Win-win or lose-lose: Study suggests breast may not “beat” bottle in multiple long-term outcomes

Every morning, I receive Google alerts for several terms: breastfeeding, formula feeding, infant formula, breastmilk, etc. And every morning, I brace myself, waiting for the inevitable headline that will cause panic among bottle feeding moms, or re-ignite the incessant argument between breastfeeding advocates and formula feeding parents (as if it ever needs reigniting – it’s like one of those trick birthday candles, always sparking back to life even after you’ve wasted all your breath), or force me to take some semblance of a “position” on an issue that is hardly ever black and white.

One might expect that this morning, I would’ve broken out in that annoying Lego Movie song. You know, ’cause everything is awesome!!!!!

Source: connectedprincipals.com

Source: connectedprincipals.com

News broke that a study out of Ohio State, which examined sibling pairs where one child was breastfed and the other formula fed, had found that there was no statistically significant advantage to breastfeeding for 11 outcomes. These outcomes included things like obesity, asthma, and various measures of childhood intelligence and behavior. As the study explains:

“Breastfeeding rates in the U.S. are socially patterned. Previous research has documented startling racial and socioeconomic disparities in infant feeding practices. However, much of the empirical evidence regarding the effects of breastfeeding on long-term child health and wellbeing does not adequately address the high degree of selection into breastfeeding. To address this important shortcoming, we employ sibling comparisons in conjunction with 25 years of panel data from the National Longitudinal Survey of Youth (NLSY) to approximate a natural experiment and more accurately estimate what a particular child’s outcome would be if he/she had been differently fed during infancy…

 

Results from between-family comparisons suggest that both breastfeeding status and duration are associated with beneficial long-term child outcomes. This trend was evident for 10 out of the 11 outcomes examined here. When we more fully account for unobserved heterogeneity between children who are breastfed and those who are not, we are forced to reconsider the notion that breastfeeding unequivocally results in improved childhood health and wellbeing. In fact, our findings provide preliminary evidence to the contrary. When comparing results from between- to within-family estimates, coefficients for 10 of the 11 outcomes are substantially attenuated toward zero and none reach statistical significance (p < 0.05). Moreover, the signs of some of the regression coefficients actually change direction suggesting that, for some outcomes, breastfed children may actually be worse off than children who were not breastfed.”

 

Source: Colen and Ramey, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling ComparisonsSocial Science & Medicine, Available online 29 January 2014

I will admit that the comments made in several news outlets by the lead author of this study, Cynthia G. Colen, have made me want to run through the streets, acting as a one-woman ticker-tape parade in her honor. (Case in point: “I’m not saying breast-feeding is not beneficial, especially for boosting nutrition and immunity in newborns. But if we really want to improve maternal and child health in this country, let’s also focus on things that can really do that in the long term – like subsidized day care, better maternity leave policies and more employment opportunities for low-income mothers that pay a living wage, for example.”) But I’m not celebrating the results of this study, any more than I’d celebrate one that said formula feeding caused children to sprout green hair from their chiny-chin-chins and opt to live under bridges.

Why? Because this shouldn’t be a freaking contest.

The backlash that comes out of studies like these feels more like if someone came out with research that claimed fried Oreos were just as healthy as raw kale. Instead, we should be approaching it as if someone came up with a way to make a vitamin supplement that would offer similar benefits to kale, for those who hated the taste. One is natural, one is synthetic; one is manufactured, one exists organically. But for those of us who don’t or can’t eat raw kale on a daily basis, a good substitute is a godsend. (And maybe helps us justify those fried Oreos. A girl can dream.) Now, a study showing comparable effects of the supplement to the organic kale would not negate the fact that kale, grown in your own garden, is a nutritious, amazing thing – and tastes quite delicious to those of us who have a palate for it. If we started telling the kale aficionados that the supplement was better in some way, that would be a problem. But if the people who loved kale insisted that the supplement wasn’t a valid option and was somehow morally wrong, that would be a problem, too. Chances are, if we were really talking about kale, nobody would care all that much. The people who liked kale would eat it, and those who didn’t, might opt for the supplement – feeling confident due to the research that suggested the supplement was a viable option.

But we’re not talking about kale. We’re talking about breastmilk. And that, apparently, is where we all fall apart, and are rendered completely incapable of rational, measured discussion.

What the Golen/Ramsey study shows should not be controversial. The results should be reassuring- evidence that formula feeding does not condemn a child to a life of obesity, poor health, and lackluster intelligence; proof that whether a woman chooses, or is capable of, feeding a baby from her breast is not what defines her as a mother.

Imagine, for a minute, if we didn’t compare breast and bottle, but rather celebrated BOTH as valid, safe, healthy options for mothers and babies. Accepting that formula has legitimacy – that there is a reason it was invented (out of a need and a desire for a safe breastmilk substitute), and a reason why a woman may decide that a substitute is preferable – should not threaten those of us who celebrate breastfeeding. Yes, we should continue to rage against predatory formula marketing, especially in the developing world. Yes, we should speak up and speak out when companies (hello, Delta) retreat to 1953 when they express their breastfeeding policies. (For that matter, we shouldn’t need breastfeeding policies – if children are allowed, breastfeeding should be allowed. End of story.) Yes, we should ensure that women are entitled to adequate pumping breaks, and given solid breastfeeding assistance, and are supported by solid research regarding medications and breastmilk and best practices from pediatric professionals. But none of that means formula has to be Public Enemy No. 1. None of that means parents who formula feed should be left floundering due to an embarrassing lack of support and education. And for the love of god, none of that means we should be smugly celebrating when formula fed babies are shown to fare poorly, or gleefully rejoicing when and if the opposite occurs.

This is one study, with its own set of limitations and biases, like any other study in the modern canon of infant feeding research. But it’s a good study, artfully designed, and one that raises some extremely important questions about how the emphasis on feeding babies might be distracting us from the real work of supporting better maternal and childhood outcomes. Because speaking of retreating to 1953, it’s awfully easy to shove the responsibility for future generations onto women’s chests, rather than addressing true social inequities that can impact children’s lives. Maybe if we stopped wasting energy trying to prove how evil formula is, and just accepted it as part of life – not a slap in the face to our mammary glands, or an excuse for idiots to treat nursing mothers as horribly as they do now – we would have more energy to understand and destroy these inequities.

Or, you know, we could do what we always do and spend time looking for vague connections to the formula industry to discredit the study authors. Because that’s a really great way of helping families thrive.

 

 

 

Is donor milk dangerous? Not as dangerous as hypocrisy.

Those of you who have been reading this blog long enough are probably well aware that I hate hypocrisy. I mean, I hate it. I hate it in politics, I hate it in religion, I hate it in the spats I have with Fearless Husband, and of course, I hate it in the breastfeeding/formula feeding debate.

But most of all, I hate it in myself.

That’s why I’m sitting here agonizing over how to report on a study that hit the news cycle tonight. According to NBC News,

…a new study finds that human milk bought and sold on the Internet may be contaminated — and dangerous…Nearly 75 percent of breast milk bought through the site OnlyTheBreast.com was tainted with high levels of disease-causing bacteria, including germs found in human waste…That’s according to Sarah A. Keim, a researcher at Nationwide Children’s Hospital in Columbus, Ohio, where her team purchased more than 100 samples of human milk last year, compared them to unpasteurized samples donated to a milk bank and then tested them for safety…what the researchers found was worrisome: more colonies of Gram-negative bacteria including coliform, staphylococcus and streptococcus bacteria in the milk purchased online, and, in about 20 percent of samples, cytomegalovirus, or CMV, which can cause serious illness in premature or sick babies. The contamination was associated with poor milk collection, storage or shipping practices, the analysis showed.

Here’s the problem: I look at articles which report on the dangers of formula with an intensely critical eye. It would be horrendously hypocritical for me not to do the same in this case – and I’m especially worried, because the people purchasing donor milk are in the same boat as many FFFs – people who wanted to breastfeed and couldn’t. I don’t want to turn my back on my audience and be a hypocrite in one fell swoop.

And yet.

Obtaining milk online is a new construct. We do not have several generations of humans raised on donor milk to examine and rely on for (admittedly insufficient, but oddly comforting) anecdata. We can’t define “donor milk” as clearly as we define commercial formula, because it isn’t a static product. Formula does not change based on a baby’s needs and age, or based on the diet or environment of the woman producing it; breastmilk does. There is not the issue of online, anonymous dealings when we discuss formula (well, unless you count the 16 cans of Alimentum my husband purchased on Ebay…I know, I know, but it was sealed. And that shit’s expensive if you buy it retail).

Discussing donor milk and the safety thereof is not the same as discussing formula, because there are so many more issues at play. This study is not about whether donor milk can nourish an infant better than formula can. This is about the biology of a live substance, and what happens to that substance once it leaves one person’s body and is transported to another’s. This is about body politics, and e-commerce. It is so much more complex than breast versus bottle.

So I hope I’m not being hypocritical when I look favorably at this study, because I do think it’s one worth taking seriously, as long as we acknowledge the limitations. Let’s review those, first:

1. It was a singular study. ONE study. Which used donor milk from one specific organization.

2. As the study is not yet available online, there’s still a lot we don’t know. NBC reports, “Of the 101 samples analyzed, 72 were contaminated with bacteria and would not have met criteria for feeding without pasteurization set by the Human Milk Banking Association of North America, or HMBANA.” I’m not sure how these criteria are set by HMBANA, and I don’t know exactly what the dangers of these bacteria are.

3. We don’t know that any of the babies who would have received this milk would necessarily have gotten sick. (This is one of the things we discuss with formula feeding studies, remember? For example, many people worry about the GMOs in formula. And yeah, most formulas contain ingredients derived from genetically modified corn, soy, and other foodstuffs.  But we have no evidence that babies fed these formulas suffer any ill effects from these tiny amounts of GMOs.)

Now, let’s talk about why this study is a little different than most of the breastmilk vs. formula studies we encounter.

1. The results were in vitro – aka, found in a lab. These were not observational or self-reported or marred by recollection bias. These were findings that were discovered from looking at samples under a microscope, in a controlled environment.

2. We do know that some of these bacteria are dangerous to babies.  20 % of the collected donor milk samples contained cytomegalovirus, which according to NBC “can cause serious illness in premature or sick babies.” 20% is a substantial amount.  The article didn’t give numbers for the samples which contained other disease-causing bacteria like coliform and staphylococcus, nor do we know if the amount of bacteria was sufficient to cause illness. (Please note: I think we do need to approach this with caution until we see more information, because there’s a chance the amount of bacteria wasn’t clinically significant.)

3. A large part of my ennui with formula studies is that most tell us the same thing: breastfeeding mothers are associated with healthier children. There’s not much variance in the theme of the research, or what can be done about it. This study is nothing like that. It is giving us actual information about the actual risk of bacterial contamination through donor milk. This is exactly why I started taking formula preparation rules so seriously when I saw in vitro studies on bacteria found in infant formula. It’s hard to argue with cold, hard science that has removed the human condition from the equation.

More importantly, this study offers us an opportunity. Not only does it allow us to improve milk sharing – something that can and should be a choice for moms who cannot or choose not to breastfeed – it reminds us that cold, hard science can be translated into better feeding options for families. Donor milk can and should be tested, to see how it needs to be stored and transported and screened. Formula can be compared with donor milk so that parents can understand the risks and benefits to both scenarios. Since one of the advantages of breastmilk is its ever-changing, adaptive personality, we could look at how the donor milk from a mom nursing a toddler might affect a newborn. We could even see if, say, the milk from women with higher IQs equates to higher IQs in babies fed their donor milk (oy, can you imagine the eugenic excitement over a finding like that? ::shudder::). You see where I’m going with this. When we’re discussing the substance rather than the behavior, a whole world of research will open up – research that can ultimately lead to improved formula, improved donor milk, and improved options for both babies and parents.

Lastly, it seems that defensiveness about negative press for one’s feeding choice is not exclusive to formula feeders. NBC quotes one milk sharing network’s founder as accusing the research of being “A blatant attack on women attempting to feed their babies”:

“..(It) is cruel and you should feel ashamed of yourself for spreading misinformation,” Khadijah Cisse, a midwife who founded MilkShare, a portal for connecting women cited in the new research, said in an email to NBC News. “Anyone can type up any bit of lies they want and make claims. Breast milk is supposed to contain bacteria.”

I feel bad for Cisse, as I know what it feels like to read research that denies my own lived experiences, or makes me feel judged for feeding my child in a specific manner. In her defense (and mine), it’s really hard to keep a lid on one’s anger when the media takes a 5k story and runs a marathon with it, without any consideration for context or nuance.

Imagine how much easier it would be to keep that proverbial lid tightly locked, if feeding choices were supported and respected. If the dialogue didn’t always involve universal bests. If we could make choices armed with more cold, hard science so that the choices themselves didn’t have to so damn cold and hard.

There’s a lot we could learn from this study.

Or, you know. It could die in an avalanche of hypocrisy.

 

 

 

 

 

 

The biggest problem with the breastfeeding discourse has nothing to do with breastfeeding

Sometimes, a cigar is just a cigar. And sometimes, it’s not.

As any journalist, blogger, or parenting-forum moderator can attest, merely mentioning the words “breastfeeding” or “formula feeding” will create controversy – or at least a comment thread that derails within the first three posts. It’s virtually impossible for someone not to feel offended. It happens on both sides of the debate; some breastfeeding advocates see red anytime a person writes favorably about formula, while some formula feeding mothers are guilty of taking it all too personally, and assuming that every positive aspect of breastfeeding is dig at their lack of lactation.

This bugs me, being someone who writes about this topic regularly, because it dilutes the conversation. We lose track of what we’re talking about, and lose the chance to understand, to evolve, to connect.

Of course, this problem is endemic to any hot-button parenting issue. Circumcision, sleep training, working vs. staying at home, vaccinations… But when it comes to breastfeeding, what I’m talking about goes far beyond the mommy war bullshit. We’ve apparently lost the ability to discuss anything to do with breastfeeding and formula without heaping layers of preconceived notions, philosophical ideals, and emotional reactions onto whatever’s being discussed. Even if the conversation takes place in a respected medical journal, the halls of a hospital, or a human rights nonprofit.

With that said, I want to make something clear: this post is not about breastfeeding. It is not about the benefits of breastfeeding. It is not about a woman’s right to breastfeed or formula feed. It is not about you, or me, or your sister-in-law. It’s about language, interpretation, and bias. If it helps, substitute the word “breastfeeding” for something less emotionally loaded. “Drinking coffee”. “Wearing palazzo pants.” Whatever.

In the past month, two stories popped up, buried so deep in the news that only someone who obsessively googles terms like “infant feeding” and “lactation” would have seen them. They were about studies showing negative associations with breastfeeding (see? Didn’t your heart start beating a bit faster? …Negative associations with palazzo pants. That’s better, right?) The first one found that longer durations of breastfeeding (past 12 months) were associated with higher rates of a specific form of breast cancer in Mexican and Mexican-American women. The evidence was based on subject recall of breastfeeding history, in a specific population. All I will say about the study itself is that it is one, isolated result; more research must be done before anyone can make proclamations about whether women of Mexican descent might want to wean after a year.

Which is basically what I say about every infant feeding study. These results do not prove a causal relationship. It would be patently false and extremely irresponsible to have headlines screeching “breastfeeding causes breast cancer!”

Luckily, there were no such headlines. The story didn’t receive much coverage in major news outlets, but here were the headlines I did find:

Breastfeeding May Increase Cancer Risk for Mexican-American Moms (http://www.nbcsandiego.com/news/health/Breastfeeding–Cancer-Rules-May-Not-Apply-to-Some-226050001.html)

Lactation may be linked to aggressive cancer in Mexican women

http://health.ucsd.edu/news/releases/Pages/2013-10-01-lactation-linked-to-cancer-in-Mexican-women.aspx

Women of Mexican descent more likely to be diagnosed with aggressive form of breast cancer http://www.news-medical.net/news/20131002/Women-of-Mexican-descent-more-likely-to-be-diagnosed-with-aggressive-form-of-breast-cancer.aspx

Mexican Women’s Breast Cancer Risk Tied to Breast-Feeding? http://healthcare.utah.edu/womenshealth/healthlibrary/doc.php?type=6&id=680757

Notice all the qualifiers. May be linked. More likely. And my favorite example, the question mark at the end of the last headline.

Now, let’s compare these measured, accurate headlines with those that stemmed from similar studies (self-reported data, specific populations, single studies rather than meta-analyses) that showed a positive effect of breastfeeding:

Breastfeeding reduces cancer risk http://www.dailymail.co.uk/news/article-88785/Breast-feeding-reduces-cancer-risk.html

Breastfeeding Cuts Breast Cancer Risk http://www.webmd.com/breast-cancer/news/20070417/breastfeeding-cuts-breast-cancer-risk

Study: Breastfeeding Decreases Cancer Risk http://www.npr.org/templates/story/story.php?storyId=9656285

Breastfeeding Protects Against Breast Cancer http://www.reuters.com/article/2009/08/10/us-breastfeeding-cancer-idUSTRE5795CZ20090810

Not one qualifier to be found.

But FFF, you’re arguing semantics, you say. Perhaps. But how can we argue that subliminal messages that come through the advertising of formula or bottles can so greatly affect a woman’s breastfeeding intention, and then argue that the language used in widely-read headlines doesn’t make an impact?

Not convinced? Let’s go beyond the headlines. The one quote from the lead researcher of the breastfeeding/cancer in Mexican women study used in the media was this:

“Our results are both puzzling and disconcerting because we do not want to give the wrong message about breastfeeding…If you treat breast cancer as one disease, breastfeeding is beneficial to both mother and baby. That should not be dismissed.”

Puzzling? Disconcerting? Science needs to be free of bias. It’s perfectly acceptable to be “surprised” by findings, but “disconcerted”? And as for the point about ”breast cancer as one disease“, this is not the sentiment expressed in the quotes from articles reporting a positive effect, many of which proudly extrapolate their specific findings and make sweeping statements about breastfeeding promotion:

Clearly, the researchers conclude, breastfeeding is associated with “multiple health benefits” for both mother and child…”That’s why we need supportive hospital policies, paid maternity leave, and workplace accommodations so that women can meet their breastfeeding goals…” (source: Reuters)

The same double standard popped up a few weeks later, when a study hit the news which found that babies breastfed longer than one year, as well as babies introduced to gluten after 6 months, had an increased risk for celiac disease. Again, hardly any media coverage; the one major outlet (Yahoo News) that covered it used the headline “Parent’s Feeding Choices May Raise Baby’s Risk for Celiac Disease“. Absolutely accurate headline, but no mention of breastfeeding. Granted, there were two findings that came from this study; both of which did involve a feeding “choice”. What I find interesting, though, is that whenever formula is associated with something negative – even if that particular finding is buried in a mess of other data – the headlines make sure to mention it. (Remember the arsenic-in-baby-formula scare of 2012?)

This study had many flaws. (Science of Mom has a great explanation of what these were over on her blog, if you’re interested.) But it didn’t have more flaws than 99% of the formula-is-risky studies which we are subjected to on a weekly basis, none of which are handled with the same degree of intelligence and moderation.

In Bottled Up, I discuss the problem of publication bias, and the professional death knell it is to report or support anything that detracts from the supreme perfection of breastfeeding. This is a bigger problem than one might believe – because if the end goal is to find ways to reduce disease and increase health in populations, we should be striving for information, not propaganda. And this is why I fight so hard to reframe how we discuss and promote breastfeeding – because if we are basing all of our support for the practice on science, then we run the risk of bastardizing – or at least “tweaking” – that science to justify our promotion.

Sometimes, a cigar is just a cigar. But when it comes to infant feeding science, the results are never just the results.

Can breastfeeding concerns be overcome with support? Depends on what “support” means

Guess what? Women are having trouble meeting their breastfeeding goals.

Contain your excitement.

Apparently, this is news to the American Academy of Pediatrics, and every major news outlet in North America. The study causing such shock and awe came out this Monday in the journal Pediatrics. Researchers used self-reported data (i.e., interviews) from 532 first-time moms giving birth at a particular medical center (can’t find where, and due to geographical differences in levels of breastfeeding support and acceptance, I think this is vital information that at least one of the articles could have shared with us). The women were asked prenatally about their breastfeeding intentions and concerns, and then re-interviewed at 3, 7, 14, 30 and 60 days postpartum. According to Reuters:

During those interviews, women raised 49 unique breastfeeding concerns, a total of 4,179 times. The most common ones included general difficulty with infant feeding at the breast – such as an infant being fussy or refusing to breastfeed – nipple or breast pain and not producing enough milk.

 

Between 20 and 50 percent of mothers stopped breastfeeding altogether or added formula to the mix sooner than they had planned to do when they were pregnant.

 

Of the 354 women who were planning to exclusively breastfeed for at least two months, for example, 166 started giving their babies formula between one and two months.

 

And of 406 women who had planned to at least partially breastfeed for two months, 86 stopped before then.

Given these results, the study authors come to the conclusion:

Breastfeeding concerns are highly prevalent and associated with stopping breastfeeding. Priority should be given to developing strategies for lowering the overall occurrence of breastfeeding concerns and resolving, in particular, infant feeding and milk quantity concerns occurring within the first 14 days postpartum. (Source: Pediatrics)

 

The headlines, as usual, were both amusing and infuriating. “Nursing Troubles May Prompt New Moms to Give Up Sooner”. “Early breastfeeding challenges make women quit.” “Some moms discontinue breastfeeding within two months die to nursing difficulties”. And my personal favorite, “95% of breastfeeding problems are reversible.”

One might easily blame the media for their usual skewering of the science to make for a juicier headline, but one can hardly blame them when the experts giving interviews about this study say things like, “It’s a shame that those early problems can be the difference between a baby only getting breast milk for a few days and going on to have a positive breastfeeding relationship for a year or longer… If we are able to provide mothers with adequate support, 95 percent of all breastfeeding problems are reversible.”

So, what’s my issue? I think the study is fine. Sort of a no-brainer, considering they could’ve came to the same conclusion years ago had they just listened to moms instead of insisting we just needed more convincing of the benefits of breastfeeding, and we’d all magically lactate to the satisfaction of the World Health Organization. But the quote above (from Laurie Nommsen-Rivers, one of the study authors) makes me wonder if the results of the study are being taken in the wrong context.

The focus is on moms not getting enough support –  something that I 100% agree needs to be focused on. Like, yesterday. But where the experts quoted in these articles and I part ways is on what type of support is needed. This passage from NPR illustrates my point:

The researchers didn’t do physical exams of the moms and babies, so they don’t know what was happening for sure. But they speculate that some of the first-time mothers may have misread the babies’ cues, mistaking fussiness for hunger, for instance, or thinking the babies weren’t getting enough milk when they’re doing just fine…

 

Once again, the assumption is that women are wrong about their bodies, and about their babies. The study authors surmise that access to lactation consultants in the first week postpartum, after hospital discharge, will be the solution to many of these problems. Again, I absolutely agree that this is a great start. And yet – reading through the scores of FFF Friday stories, I have to wonder… is this really going to make a difference, given the current state of our breastfeeding culture? How many LCs have we all seen, cumulatively? How many were bullied or shamed by medical professionals? How many of us have been told our babies were fine, only to end up in the ER with a dehydrated infant? How many of us were told – by professional lactation consultants and pediatricians – that every woman can breastfeed, and that we should just keep on nursing and it will all work out?

Looking at this study, this is what I see: a ton of women are claiming to have pain, trouble latching, and concerns that their babies aren’t getting enough milk. NPR also reports that the group with the least amount of reported problems was comprised mostly of women under 30, and women of Hispanic origin. That begs for further research, doesn’t it? Could age and legitimate lactation failure be associated? What about race/ethnicity? Are there conditions more prevalent in older, non-Hispanic populations that are also associated with breastfeeding problems?

And this is what I also see: We have an opportunity – no, a responsibility- to look at the type of support these women are getting. Is it truly evidence-based? Or is it based on dogma; on the belief that “95% of breastfeeding problems are reversible”? (By the way, I am super curious about the research backing up that claim.) Are the individuals giving the support truly listening to the mothers, examining them, considering the delicate balance of hormones necessary for lactation, or the effect of emotional or physical trauma around birth on a woman’s ability to withstand latching pain or her infant’s cries? Is there nuance? Are these mothers being seen, or are they being treated as uniform breasts, needing to be “handled” so that they can fulfill their duty of providing exclusive breastmilk for 6 months?

I’m not knocking a study that advocates for more support for moms. I simply want us to open up the discussion, rather than going in circles, with the same researchers and the same experts telling us the same things – if mothers only knew better. If they could only be taught to recognize their babies’ cues. If they would only listen to us. 

I think it’s time they listened to us, instead. Which brings me to what I’d really like to see from this study: a follow-up where they ask the women who “failed” to meet breastfeeding recommendations what they think would have helped them reach their goals. Because without that piece, I really don’t think we can get very far.

 

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.

 

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