Category Archives: policy

A slightly curmudgeonly rant about the drama over Save the Children’s “Superfood for Babies” campaign

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The problem with writing a post which criticizes an organization which strives to help starving kids is that it makes you feel like the Grinch. Or Gargamel. I feel like I should be stroking an acrimonious cat and arching a pair of overgrown eyebrows inward.

Save the Children does a lot of wonderful things for children in dire straits, and I don’t want to come down on them too hard. And in many respects, I applaud their recently announced “Superfood for Babies” initiative. I do believe that breastfeeding is a hugely important part of improving childhood mortality in resource-poor nations, and the report supporting the program offers some excellent perspective on the challenges of raising exclusive breastfeeding rates in these areas.

In public health circles, there’s a lot of discussion on messaging – how to make PSAs culturally appropriate, sensitive, and effective. The thing is, this doesn’t only hold true for at-risk groups – it also applies to the middle-class factions of western nations. It’s just as ineffective (and inappropriate) to try and graft a message addressed to people living in tribal societies with problematic water sources onto a secretary in suburban Iowa as it would be to do the opposite. Yet, this is what happens – repeatedly – in our international discussions of breastfeeding. (Incidentally, this is at the root of my beef with Unicef and WHO, and why I feel it’s necessary to amend the Baby Friendly Hospital Initiative set forth by those organizations to be more culturally appropriate to developed, Western societies.)

This brings us to my scroogey analysis of the “Superfood for Babies” campaign.  I would encourage everyone to read the literature – it offers some truly excellent insight into the specific issues at play in a variety of developing nations, and makes it clear (whether or not it intends to) that formula is not the only barrier to encouraging exclusive breastfeeding. In some cultures, there are beliefs that breastfeeding for the first few days of a babies life is detrimental; in others, women feel pressured to produce as many babies as possible, thus making the fertility-restricting nature of breastfeeding a downside; and in others, it’s not formula which is used as a supplement but raw animal milks or concoctions of grains.

Save the Children (STC) did a lot right with this report. They addressed the need for social change; advised that governments subsidize breastfeeding women so that those in unstructured agricultural jobs (which don’t exactly come with a 401k or paid maternity leave) don’t need to return to work immediately, and have to choose between making a living and feeding their babies; and they press for better education and involvement from medical workers and midwives. I think their motives were great, and they did their homework.

Unfortunately, in their excitement, they lost perspective in three key areas…

1. They were (intentionally or unintentionally) vague about the research

Look, I would never argue that breastfeeding isn’t the best choice – by far – for babies in places where food is scarce, infection and disease runs rampant, medical care and antibiotics are severely limited, and the water source is questionable. Formula feeding is dangerous in these settings. But since breastfeeding advocates and orgs like WHO have made breastfeeding a global issue, we have a responsibility to be honest about what our body of research actually says. There are numerous instances in the STC report where claims are simply not held up by their citations. For example, this quote, on page vii of the report’s introduction:

It is not only through the ‘power of the first hour’ that breastfeeding is beneficial. If an infant is fed only breast milk for the first six months they are protected against major childhood diseases. A child who is not breastfed is 15 times more likely to die from pneumonia and 11 times more likely to die from diarrhoea[2]. Around one in eight of the young lives lost each year could be prevented through breastfeeding,[3] making it the most effective of all ways to prevent the diseases and malnutrition that can cause child deaths[4].

Let’s take a closer look at the citations. The first one, #2, is from a UNICEF report on diarrhea and pneumonia- not a study, but a report. So it took a bit of digging to see exactly where they were getting their data from. I *think* this figure comes from a table attributed to a Lancet piece, which “estimated”  that “Suboptimum breastfeeding was… responsible for 1·4 million child deaths and 44 million disability-adjusted life years”. I couldn’t get the full study on this one, but again – it was an estimate, most likely based on other studies – not hard data.

Citation #4 is the one that’s bothersome, however (#3 is just a footnote with the definition of “exclusive breastfeeding”). The sentence “making it the most effective of all ways to prevent the diseases and malnutrition that can cause child deaths” is most likely read as “breastfeeding is the most effective way to prevent child death”. That’s quite emotive. The citation leads you to a Lancet paper on child survival, which does have some dramatic data and charts regarding the interventions which would most reduce infant mortality in the developing world. Breastfeeding is shown to offer the most dramatic reduction in risk- but there’s one important point to consider: while this report focuses on death in children ages 0-5, the majority of these deaths occur in the first few months of life. Exclusive breastfeeding, as opposed to mixed feeding or exclusive feeding of substitutes including goat or buffalo milk, paps, or formula (important to note that in many of the countries STC is concerned about, traditions include feeding neonates animal milks or solids within hours of birth – so I think it’s arguable that the issue here is the risk of giving a baby anything but breastmilk via the breast, rather than breastfeeding being the “magic bullet” the report dubs it to be. Otherwise, we probably wouldn’t see consistently poor outcomes in mixed-fed kids, as a “magical” substance would compensate) is going to reduce the risk of infections that cause death in very young babies. In other words – if the most deaths are in newborns, and breastfeeding saves newborns more than any other interventions like vaccines, clean water, etc – then there will be a disproportionate representation of “babies saved by breastmilk” in the results. This is not to say that breastfeeding isn’t an incredibly worthwhile and effective solution to reduce infant mortality, but it’s a bit of a stretch to suggest that breastfeeding alone will be the most effective intervention for ALL childhood deaths, which is exactly what the STC report does.

2. They didn’t consider the societal implications of their recommendations, beyond the scope of infant health

I was taking notes as I read the STC report, and my heading for the section which included this quote was “OMGOMGOMG”:

Many women are not free to make their own decisions about whether they will breastfeed, or for how long. In Pakistan, a Save the Children survey revealed that only 44% of mothers considered themselves the prime decision-maker over how their children were fed. Instead it is often husbands or mothers-in-law who decide….

 

….To overcome harmful practices and tackle breastfeeding taboos, developing country governments must fund projects that focus on changing the power and gender dynamics in the community to empower young women to make their own decisions.

Changing the power and gender dynamics sounds like a fantastic idea, and I would support any program that attempted to do this. But STC has to realize that “empower(ing) young women (in developing countries) to make their own decisions is a complex and uphill battle that extends far beyond infant feeding. I fear that by placing an emphasis on UNICEF-lauded solutions like warning labels on formula cans/making formula prescription-only, and on educating fathers/elders on the importance of breastfeeding using the current overzealous and often misleading messages, in these countries – places where, all too often, females are already considered “property” and subjected to any manner of injustices – it will create an atmosphere where women who are physically unable to breastfeed will be ostracized, shamed, or penalized. I agree that we need to empower women, but I think that we also need to be verrrry careful about presenting “suboptimal breastfeeding” as a risky behavior in certain cultures.

In another section, the authors report that breastfeeding rates have gone up in Malawai despite poor legislation on maternity leave, breastfeeding rights, etc. – that these improvements are based solely on strict implementation of WHO Code. I’d like to be reassured that as women are being given no option other than breastfeeding without any of the protections which would make EBF feasible while working, this isn’t having a deleterious effect on their lives. It’s wonderful that breastfeeding rates are up, but what about correlating rates of employment, poverty, and maternal health?

3. They failed to differentiate between resource poor and resource rich countries

I’ve seen a wide range of opinions on the STC program online in the past few days. Most of the drama is over British media reports which mention putting large warning labels on all formula tins – not just the ones going to resource-poor countries. Some feel that these labels will cause unnecessary upset in the West; others argue that when it comes to saving starving/sick third-world babies, privileged mommy pundits should STFU. And others keep insisting that the STC report was misrepresented, and that the labeling stuff was a minor part of the larger plan and shouldn’t be harped on.

All of these arguments are valid, and yet all are missing the nuance necessary to have a productive conversation. We need to realize that not breastfeeding has quite different implications in certain parts of the world. We also need to acknowledge that a woman’s rights are important no matter how much money she has or where she lives, and that we all have a right to stand up for what we believe – it’s rather useless to play the “eat your dinner because children are starving in Africa” game, and rather un-PC as well.

But STC also needs to take responsibility, here. The fact is that the report does not really differentiate between resource-poor and resource-rich countries when it is discussing WHO Code and formula marketing.  For example, this passage on p. 45 describes laws which STC wants implemented worldwide:

Breast-milk substitute companies should adopt and implement a business code of conduct regarding their engagement with governments in relation to breast-milk substitutes legislation. Companies should include a public register on their website that outlines their membership of national or regional industry bodies or associations, any meetings where the WHO Code or breastfeeding is discussed, and details of any public affairs or public relations companies they have hired, alongside the nature of this work… Any associations (such as nutrition associations or working mothers’ associations) that receive funding from infant formula companies should be required to declare it publicly. In addition to this information being made publicly available on the websites of individual companies, the International Association of Infant Food Manufacturers should publish a consolidated record of this information, updated on a quarterly basis.

Personally, I think the money spent on a “governing association” in order to police this policy would be better spent on funding literacy programs to help parents read the labels we’re arguing about. Some of these countries have literacy rates of like 30% – which makes me wonder exactly who the labels are geared to, if not the Westerners for whom formula feeding is far, far less of a risky endeavor.

Don’t mistake me – the evidence given in this report about the shady practices of formula co’s is alarming. There needs to be something done about unethical marketing practices in parts of the world where information is limited, education is a true privilege, and options are a joke. Yet, in the STC report, there is ample (and quite good) evidence that the unethical efforts of formula companies are only one slice of a thick-crust, Chicago-style pizza. There’s a lot of gooey, barely distinguishable elements which all combine to make a rather heavy problem, and focusing so much on one of them will leave you with the policy equivalent of Domino’s.

Further, the situation with breastfeeding in the developing world is markedly different from what’s going on in Great Britain, the US, Canada, and so forth. The online arguments are proof of this. I’ve seen the same people who argue that breastfeeding is a global issue turn around and tell concerned Americans and Brits that they have no idea what’s appropriate in Peru or Ghana. This may be true, but so is the reverse. International groups like STC have to remember that when they release papers making global recommendations about infant feeding, that they are inviting commentary from a global audience. That’s why we can’t make blanket statements about infant feeding and child health, or try and implement the same rules in order to get the same results. We wouldn’t go into a rural village where families share a 300-square foot hut and start lecturing them about the dangers of co-sleeping, and yet we assume that the same one-size-fits-all public health messaging is fair game when it comes to infant feeding. Breastfeeding might indeed be a global issue, but the type of issue it is varies greatly depending on what part of the globe you’re on.

 

Dear Mayor Bloomberg: Please stop the smoke and mirrors

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Dear Mayor Bloomberg,

I’m sure you’re sick to death of hearing about the Latch On NYC initiative. There’s been so many blog posts, opinion pieces, counter-opinion pieces, etc., inspired by the announcement of this policy… I felt it was redundant to add more fuel to the fire, after I said my piece the week the policy was made public. I was hoping to avoid making this personal, as we’re both from the same town (in fact, my mom and you were neighbors growing up) and I always had a soft spot in my heart for the local boy made good.

But unfortunately, your camp has made that an impossibility. Not necessarily because of the policy itself (although I do have many problems with it), but because they have pulled the most transparent, juvenile stunt that essentially begs for caustic commentary.

Back to the policy for a minute: I’m sure you’re aware that it has changed dramatically. So much so that everything I talked about in my prior post now sounds like the rantings of a paranoid moron, with a fondness for extrapolation. And it’s not just me – smart, rational women like Katherine Stone are enduring an onslaught of patronizing op/eds which reduce their concerns over personal autonomy and women’s rights to a “misunderstanding” of the policy.

I have serious concerns about the capabilities of our country’s journalists for not pointing out the giant, defecating elephant in the room: the reason there is a disconnect between what those of us who have raged against the policy wrote, and what is now being written by people sounding far more rational and balanced, is that the literature that was initially published online by your Dept of Health has been erased from existence. In its stead lies a “Myths and Facts” document, a step-by-step dismantling of the concerns brought forth by the initiative’s critics.

The outlining of the plan which made me so hysterical? They literally made it disappear. As in, whoosh, the hat became a rabbit. No public announcement admitting that your administration had overstepped or misjudged; not even an acknowledgment that the policy had been altered or revised. Just one day there, next day not.

Let’s walk through the new “Myths and Facts” document which took the place of the old “FAQ”. Unfortunately, I did not take screen shots of the original – I wish to god I did, but I naively never thought your office would condone such a blatantly disrespectful, Orwellian action. Luckily, a fantastic blogger at a site called Breastfeeding Without BS copied the sections I found most troubling verbatim on her post about the initiative, so we still have access to the text as it originally appeared.

What the new document says:

Myth: The city is requiring hospitals to put formula under lock and key.

Fact: Hospitals are not being required to keep formula under lock and key under the City’s voluntary initiative. Formula will be fully available to any mother who chooses to feed her baby with formula. What the program does is encourage hospitals to end what had long been common practice: putting promotional formula in a mother’s room, or in a baby’s bassinet or in a go-bag – even for breastfeeding mothers who had not requested it.

What the old document said:

What does it mean to restrict access to formula?

Restricting access to formula means storing formula away from where it is easily visible and accessible to staff and mothers. Access to formula is restricted by both:

…Storing formula in a locked location, such as a storage room, cabinet or an automated medication system or, storing formula in a location outside, but reasonably near, the maternity unit……Limiting the number of hospital staff with access to formula by implementing a system to identify which hospital member accessed the formula supply; some examples are a log book, a code or a key system. 

 

Mayor, I’m confused. How is keeping formula in a “locked location”, available to only a “limited number of hospital staff” who should use a “log book, code or a key system”, making formula “fully available to any mother who chooses to feed her baby with formula”? I don’t recall if the original document explicitly stated that hospitals must keep formula locked up or if it was merely suggested, but in either case, I don’t think it’s a stretch to see why this particular “myth” seemed like a scary truth to many of us.

 

What the new document says:

Myth: Mothers who want formula will have to convince a nurse to sign it out by giving a medical reason.

Fact: Mothers can and always will be able to simply ask for formula and receive it free of charge in the hospital – no medical necessity required, no written consent required.

Myth: Mothers requesting formula will be subject to a lecture from the nurse.

Fact: The City’s new initiative does not set a requirement that mothers asking for formula receive a lecture or mandated talk. For the last three years, New York State Law under the Breastfeeding Bill of Rights, has required that mothers simply be provided accurate information on the benefits of breastfeeding. This requirement has not changed under the City’s new initiative.

What the original document said:

What do we tell our staff to do when mothers (families) request infant formula? 

While breastfeeding is healthier for both mothers and babies, staff must respect a mother’s infant feeding choice. Educating mothers and families about breastfeeding and providing encouragement and support, both prenatally and after birth, is the best way to ensure breastfeeding success in your hospital.

While in the hospital your staff can:
Assess if breastfeeding is going well and encourage the mother to keep trying.
Provide education and support to mothers who are experiencing difficulties.
If the mother still insists on receiving formula, document it in the chart along with the  reason and distribute only the amount of formula needed for the feeding.
Train staff in breastfeeding support (CLC, IBCLC) who can be available to assist new mothers at all times regardless of day, night or weekends.

 

Notice the difference in language and tone here. “Mothers can and always will be able to simply ask for formula…no medical reason or written consent needed….” versus ‘Assess if breastfeeding is going well and encourage the mother to keep trying…if the mother still insists on receiving formula, document it in the chart along with the reason and distribute only the amount of formula needed for the feeding.” We’re talking semantics here, but policy is all about semantics – and the “myth” sounds an awful lot like what was written in their initial, official FAQ literature. Obviously it does not state simplistically that moms will have to “convince a nurse” that there is a medical reason, or be “subject to a lecture”, but I don’t think it’s much of a stretch to imagine that this will be what ends up happening when the policy enlists health care providers to “encourage” a mom who has already made a decision – for whatever personal reason – that she wants to supplement; I don’t think it’s overreacting to take umbrage at the terminology “if the mother still insists” or the fact that nurses are told to only give the amount of formula needed for that feeding. As BF without BS so eloquently put it:

But what does “Assess if breastfeeding is going well and encourage the mother to keep trying” actually mean in practice? If the mother says clearly “I don’t want to do this any more,” is the nurse required to keep urging her to continue? Where do you draw the line between support and nagging? The initiative gives us no clear answers. Certainly, the use of the word “insist” here is deeply problematic. My understanding is that a person only “insists” on doing something when they continue to state their need after having experienced a considerable amount of pressure to do the opposite.

 

What the new document says:

Myth: Latch on NYC is taking away and/or jeopardizing a woman’s right to choose how to feed her baby.

Fact: The initiative is designed to support mothers who decide to breastfeed. For those women, the program asks hospital staff to respect the mother’s wishes and refrain from supplementing her baby with formula (unless it becomes medically necessary or the mother changes her mind). It does not restrict the mother’s nursing options in any way – nor does it restrict access to formula for those who want it.

Myth: Formula will be forbidden in some fashion.

Fact: If a mother decides she wants to use formula (or a combination of formula and breastmilk), she will be supported in her decision and her baby will be given formula during the hospital stay. If a breastfeeding mother changes her mind or requests formula at any time, her baby will be given formula.

 

In the original document, considering there is no further instruction given on subsequent requests, I think it was fair fair to assume – or at least to fear – that a lecture and limited formula will be the protocol for each and every feeding. It would have been easy enough for the authors of this document to add “Once it has been established that the mother has made an informed decision to formula feed, she should be given formula without further questioning, upon request” or even better, “a supply of ready-to-feed, pre-sterilized bottles and nipples should be left in her room for feedings.” As a formula feeding mother, that is what  ”not restrict(ing) the mother’s nursing options in any way “ and not “restrict(ing) access to formula for those who want it” means.

 

What the new document says:

Myth: Positive benefits from breastfeeding are being overblown or aren’t true.

Fact: There is overwhelming evidence, supported by national and international health organizations, showing that breastfeeding produces better health outcomes for babies and mothers than formula. For mothers, breastfeeding reduces the risk of breast and ovarian cancers. Babies that are breastfed have a lower risk of ear, respiratory and gastrointestinal infections, as well as childhood asthma, than babies who are formula fed.

The American Academy of Pediatrics just published new guidance to pediatricians in February 2012, reaffirming the evidence that the health benefits of breastfeeding over formula are clear: http://pediatrics.aappublications.org/content/129/3/e827.full.pdf+html

What the “Initiative Description” (which is still available – for now – here) says:

Formula feeding markedly increases serious health risks for infants, including:

o 257% excess risk of hospitalization for lower respiratory infection

o 178% excess risk of diarrhea and vomiting o 100% excess risk of acute ear infections

o 67% excess risk of asthma for infants with a family history of asthma (35% for infants with no family history of asthma)

 

Again, the language here is markedly different. The spin doctors who have performed surgery on this document are skilled; I’ll give them that. I don’t think most of us would argue that there have been “better health outcomes” reported for breastfed babies; it’s the inflated representation of the statistics that we found misleading – a “100% excess risk of acute ear infections” sounds like formula fed babies have a 100% greater chance of getting ear infections to the untrained ear, and most of the NY public probably doesn’t have an advanced understanding of statistics.  But that’s almost irrelevant. The more important point here is that neither of these passages addresses the concerns that scholars like Joan Wolf have brought up, or the writers who have used her work to illustrate their essays: concerns like the confusion of correlation and causation, and the inherent flaws in breastfeeding studies, which make these statistics (even in their non-puffed-up form) questionable. Where’s the acknowledgment that even the literature used to support these claims has a clear warning that these very issues need to be addressed?

As I stated in my original post on Latch On NYC, I think it is a positive thing to support breastfeeding by not shoving formula in a mother’s face at the first sign of breastfeeding challenges. I think it’s wonderful to offer more lactation support, and to encourage rooming in, and not insist on formula supplementation unless it is medically indicated.  But this is not  all that Latch On NYC, as initially put forth to the public, is doing. Notice that there has not been the sort of outrage we’ve seen regarding this initiative towards any other Baby Friendly Hospital Initiative in the country. This outrage has come from breastfeeding moms and formula feeding moms alike. It has come from Democrats and Republicans and Independents. It has come from people who don’t even have children, nor plan to. There was a reason for this outrage, and I think it is unspeakably rotten for the mayor’s office to perform this rather amateur feat of smoke and mirrors to make it look like the vast majority that disapprove of this act are either anti-breastfeeding or ignorant.

Mayor Bloomberg, I hope that the scarier aspects of this initiative have been erased along with the document that outlined them. I’d much rather have the expectant mother of NYC be spared from injustices than be “right” about what I feared regarding this policy. But I would implore you to come clean about how this all went down; to allow this initiative to start out on the right foot. It will not help raise breastfeeding rates to have women going into    NYC labor and delivery suites with their cockles up, ready for battle. There are elements of this plan which should be rightly celebrated, and you have essentially rendered that impossible by allowing for such dirty warfare. Those of us who raged against the original plan are not a bunch of uneducated militants who work for the formula companies. We are mothers, daughters, and concerned sisters, some of whom have experienced the sting of breastfeeding “failure” on a personal level, and others who have studied this discourse and its historical relevance at length, and simply feel that there are better ways to support breastfeeding than to frame formula as the enemy. I beg you to sit down with some of us and listen to what we have to say, and at the very least, make the original FAQ PDF reappear. It won’t require magic, just the small bit of courage it takes to admit you were wrong and promise to try better next time. We are all trying to win the same war (better support for new moms, and healthier babies for NYC and the country at large), so let’s not get ourselves caught up in friendly fire…okay?

Best,

Suzanne Barston, FearlessFormulaFeeder.com

 

Fun and games with Kaiser’s new breastfeeding policy

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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?

Formula feeding in disaster situations: Is there a dose of reality in your emegency kit?

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I hope there is a correlation between formula feeding and developing a good bullshit meter, because guys – you all need one to survive what’s going on in the world of infant feeding.

Someone emailed me today about emergency preparedness. She was in the process of weaning, after an extremely difficult struggle with breastfeeding and an emotionally draining decision to stop the madness. There were storms where she lived, and she got to thinking that in the case of emergency, she’d need formula. So she did what any educated, concerned, modern mother would do: she googled. And instead of finding practical information on what should be in a formula feeding parent’s emergency preparedness kit, she found endless supplies of breast-is-best admonishments.

Her email could not have come at a more opportune time, because later in the day, I came across a series of Tweets about a “new study” outlining the specifics of emergency preparedness for both breastfeeding and formula feeding moms. The tweets linked to articles alluding to this paper from the International Breastfeeding Journal (surprising, isn’t it?), which the media presented as a “study” about how dangerous it is to be a formula fed baby in a disaster, even in a developed country.

Erm, no.

The “study” is actually a paper talking about the stuff mothers should have in stock in case of emergency. Now, it’s perfectly understandable that breastfeeding is far more ideal than formula feeding in emergency situations. Formula feeding in times of disaster, especially when water and supplies are scarce, is terribly difficult. But the way that this paper presents these facts is highly offensive, as it reads like a bad joke: What do formula feeding moms need in disasters? $500 worth of gasoline, formula, bottled water, cleaning supplies, a tool kit, knife, and Davy Crockett. What do breastfeeding moms need? Diapers and wipes.

There’s truth to this, of course. The abstract states that “Emergency management authorities should provide those who care for infants with accurate and detailed information on the supplies necessary to care for them in an emergency, distinguishing between the needs of breastfed infants and the needs of formula fed infants.” Fair enough… I agree that it is vitally important that parents and emergency workers know how to prepare and provide safe formula to babies.

Going back to that bullshit meter, though, mine was registering a 9/10 for this “study”. As early on as the introduction, the authors reveal their bias:

“In an emergency situation, infants who are exclusively breastfed have their health and well being protected by the food, water and immune factors provided by breast milk. Breastfeeding also mitigates physiological responses to stress in both infants and their mothers, helping them to cope with the stress of being caught up in an emergency situation… mothers who are exclusively breastfeeding are able to continue to provide food to their infants regardless of the stress they might be experiencing and their own access to food.”

Based on WHAT? They do not cite any studies for the latter claim; as for the one about breastfeeding mitigating stress, the only citation is an e-pub by one of the same authors as this study, in a journal called “Disasters.” I’ll have to track it down, because I’m curious what evidence they have for this dubious statement. Frankly, knowing the trouble most American women have initiating breastfeeding successfully, I kind of doubt a mom with a 5-week-old would find breastfeeding less stressful than trying to prepare formula safely (even if she had to use a knife and liquid petroleum gas, as this paper suggests).

As for the assertion that a mom can produce adequate milk no matter if her own food supply is insufficient or if she is under extreme stress, I again cry bullshit. What about this study, which shows that stress hinders letdown? Or this one, which talks about the effect of dehydration on lactating mothers? (Let me not the scarcity of studies on maternal stores… lots of them on goats, but not so much on human females. Doesn’t seem to matter if the mom drops dead from malnutrition or dehydration as long as the baby is getting enough, apparently.)

Then, the authors begin to delve into what appears to be their real agenda – discouraging formula donations, even from the formula companies themselves. They claim it’s because breastfeeding moms may receive the samples and sabotage their breastfeeding abilities (okay, I will concede that point, but what about the moms who are having trouble keeping up supply for the reasons above?), and also because it might be distributed to those who don’t know how to properly store and prepare it. Bullshit. If it’s between a baby starving to death or taking the risk that the parents don’t know you’re supposed to slice the top of the formula jar with a knife cooked to 100 degrees celsius, well, I think the answer is pretty obvious. A parent will either know this stuff because the message has been adequately imparted, or they won’t. Not having enough formula is not going to change that. The authors recommend that money be given to the “proper” organizations instead, who can correctly distribute the formula. No offense, but UNICEF has not impressed me with their knowledge or concern for formula feeding or non-breastfeeding Western women.

Speaking of non-breastfeeding Western women, I also wanted to know – especially in light of that Tweet about the Japan earthquake I talked about yesterday – what all of this hullabaloo was based on. The authors of this study cite a case (no citation, so I can assume this was something the authors heard word-of-mouth) from Katrina where a 3-week-old baby starved to death after being stranded on a roof with its mother and no formula. Apparently, the woman’s breasts were full of milk, but “initiating breastfeeding had not occured to her.”

Maybe that happened. If it did, that is horribly tragic. But we’re talking about disasters. Disasters. People do not think straight. That woman was stuck on a roof with a baby. Even if she had been successfully breastfeeding, god knows what would have happened. It seems really inhumane to me to take stories like this and turn them into cautionary tales against formula feeding.

The authors claim that “(t)he purpose of this paper is to detail the supplies needed by the caregivers of breastfed and formula fed infants in an emergency situation where essential services such as electricity and clean water supplies are unavailable and to discuss some of the practicalities of caring for infants in emergencies. The amounts provided for each emergency item are based on the clinical experience of the authors’, the author’s trial of the procedures, and the manufacturer’s instructions.” So again, I’m not convinced that any of this is based on actual empirical evidence, but rather assumptions and vague reasoning from people with an obvious axe to grind against formula feeding. Bullshit.

As for practical advice on what should be in your own emergency preparedness kit, I’ll work on it, peeps. Besides the normal emergency stuff (tons of bottled water, etc) I personally have a week’s worth of bottles of RTF formula, a few packs of disposable bottle liners and the bottles you use with them (you know, from that company that rhymes with Shmaytex), and about 10 nipples. I also have antibacterial wipes, in spades. That’s probably not the safest way to go about things, so I will look into the realities of what this paper recommends. Somehow, I don’t think it would cost $550 Australian dollars (about $569 USD) to ensure a formula fed baby’s safety for a week. But I’ll have to look at it more closely, because I seriously know nothing about disaster prep.

Until then, I’d be more concerned with honing your bullshit meter than worrying about a natural disaster. Statistically, it’s a fair assumption that you’ll be needing the former way more than the latter.

British people are cool

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About six months ago, when I was seeking experts to interview for my book, I considered contacting a well-known British researcher by the name of Alan Lucas. Problem was, I couldn’t tell where he stood on things. It’s not that I only wanted to talk to folks who agreed with everything I thought – it was simply that at this particular point in the process, I was attempting to speak with researchers who’d strayed from the party line, to see if they’d essentially been “silenced” by bad press and accusations of being in bed with Big Formula. But I wasn’t sure if Lucas was the right guy to talk to; while I found some of his research really interesting and potentially controversial (for example, he worked on one study that suggested our Western diets may not be well-suited to breastfeeding), he was also one of the first people to support the breastfeeding-leads-to-higher-IQ argument, and his work is cited by a plethora of lactivist literature. (For example, in one article about a study he did on breastfeeding and later heart disease, he said “It is quite possible that hundreds of thousands of deaths in the west are prevented by breastfeeding and many more would be prevented if the uptake of breastfeeding were greater.” Ironically, he also authored a different study warning that prolonged breastfeeding could cause hardening of the arteries. Not sure what the message is here – breastfeed, but not for too long…??)  So while a small section of his CV may have been controversial, it seemed that he was still relatively beloved by breastfeeding advocates.

In hindsight, he probably would’ve been a fascinating guy to talk to, for just this reason. Here was someone who managed to ask some potentially damning questions and remain unscathed – perhaps because he’d paid his dues by providing ample research supporting breastfeeding?

Anyway. I was thinking about Lucas a lot today, since his name was on the list of authors for this “Analysis” from the British Medical Journal which has been causing quite a stir. Entitled “Six months of exclusive breastfeeding: how good is the evidence?”, the piece is basically a review of what know, to date, about breastfeeding duration/exclusivity, delayed introduction of solids, and the risk for allergies and celiac disease (obesity is also briefly mentioned). The authors contend that WHO recommendations (6 months exclusive breastfeeding) may not necessarily be appropriate for those in developed countries. Speaking of the adoption of WHO recommendations, they suggest that “…the evidence base supporting a major, population-wide change in public health policy underwent surprisingly little scrutiny” in the first place, and that a “reappraisal of the evidence is timely in view of new data.”

The most interesting point that these authors make is that since delaying solids – especially ones with high risk for allergy- has become common practice, the incidence of food allergies and celiac’s disease have risen. Other than that, there’s really nothing all that controversial in the paper, which is why I find it amusing that it’s pissed so many people off . There was a veritable media shitstorm that occurred in the last 24 hours surrounding this paper, mostly from the breastfeeding advocacy front, who took it as a direct attack on breastfeeding. But the authors actually make a point to say that they are advocating an earlier introduction of solids (4 months versus 6 months), not formula; they are simply questioning if breastmilk alone is the ideal diet for those in developed countries after a certain point. In other words, they are still saying that women should breastfeed rather than formula feed, but that it might be advisable to offer foods along with breastmilk after four months. Not a huge deal, one would think.

One would be wrong, apparently. Within hours of the media coverage surrounding this analysis, not only were the blogs and Twitter were abuzz, reputable organizations like Baby Milk Action were freaking out, accusing the authors of being funded by baby food companies (apparently it’s not just formula makers who are out to undermine breastfeeding, but the makers of blended chicken and carrots, too. Personally, I think there is something inherently evil about blended chicken and carrots, but I doubt it’s the same kind of evil these folks are talking about).

But Lucas, and my new hero, Mary Fewtrell, who seems like the coolest cucumber ever, are taking this all in stride. And their attitudes are what I’m really excited about. Sure, the analysis is cool; I think there’s probably some truth to the assertion that earlier introduction of solids is better for us in the long run, but they aren’t the first to bring this up. It’s what’s between the lines of this analysis – and what its authors have said in the press – which really gets the FFF in me all riled up. Read the BMJ piece for yourself; it’s available for free here. Other than that, I want to submit the following as evidence for why I have good reason to think these authors are, as the kids like to say, “da bomb”:

1. They question WHO’s infant feeding recommendations, which is Simply. Not. Done.

2. They make reference to the fact that studies regarding breastfeeding are inherently flawed: “Apart from two randomised trials in Honduras, the studies were observational, precluding proof of causation for the outcomes examined, since residual or unidentified confounding may remain even after adjusting for potential confounders…”

3. They say this: “It can be argued that, from a biological perspective, the point when breast milk ceases to be an adequate sole source of nutrition would not be expected to be fixed, but to vary according to the infant’s size, activity, growth rate, and sex, and the quality and volume of the breast milk supply,” to which I say YESYESYESYESYES.

4. In interviews regarding the study, Alan Lucas explained that  “The WHO recommendation is very sensible for developing countries…But in the UK, it’s important we take a balanced look at the evidence.” Fewtrell told the Guardian that “she supported the WHO recommendation, but… that it needed to be interpreted differently in different countries. Exclusive breastfeeding protects against infections, which is critical in developing countries, but less important in the UK where hygiene and sanitation are better. ‘There’s only one piece of evidence relevant to babies in the UK – a slightly decreased risk of gastroenteritis,’” She also wrote off the criticism the study has received because she and some of the other study authors had worked with commercial baby food companies within the past three years (a conflict openly divulged in BMJ, incidentally), saying “This is not an attempt to promote commercial weaning foods…We are a university and Medical Research Council-funded group”, member of whom had “advised babyfood manufacturers because they were specialists in child nutrition”.

5. Fewtrell also provided my absolute favorite quote of the day, earning her a permanent place in the FFF Hall of Heroes: “Some organisations are all too happy to quote our data when it supports breastfeeding,” she said. “They are choosy in what they will allow.”

Word to your mom. Or actually, word to all moms. The truth is out there; we just need some more kick-ass women like Fewtrell to help us find it.

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