dangerous. If women believe that breastfeeding protects them from getting PPD, they may fail to seek treatment when symptoms arise. The only studies I’m aware of show an association between breastfeeding cessation and PPD; all this proves is that women who already are showing symptoms of PPD are more likely to quit breastfeeding (another plausible theory is that breastfeeding failure may be a risk factor for PPD).
I’m not sure how this image is being used, but it concerns me…. this is exactly how misleading information spirals out of control. If policymakers and physicians do not have the good sense to differentiate between “links” and causalities, what hope do we have for the general public having a decent understanding of what will impact our health?
Breastfeeding may be good for baby, and good for mom. But please, can we stop with the false advertising? It’s not fair for the formula companies to do it, but it’s just as unfair for the government or health authorities to make unsubstantiated claims. Maybe even worse – we are taught to be skeptical of big corporations, but most of us still have a blind faith that doctors and health organizations are 1) honest and 2) out for the common good. I still believe #2 but I am highly doubtful of #1. And I’d still prefer the truth, even if does make for a less convincing “sell”.

One more little postscript…. my friend J is exclusively breastfeeding, and is a member of Kaiser. Despite the fact that you can’t go two feet in a Kaiser hallway without seeing a breastfeeding promotion poster, she was recently prescribed an allergy medicine that killed her milk supply. She couldn’t understand why her son seemed fussier all of a sudden, until she tried pumping first thing in the morning (her son sleeps through the night, so she hadn’t nursed for over 6 hours and should have been full) and only got a few drips. When she called Kaiser to inform them of this development, they told her that since the meds she was given weren’t contraindicated for breastfeeding, they were deemed “safe” even though she was a nursing mom. She asked what was safe about not having enough milk to satisfy her baby, and the nurse on the phone told her that “she could always just give him formula.”
Interesting. I guess she can blame that nurse if her son is chubby at the age of 5, huh?
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