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.

Study says: Breastfeeding problems aren’t serious. And are probably your fault, anyway.

One of the most interesting interviews I did in my research for Bottled Up was with a physician who had studied breastfeeding-related neonatal hypernatremia (severe dehydration leading to electrolyte imbalance). We discussed the fact that these days, this condition is typically caught early and can be treated successfully. But the doctor also cautioned that while the prognosis wasn’t usually dire in terms of long-term health (thanks to modern medicine), we shouldn’t forget about the emotional and financial effects on the parents. He worried about a first time mom, trying to do the best for her child, who ends up seeing that baby hospitalized – sometimes for weeks- due to what she might perceive as her own failure to nourish him adequately.

I’ve been thinking about this interview since I read several articles yesterday, detailing a new study about the same condition. According to the Guardian (“Breastfeeding problems rarely lead to serious illness, study says“), a new paper on neonatal hypernatraemia found that “Very few babies become dehydrated and seriously ill because they are not getting enough milk from breastfeeding…Dr Sam Oddie and colleagues found only 62 cases from May 2009 to June 2010, a prevalence of seven in every 100,000 live births… the babies were admitted to hospital, mostly because of weight loss, and some were intravenously fed…However, all were discharged within two days to two weeks having gained weight and none had long-term damage.”

Seem like good news, right? Put on the Def Leopard, because we’re about to start headbanging.

Source: http://www.yaindie.com/2012/12/banging-your-head-against-wall-is-it.html

Banging-my-head-against-the-wall Problem #1: 

Okay. So, correct me if I’m wrong, but having a 2-week-old newborn in the hospital hooked up to an IV for a week or two isn’t considered serious? And as for long-term effects – these babies were born between 2009-2010. The study is not available online, so I don’t know what the details are in terms of how the researchers followed up with the subjects… but considering studies on breastfeeding and intelligence have tested kids at the age of 8, I think one could fairly say the jury is still out on this sample of 4 and 5-year-old kids. And how were they assessed in terms of long-term effects? Psychological? Emotional? Physical?

With all the focus on mother-child interaction in the first days, and the effect of fatty acids on brain development, the superiority of breastmilk in the first weeks… doesn’t it seem a little ironic that we’re so quick to dismiss a condition which a) separates parents from babies through NICU stays and b) starves/dehydrates a child in those same “fundamental” weeks?

I understand that we’re talking small numbers here – 7 in every 100, 000 is admittedly a reassuring statistic. But while we’re talking about that figure… what exactly does it mean?

Banging-my-head-against-the-wall Problem #2:

First, without access to the study, I can’t tell you if this statistic means 7 in 100,000 of ALL LIVE BIRTHS – meaning EBF, formula-fed and mixed-fed infants, inclusive. The UK has lower breastfeeding rates than many countries, so if this was the number of babies in all live births, it doesn’t mean anything substantial. What we need to know is the number of babies admitted who were exclusively breastfed before we can start making statements about breastfeeding, milk supply, and what needs to happen to avoid this risk.

Banging-my-head-against-the-wall Problem #3: 

Even if this study did look only at EBF babies, there are major limitations in what we can fairly assess from the data.  We can’t know how many women can adequately produce milk so that their babies aren’t at risk, because most people would supplement before it got to the point of hospitalization. What the researchers did discover is that the babies hospitalized could nearly all breastfeed successfully:

Almost every baby is capable of breastfeeding, Oddie said. “In only a few cases were there special features of the baby that made it likely that there would be a severe feeding problem. [One of the babies, for instance, was found to have a cleft palate.] Normally all babies can get established with breastfeeding with the right support.”

Again, I’m a little confused. If there were only a few cases of this condition, what exactly is a “few” of a few? Of the seven babies hospitalized in a group of 100,000, does that mean one of them had a “special feature” which created a feeding problem? Was it a statistically significant number?

Then, the Deputy Manager of UNICEF’s Baby Friendly Initiative weighed in:

Anne Woods, deputy programme manager for Unicef’s Baby Friendly Initiative (BFI)…said the number of babies who could not feed was negligible and only a very small percentage – about 1% – of women would struggle to make enough milk. “The numbers who breastfeed in this country do not reflect the numbers who could breastfeed if they had effective support,” she said.

Where there are problems, she added, “it fundamentally boils down to the fact that the baby is not attached to the breast effectively. The whole of the baby’s mouth has to make contact and draw the breast tissue into the mouth.”

But because we have a bottle-feeding culture in the UK, she said, some women do not realise this and “try to bottle-feed with their breast”, so the baby takes only the nipple and does not get enough milk.

The other problem is when babies do not feed often enough. After a difficult labour or pain relief, the baby may be sleepy. There is also an expectation she said, that a baby will feed and then sleep.

Ah, right. It’s the mom’s fault. Who cares that this study proves – hell, even suggests – nothing about the true incidence of physiological lactation failure. The researchers are talking about the baby’s ability to feed, not the mother’s ability to produce milk. That doesn’t stop Anne Woods from hurling the 1% (the lowest number bandied about regarding lactation failure, by the way – she could’ve at least given us a break and used the higher end of the oft-cited 1-5% assumption figure) statistic at moms who’re already feeling like failures for landing their babies in the hospital. And of course, the mom probably can’t be bothered to feed as frequently as needed – not that it’s entirely her fault, since the formula companies have convinced her that her breast is actually…wait for it… a bottle!

Banging-my-head-against-the-wall Problem #4: 

I know, I’m being snarky. And I do appreciate that the lead researcher of this study, Sam Oddie, emphasized the need for better breastfeeding management and support. I’m fully on board with that. But I’m also concerned about what Dr. Oddie was saying back in 2009, when he embarked on his study:

Dr Sam Oddie, a consultant in the neonatal unit at Bradford Royal Infirmary, who is leading the study, said: ‘Once we understand the scale of the problem we can work out what to do about it – how to spot it, and how to act on it. But as far as I’m concerned the answer isn’t more formula feeding, but increased support for breastfeeding from the outset in the form of counsellors.” (Marie Claire, 2009).

I don’t disagree with him, necessarily, but going in to a study on hypernatraemia with a strong desire to avoid formula supplementation – even if that ended up being the best course of treatment – implies a certain degree of bias.

One could argue that there’s no harm in a study like this making the news; it will bring attention to those experiencing early breastfeeding problems and perhaps make medical professionals take them more seriously. But as we’ve seen so many times, these studies have a way of creeping into the breastfeeding canon and being misused as “truth” to back up future claims. I can already see Dr. Oddie’s quotes as being taken out of context, being used as “proof” that “all babies can breastfeed” and that the risk of inadequate feeding isn’t all that serious (so there’s never a need to supplement, even if your formula-pushing pediatrician tells you that there is).

Still think I’m overreacting? Here are the headlines from the other two major news sources covering the study:

Most mothers who struggle to breastfeed WILL be providing enough milk for their babies, say experts (The Daily Mail)

Dehydration risks from breastfeeding are ‘negligible’, study finds (The Telegraph)

Would you like me to move over and make a little space for you on the wall? Come on over. Bring some Metallica, and wear a helmet.

 

Read more about neonatal hypernatraemia:

http://fn.bmj.com/content/87/3/F158.full http://pediatrics.aappublications.org/content/116/3/e343.full

 

 

The two headed chimera of infant feeding studies

It’s been a crazy week here, and I was really hoping to pull some pithy, short post out of the exhausted recesses of my brain. So when a study came across the wire touting extended formula feeding as a risk factor for a certain kind of childhood leukemia, I stuck my fingers in my ears. (Well, I posted about it on the Facebook page, but that’s kind of like the passive aggressive form of social media, isn’t it?) And a day or two later, when the Interwebz started buzzing about the British version of the infamous Burden of Suboptimal Breastfeeding “study”, I shoved a pillow over my head and sang the soundtrack of Beauty and the Beast really loudly (that’s what’s popular with the Fearless Children these days. It’s a great soundtrack and all, but seriously, how many times can a person hear Be Our Guest without going nuts? Although I did recently discover this YouTube gem, which has given Little Town – or, as Fearlette calls it, “Belle Sahwng” – a whole new meaning…).

One is named “Twitter”, the other “Parenting Science”

Unfortunately, I’m realizing that there is far too much inaccuracy and fear mongering going around to ignore. I don’t think I have the mental capacity to write a whole long diatribe, but I do want to address a few memes that are spreading like a California wildfire.

Courtesy of the UNICEF “Preventing disease, saving resources” report, I recently saw a discussion of how in the UK, only 1% of women are breastfeeding exclusively at 6 months. The consensus was that since formula feeders are so obviously in the majority, there is no need for them to feel marginalized.

I was shocked at that 1% statistic, and when I first heard it I was seriously blown away. But let’s look a bit closer at what the report actually says:

“….the proportion of women still breastfeeding at six weeks after birth increased by only a few percentage points between 2000 and 2005 – to just under 50% (Bolling et al, 2007). Rates of exclusive breastfeeding are much lower – only 45% of women reported that they were breastfeeding exclusively at one week after birth; fewer than 1% were still doing so at six months (Bolling et al, 2007). The rapid discontinuation of breastfeeding in the early days and weeks after birth, seen consistently since national surveys began in 1975, has only marginally improved to date, demonstrating that women who start to breastfeed often encounter problems, whether socio-cultural or clinical in nature, and stop. Ninety per cent of women who stop breastfeeding in the first six weeks report that they discontinue breastfeeding before they want to (Bolling et al, 2007). As a consequence, women can feel that they have failed their babies (Lee, 2007), and the great majority of babies in the UK are fed with formula in full or in part at some time during the first six months of life, and by five months of age, 75% of babies in the UK receive no breastmilk at all.” (p. 35)

First things first: notice the amount of 2007s in that paragraph. Yup, the stats they are citing are from a 2007 report, which offered statistics gleaned from a 2005 infant feeding survey. 

Aw, come off it FFF, 2005 wasn’t that long ago.  Things can’t have changed all that much in 7.5 years. 

Well, let me just say this: I want to see statistics from at least 2010. (They have them, but these 2010 survey results do not include information on duration, just initiation.) I have a gut feeling, from my reading of the research and observations I’ve made from the sheer number of emails I get from our UK sisters, that things have changed. In a Twitter conversation tonight, someone with an adolescent son mused that if social media had been around when she was a new mom, her postpartum experience would have been markedly different. The advent of social media has changed the infant feeding world – yes, it may only be on a sociological level, and we may not yet be seeing huge statistical jumps in breastfeeding rates, but both breastfeeding awareness and pressure have increased since new mothers began spending more time on Twitter and Facebook than in mommy-and-me groups, or with their sisters, friends, or mothers.

Additionally, the last sentence of the paragraph – perhaps the most jarring- carries no citation. If we don’t know what they are basing this on, it’s hard to say if it’s hard fact, or merely an assumption by the authors. (Oh- and that reference to women feeling like they have “failed their babies” rather diminishes its citation, Ellie Lee’s landmark 2007 paper about how morality plays into the infant feeding debate. From what I gathered from her work, these women do feel they failed their babies when they switch to formula because they are MADE to feel that way by society- not because they have an innate sense of wrong-doing. I think this allusion ignores a large piece of the puzzle, and allows the authors to pay lip service to formula feeders while simultaneously perpetuating the cycle of shame. Then again, I’m already ornery, so maybe I’m over-analyzing this.)

What strikes me as odd is that I recently saw this press release, also from Unicef, applauding NHS for achieving a landmark: 8 out of 10 British babies are now breastfed, thanks to the Baby Friendly Initiative. Obviously, this is referring to initiation rates, not duration, so it’s apples and oranges. Any yet, the difference in tone confuses me – if the rates are going up, and it’s a cause for celebration, why the pessimism in this new UNICEF report?

I don’t doubt that UK breastfeeding rates are lower than most Western nations. That’s been the case for awhile. But even in Norway, exclusive breastfeeding rates at 6 months are pretty abysmal. That’s because… wait for it… most babies have received some solids by then. Even before the 6-month “ready for solids” party line started being questioned, most moms were letting their babies try a bit of rice cereal or some veggies between 5-6 months. Exclusive breastfeeding means exactly that – exclusive. As in NOTHING BUT BREASTMILK. This 99% of women not exclusively breastfeeding at 6 months back in 2007 was not necessarily a group of supplementers or early weaners – they could just as well have been people who cheated a bit on the 6-month rule for solids. (And more power to them if they did, considering some experts – and many moms- believe that when to start solids should be an individual thing, and based on a baby’s readiness anytime between 4-6 months).

The thing that scares me is that this paragraph – oh bloody hell, this whole report – is based on the assumption that no journalist or policy maker is going to take the time to dig up every cited study, or to pay attention to where the statistics are coming from. I would say the majority of people (shall we say 99%?) are going to assume that this paragraph translates to only 1% of women nowadays, in 2012, are making it to 6 months without using formula and that, my friends, is simply not the case.

Stupid thing to obsess about, right? Well, it might be, except this kind of confusing rhetoric is used throughout the report. They make a big stink about only using “quality” evidence, stating that the costs to British society would be far greater if they were able to use the plethora of less-conclusive scientific literature which links “not breastfeeding” (the word “not” is italicized every time it appears in this context. Kinda weird…) with things like ovarian cancer, SIDS, adult obesity, and Celiac disease. As it stands, they have calculated the health care costs of treating diseases primarily seen in non-breastfed babies: ear infections, gastrointestinal infections, respiratory disease, and necrotising enterocolitis, as well as breast cancer in mothers.

But what exactly does this “robust evidence” consist of? The authors thoroughly vetted the studies they used to determine the rates of specific diseases – so much so, that the outcomes were often based on one or two studies (like in the case of ear infection), as well as a few used for “corroborative evidence”. This report was not trying to determine the quality of breastfeeding research, nor does it purport to offer new evidence for the correlations they site. Rather, they are simply going through, deciding which studies to use based on specific criteria, and using those outcomes to determine economic savings.

(FYI, the authors admit that they leaned heavily on the Burden of Suboptimal Breastfeeding methodology to calculate their own costs. Please refer to our friend Polly over at MommaData for a good breakdown of why this method is inherently flawed.)

The report, which was distributed to and covered by every major media outlet in the UK, is lengthy and exhaustive – great for researchers, not so great for journalists. I doubt many who reported on this study read all 104 pages, including citations; I doubt many understood that the goal of the report was not to determine whether any of these conditions are actually caused by not breastfeeding versus being a matter of correlation too muddled by confounding factors, but rather it went under the assumption that these diseases/conditions were in fact PROVEN to be directly influenced by suboptimal breastfeeding. Get it? Report= economic case for breastfeeding. This is not a study proving anything new.

I admit that this report is far more palatable than its Yankee counterpart. There is legitimate attention paid to why women aren’t breastfeeding, and it even references studies and literature about the guilt and feelings of failure which occur when women cannot breastfeed (if somewhat incorrectly – see above reference to Ellie Lee). I appreciate that. But just as I worried (justifiably, it seems) with the Burden of Suboptimal Breastfeeding, I fear that this will be adopted into the infant feeding canon, and used incorrectly to support a myriad of other studies. This is how it works, unfortunately.

I also want to mention that the lead author of this study is Mary Renfrew, who has been quoted as saying that “women are born to breastfeed”. To me, this rings of bias, which can easily lead to confirmation bias. And when you’re basing a report on the opinions of a few key people as to what is considered “quality” evidence… I wonder if a neutral party would have given this study more gravitas. Good luck finding a neutral party in this field, though…

Moving on. The next hot new thing on my Twitter feed is a study which links childhood leukemia with a longer duration of formula feeding. This study may very well be credible. I have no idea, and neither does anyone else commenting on it – because it isn’t published. It isn’t even peer reviewed. And yet it is flying through the airwaves, causing squeals of “formula feeding causes cancer!!” in a manner that echoes with thinly veiled I-told-you-so’s.

But that’s not even the interesting part. Let’s go under the assumption that this study will come out and be stellar and scientifically sound (because we can’t really do anything in terms of dissecting it until we can see the damn thing, anyway). According to the study, do you know what also carries a comparable risk of childhood cancer development? Later introduction of solids, regardless of infant feeding method. Breastfeeding alone did not have a significant effect, but rather the length of time using formula, and the length of time the child went without solids in their diet.

I haven’t seen one freaking tweet about the solids thing. Not ONE.

I may well be a Defensive Formula Feeder, as one beloved lactivist blogger has knighted me, but here’s what I don’t get: one of these (assumed) correlations supports advocating for an act which often involves major social, emotional, physical, and economical sacrifice on the part of women. (It shouldn’t, but right now, in our society, it often does.) The other correlation just implies that you need to start giving Junior a daily dose of butternut squash around 6 months of age. Why are we so focused on the one that is complicated by socio-biological factors, and not one the one which would be easy for most parents to incorporate into their child-rearing?

I’m not pissed about the studies, people. I’m pissed because THIS is how we’ve arrived at this place. This place where women are being pitted against each other; this place where we are made to feel responsible for the wealth and health of the nation, so that our governments can spend a few bucks pressuring women to breastfeed rather than figuring out real ways to enhance socioeconomic disparities; this place where one can’t question the intentions or quality of a research paper without being accused of being anti-breastfeeding or anti-mother or anti-science.

Speaking of Beauty and the Beast…this game of championing-research-which-can-mislead-and-and-scare-new-parents-before-stopping-to-fully-comprehend-it reminds me of The Mob Song (my son’s favorite). As the townspeople march towards the Beast’s castle with fiery torches, they sing: “We don’t like what we don’t understand- in fact it scares us, and this monster is mysterious at least… here we come, fifty strong, and fifty Frenchmen can’t be wrong…”

Imagine those Frenchmen with Twitter and Facebook accounts, multiply them by about 1000, and you have a great explanation of what’s wrong with social media and parenting science, my own personal two-headed Chimera.

 

 

 

Dear Mayor Bloomberg: Please stop the smoke and mirrors

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

 

Why statistics are like sexy bad boys

I’ve been thinking a lot about statistics and studies lately. I can thank Rebecca Goldin and Polly Palumbo for this, since reading their work has taught me to look at numbers and research with a more critical eye.

Case in point: a good friend texted me early in the week about the latest study linking sunscreen use to cancer. There were many exclamation points and frowny-faces in the text, as well as a link to a foreboding article about the study. This one had scared her. Granted, she literally bathes her toddler in SPF 50, but what can you do? We live in sunny LA. It’s practically child abuse not to carry California Baby Sunscreen with you at all times. Anyway, before I even glanced at the article which had spooked her so, I knew what the real story would be. Correlation. Here’s two immediate theories:

1. People who wear high-level sunscreen might have a false sense of security about their time in the sun. Maybe they don’t reapply as often as they should.

2. Very possibly, these are same people who have a higher risk of skin cancer due to family history. Why else would you spend the money (and forgo that guilt-free “breakthrough tan” possible with the lower SPFs) on SPF 50 or higher?

I wasn’t completely correct in my assumptions; there was talk of the Vitamin A in the sunscreen speeding up UV exposure, and some concern that other chemicals used in these lotion could actually cause cancer (one report I heard from our local Fox affiliate suggested that the only people who might want to heed this warning is parents of kids under 2; their skin might be more susceptible to these chemicals). But many of the doctors interviewed in the media fallout from this study did refer to similar correlation theories. Like so many of these media-touted studies, it’s imperative for us to think critically about what we hear, and not jump to the same doomsday conclusions as our media brethren.

What does all of this have to do with formula feeding? A lot, I think. When I read breastfeeding/formula studies, I don’t go into it wanting to disprove the superiority of breastmilk; to the contrary, I think that anytime Mother Nature kicks technology’s ass, it’s pretty darn cool. But I do want to separate truth from overblown claims; to see the reality in the science, the human face behind the statistics.

Statistics are like sexy bad boys. They can be thrillingly dangerous, and look so promising – if you can just tweak them a bit to make them into a better version of themselves. They make an impression. But they mislead; they can be all gloss and no substance. Sometimes, there’s a wonderful heart under a rough exterior; not all bad boys are truly bad. You just need to go into the relationship with your eyes open, and realize that there might be more than they are showing you at first.

Like I said: it’s about reading the studies critically.

Which is why I was so thrilled to find Joel Best’s book, Damned Lies and Statistics: Untangling Numbers from the Media, Politicans, and Activists (University of California Press, 2001). It’s a few years old, but remains as topical as ever. Consider it required reading for all FFFs. I promise you, it’s not your father’s statistics book. It’s funny, acerbic, and easy enough for someone who dropped out of math junior year in high school (ahem, moi) to understand. Don’t believe me? You can read the introduction here. If you don’t love it, you can write me and tell me to shove it. Pinky swear.

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