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Are the benefits of breastfeeding oversold?

As a mother, I am a passionate advocate of breastfeeding and I breastfed my four children. As a clinician, though, I need to be mindful not to counsel patients based on my personal preferences, but rather based on the scientific evidence. While breastfeeding has indisputable advantages, the medical advantages are quite small. Many current efforts to promote breastfeeding, while well meaning, overstate the benefits of breastfeeding and distorts the risks of not breastfeeding, particularly in regard to longterm benefits.

As Joan Wolf explains in an article entitled Is Breast Really Best? Risk and Total Motherhood in the National Breastfeeding Awareness Campaign:

… Medical journals are replete with contradictory conclusions about the impact of breast-feeding: for every study linking it to better health, another finds it to be irrelevant, weakly significant, or inextricably tied to other unmeasured or unmeasurable factors. While many of these investigations describe a correlation between breast-feeding and more desirable outcomes, the notion that breast-feeding itself contributes to better health is far less certain, and this is a crucial distinction that breast-feeding proponents have consistently elided. If current research is a weak justification for public health recommendations, it is all the more so for a risk-based message that generates and then profits from the anxieties of soon-to-be and new mothers…

Wolf describes the problems with many studies of breastfeeding, particularly those that focus on long term outcomes:

In breast-feeding studies, potential confounding makes it difficult to isolate the protective powers of breast milk itself or to rule out the possibility that something associated with breast-feeding is responsible for the benefits attributed to breast milk. As the number of years between breastfeeding and the measured health outcome grows, so too does the list of possibly influential factors, which means that the challenge is magnifiedwhen trying to evaluate long-term benefits of breastfeeding… Breast-feeding, in other words, cannot be distinguished from the decision to breast-feed, which, irrespective of socioeconomic status or education,could represent an orientation toward parenting that is itself likely to have a positive impact on children’s health. In instances such as this, in which the exposure (breast-feeding) and confounder (behavior) are likely to be very highly correlated, confounding is especially difficult to detect. When behavior associated with breast-feeding has the potential to explain much of the statistical advantage attributed to breast milk, the scientific claim that breast-feeding confers health benefits … needs to be reexamined.

But even studies that may be biased show limited, if any, long term benefits of breastfeeding. The World Health Organization published a comprehensive review of the evidence  in 2007, Evidence on the long-term effects of breastfeeding, by Horta et al. According to the authors:

…[T]here is some controversy on the long-term consequences of breastfeeding. Whereas some studies reported that breastfed subjects present a higher level of school achievement and performance in intelligence tests, as well as lower blood pressure, lower total cholesterol and a lower prevalence of overweight and obesity, others have failed to detect such associations.

Objectives: The primary objective of this series of systematic reviews was to assess the effects of breastfeeding on blood pressure, diabetes and related indicators, serum cholesterol, overweight and obesity, and intellectual performance.

The authors reviewed the existing scientific literature on 5 specific claims.

1. Does breastfeeding leader to lower blood pressure?

The authors reviewed two meta analyses and three studies:

According to Owen et al, the association between breastfeeding and lower blood pressure was mainly due to publication bias, and any effect of breastfeeding was modest and of limited clinical or public health relevance. In spite of not being able to exclude residual confounding and publication bias, Martin et al concluded that breastfeeding was negatively associated with blood pressure. They argued that even a small protective effect of breastfeeding would be important from a public health perspective… Three large studies were published since the last review, two of which found no association and one found a protective effect of breastfeeding.

Both meta-analyses may have been affected by publication bias… Lack of control for confounding is another methodological issue, as pointed out by Martin et al…

In summary, the present updated meta-analyses show that there are small but significant protective effects of breastfeeding on systolic and diastolic blood pressure. Publication bias is unlikely to explain this finding because a significant protective effect was observed even among the larger studies. However, residual confounding cannot be excluded because of the marked reduction in effect size after adjustment for known confounders.

2. Does breastfeeding lead to lower cholesterol levels?

[N]o significant effect was observed in children or adolescents, mean cholesterol levels among adults who were breastfed were 0.18 mmol/L (6.9 mg/dl) lower than among non-breastfed subjects… [T]he observed reduction associated with breastfeeding corresponds to about 3.2% of [the] median.

3. Does breastfeeding reduce the risk of overweight and obesity?

The evidence suggests that breastfeeding may have a small protective effect on the prevalence of obesity. In spite of the evidence of publication bias, a protective effect of breastfeeding was still observed among the larger studies (>1500 participants),.. This effect seems to be more important against obesity than against overweight.

Because the great majority of the published studies were conducted in Western Europe and North America, we are not able to assess whether this association is present in low and middle-income settings.

4. Does breastfeeding lower the risk of type 2 diabetes?

Evidence on a possible programming effect of breastfeeding on glucose metabolism is sparse. Studies assessing the risk of type-2 diabetes reported a protective effect of breastfeeding, with a pooled odds ratio of 0.63 (95% CI: 0.45–0.89) in breastfed compared to non-breastfed subjects. On the other hand, two other studies failed to report an association between HOMA index, a measure of insulin resistance, and breastfeeding duration, and a study on fasting blood glucose levels was also negative. At this stage, it is not possible to draw firm conclusions about the longterm effect of breastfeeding on the risk of type-2 diabetes and related outcomes…

5. Does breastfeeding raise the level of school achievement or intelligence?

This meta-analysis suggests that breastfeeding is associated with increased cognitive development in childhood, in studies that controlled for confounding by socioeconomic status and stimulation at home. The practical implications of a relatively small increase in the performance in developmental tests in childhood may be open to debate. However, evidence from the only three studies on school performance in late adolescence or young adulthood suggests that breastfeeding is also positively associated with educational attainment.

The issue remains of whether the association is related to the properties of breastmilk itself, or whether breastfeeding enhances the bonding between mother and child, and thus contributes to intellectual development. Although in observational studies it is not possible to disentangle these two effects, the positive results from the randomized trial carried out by Lucas et al suggest that the nutritional properties of breastmilk alone seem to have an effect.

In the case of these five longterm outcomes, the existing scientific evidence shows that breastfeeding has either no benefit or a small benefit.

Adriano Canttaneo, an pediatric epidemiologist and enthusiastic supporter of breastfeeding, writing in the Journal of Pediatrics and Child Health in 2008 in The benefits of breastfeeding or the harm of formula feeding? cautions against making sweeping and unsupported claims about breastfeeding:

… We do not need to use weak and shaky arguments to convince mammals to breastfeed. What we need is effective care to let them breastfeed as much and as long as they wish.

Breastfeeding is desirable and beneficial, and we should promote breastfeeding as much as possible. However, breastfeeding advocates should not overstate the benefits of breastfeeding or overstate the risks of formula feeding. Rather, we should do whatever we can to allow women who wish to breastfeed to start and maintain breastfeeding for as long as they would like.

Posted in: Nutrition, Obstetrics & gynecology

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206 thoughts on “Are the benefits of breastfeeding oversold?

  1. jcwelch says:

    What “needs” to happen is that the relentless, absolutely relentless guilt-tripping of women who choose to not breastfeed must.stop.

    When my child was born, my ex tried like hell to breastfeed. She was hypoglycemic as they come, and i could literally watch the color drain from her face as she tried to breastfeed. After every attempt, it was almost an hour before she was back to normal. In light of that, she made, with my support, the rather obvious decision to move to formula.

    Oh.My.God. You’d have thought we announced we were joining NAMBLA. The unrelenting bullshit we got from the La Leche crowd and their fans. “You can’t bond with your child if you don’t breast feed!” “You’re depriving your child!” on and on, and those were the most mild examples. It got far worse. One “enthusiastic supporter of breast feeding” said that in her opinion, mothers who formula feed were clearly unfit, and should have their children taken away and sent into foster homes where they’d be properly cared for.

    Yeah.

    It was years after that stage before I could hear a woman talk about breastfeeding and not have the impulse to move away. To this day, when I hear a complaint from a woman because everyone in a six mile radius is not overjoyed to watch her breast feed in public, my first impulse is from The Simpsons: HA-ha.

    However you wish to promote breastfeeding, the meme that those who don’t are ‘bad’, ‘uncaring’, ‘cold’, or ‘unfit mothers’ needs to stop.

  2. Alexander Han says:

    Dr. Tuteur, do you know if any studies have been done on kids who are breastfed until, like, age 12? That practice always seemed really bizarre to me.

  3. Dawn says:

    @Alexander: I’ve never heard of any child breastfeeding for that long. Up to age 4 or 5 I’ve heard of. I’m not sure there is any benefit to it.

    @Dr Tuteur: I agree with you. I have always encouraged my patients to breastfeed if that is what they wanted to do. However, I also always felt that a baby would do better with a mentally happy mother, and if the idea of breastfeeding “gave her the creeps (the actual quote from a friend of mine who, for various reaons, doesn’t like having her breasts touched, even by her husband), I encouraged her to bottle feed. I think a baby is happier and does better with a loving, interacting bottle-feeding mother than an unhappy, cringing, revolted breastfeeding mother.

  4. “do you know if any studies have been done on kids who are breastfed until, like, age 12?”

    I can’t find any studies, but evidently the issue comes up in legal proceedings (particularly divorce cases. In fact, Katherine Dettwyler, an anthropology professor who describes herself as “the acknowledged world expert on extended breastfeeding and weaning from both evolutionary and cross-cultural perspectives” offer an all purpose “court letter” on her website (http://www.kathydettwyler.org/detletter.htm).

    “My research concludes that the normal and natural duration of breastfeeding for modern humans falls between 2.5 years and 7 years. Some children nurse less than 2.5 years, and some nurse longer than 7 years. It is quite common for children in many cultures around the world to be breastfed for 3-4-5-6-7 years …

    In addition, my research has been used to counter charges of child abuse and “inappropriate parenting behaviors” in many court cases, especially involving divorce and custody disputes, where fathers may accuse the mother of “inappropriate parenting by virtue of extended breastfeeding” as a strategy to gain custody of children, or may simply claim that ‘continued breastfeeding’ is not relevant to shared custody arrangements.”

  5. “I also always felt that a baby would do better with a mentally happy mother”

    I suspect that you are right.

    We should be counseling women on the benefits of breastfeeding, but we should not be making mothers feel guilty for making a different choice. Although the benefits of breastfeeding are real, they are small, and other factors (including the mother’s wishes and needs) are relevant.

  6. Enkidu says:

    My daughter was born 3 months early, and spent the first 2 months of her life in the NICU. I started pumping for breast milk on Day 2 (after recovering from an eC-section). Two weeks later, I was pumping every 2 hours only to get less than an ounce at each sitting. I was in tears at the end of every pumping session when I saw how little milk I had produced. My daughter had to go on donor breast milk because I wasn’t producing. I felt like a total failure, not only was my daughter in intensive care, but I coudn’t even tend to her most basic need. I had to give up pumping, and my daughter stayed on donor milk for 1 month and then was switched to formula. The doctors assured me that the benefits of breast milk were given in that first month, and she would be perfectly fine on formula. But then I would go home and visit parenting boards, and the studies promoting health and IQ felt like a slap in the face.

    Looking back on it all now, I was a depressed, sleep-deprived, hysterical mess those first two weeks, not because my daughter was in the NICU but because I couldn’t breast feed! I felt like the worst mother on the planet.

  7. Helen Schwalme says:

    I think you are looking at this from completely the wrong angle!

    Breastfeeding is the biological norm for humans. Why should breastfeeding have to prove its self as being healthier/better? Why are you not informing your patients of the health risks of artificial feeding ie formula? On cigarette packets the warnings do not read ” NOT smoking lowers your risk of cancer” or “NOT smoking in pregnancy lowers your babies risk of asthma” rather it is very clearly stated “Smoking causes cancer” etc etc. The same is true of formula feeding…babies who are fed formula are at an increased risk of diabetes, obesity, asthma, respiratory infections, ear infections etc etc. Women who formula feed are also at an increased risk of breast cancer and ovarian cancer. Why is this? Because after pregnancy the female human body EXPECTS to breastfeed, if breastfeeding does not occur there are risks to health.

    We do not need to over sell the benefits of breastfeeding at all. Breastfeeding is normal for our species however we are doing mothers a disservice by letting them believe that artificial feeding is safe (there are NO studies to show formula is safe), that there are no health risks associated. Why do we have no qualms about telling mothers that drinking alcohol in pregnancy can cause birth defects and damage their babies but we cannot tell these same mothers that formula feeding has health risks for fear of “making them feel guilty”?????

  8. latenac says:

    What eventually turned me away from a parenting site I used to visit is that the definition of Attachment Parenting had switched from a “be informed of your options, listen to your child and family, and find your way” type of parenting to “Here’s a checklist of everything you must do to be considered AP whether it works for your family or not”. And to back up this checklist, it tends to revolve around dubious science at best to prove that this is what’s best for your child like all of these claims about breastfeeding.

    That said, I do believe breast is best. I’d love to see better support for mothers especially in the early weeks postpartum. I was lucky when I had my daughter my insurance covered 3 visits by a LC and a mother’s helper within the first 6 weeks. From what I understand now they cover even more visits. I credit the nurse they sent with being able to breastfeed my daughter after a difficult weeks stay in NICU. After the early stages the biggest advantage to breastfeeding is that it was just easier and cheaper than bottle feeding. However, I also know breastfeeding isn’t for everyone and a happy mother is much better than a martyr mother.

  9. Erika says:

    What about health effects on the mother? I’d always heard that breast-feeding lowers the risk of breast cancer. Is there truth to that?

  10. Calli Arcale says:

    It does lower the risk of breast cancer, though not by a huge amount, IIRC. Longer breastfeeding is better in that regard, but how long? The studies I’ve seen considered “six months” to be long term. (And indeed, it often is. Fewer than half of all American mothers will breastfeed for six months, even if they went home from the hospital breastfeeding.) It’s not clear why. But I don’t think “reducing cancer risk” is enough, in and of itself, to make breast best, because the effect is modest.

    In fact, I think *all* of the effects are modest, if indeed they’re even real. Put them all together, and I believe that for most mothers and babies, breast really is best. But none of them are enough by themselves, and other factors are far more important in the health of both mother and child.

    I breastfed both of my children until they were over a year old. It was a wonderful experience, and if I got pregnant again, I’d breastfeed again. I strongly encourage all mothers to try. Setup is extremely simple, it’s not unpleasant once you get used to it, and it’s *cheap*. I was, however, very fortunate in that I have an employer who is supportive of mothers taking lactation breaks. Not all employers do, and indeed, not all jobs can be arranged around milk breaks. Also, the equipment isn’t cheap. It’s cheaper, in the long run, than formula. But I don’t think you can use WIC credits to buy or rent a pump, and you need a really *good* pump if you want to keep up your milk supply while working full-time. Thus, counter-intuitively, many low-income mothers will switch their children to formula so they can return to work, even though breastmilk is essentially free.

    Bottom line, though, is that you need to do whatever it will take to get your baby’s health needs seen to. Forget about pride for having “achieved breastfeeding”. It’s not about pride in your achievements. It’s about raising a healthy kid. It’s okay to switch to formula, or even to use formula from the start. Do what you need to do in order for the child to be well. Everything else is details.

  11. Dawn says:

    @Calli: “Bottom line, though, is that you need to do whatever it will take to get your baby’s health needs seen to. Forget about pride for having “achieved breastfeeding”. It’s not about pride in your achievements. It’s about raising a healthy kid. It’s okay to switch to formula, or even to use formula from the start. Do what you need to do in order for the child to be well. Everything else is details.”

    Hear, Hear!! :-)

  12. Helen Schwalme says:

    I would say that the 33% increased risk of breast cancer in formula feeding mothers is huge and not at all minimal!

    Why is everyone in denial about formula risks? If you choose to formula feed and are truly genuinely informed then that is your choice but by not educating mother’s on the risks of formula and saying “it’s just the same, or it’s fine” you are doing mothers a disservice and are basically lying to them. I find this very disturbing. I am a woman and a mother and I demand to be given accurate, evidence based information by my heath care practitioners…not fed whatever they feel will make us feel better.

    I know of no doctor who would hesitate to tell a pregnant mother that her smoking and drinking are dangerous to her baby, why is the same not true of talking to mothers about the risks of formula? By not allowing women to make genuinely informed choices you are treating them unfairly and failing in your professional responsibilities.

  13. Erika says:

    I have to say, the chief attraction for me (in the end) was the ease. I was far to disorganized (still am) to deal w/ prepping bottles anytime I wanted to go somewhere.

  14. Erika:

    “What about health effects on the mother? I’d always heard that breast-feeding lowers the risk of breast cancer. Is there truth to that?”

    Yes, the evidence indicates that breastfeeding is protective against breast cancer.

    There are real benefits to breastfeeding for both the baby and the mother, and I always recommend it. Unfortunately, though, in some circles it has become a proxy for being a “good mother.” The benefits are simply not large enough to justify any claims that mothers who breastfeed are better mothers or that women who bottlefeed are “hurting” their babies.

  15. LindaRosaRN says:

    A number of nurses call themselves lactation specialists or coaches. One of the frequent claims by you hear from them even the best of them is that breast feeding helps the infant bond or form an attachment to the mother.

    You frequently hear the terms “bond” and “attach” interchangeably. But bonding is the perinatal connection parents feel towards a infant. Behavioral changes in the child around the age of eight months is attachment, i.e. where he begins to learn that his caregivers are separate people and he shows a definite preference for them over other people.

    Yet it is so common to hear health care professionals say that infants bond or attach to their mother *as a newborn, or even in utero.*

    Attachments Therapist claim that the ovum may even form an attachment, and that “Attachment Disorder” can develop at conception if the ovum is attacked by a drunken sperm! Such beliefs go over big with the anti-abortion crowd.

    Some Attachment Therapists write that in order to avoid (the bogus) “Attachment Disorder,” the newborn must make eye contact with the mother during breast feeding and that they shouldn’t be fed until they do! This connection, they teach, is vital so that the child’s development does not become “stuck.”

    There’s whole lot of nonsense out there for new parents to sort through.

    I recommend Jean Mercer’s newest book, “Child Development: Myths and Misunderstandings” (2009).

  16. Molly, NYC says:

    I’m with Erika. Being a mother has its rewards but it’s chaotic. You make a lot of concessions to convenience. And breastfeeding is really convenient.

  17. ErikD says:

    This is an issue that has driven me nuts ever since we had our first kid, and went through the breastfeeding course at Mt. Sinai, the main birthing hospital in Toronto. The course was run by nurses, and there was such fantastic bias that you left there thinking bottle feeding was a form of child abuse. At one point, they showed a video of a newborn left on the mother’s stomach somehow managing to crawl up to the breast. It was pure propaganda, and insulting. Yet still, when our daughter was born under 5lbs and they advised us to supplement with formula, I felt like I was feeding the child poison.

    Later, reading how limited the benefits actually are, and considering how my whole generation born in the late 60′s / early 70′s was raised on formula because the doctor’s thought it was better, it still enrages me that I bought into it. But still, you can’t discuss this with an awful lot of people – it’s become a religious argument and no amount of data will change people’s minds.

    Which is a shame, because all of the research I’ve read up to an including this post, says that on balance, breast feeding is still preferable. But given that the benefits are marginal, creating a significant negative in terms of increased parental stress caused by the breast-feeding lobby might just be enough to tip the scales the other way.

  18. Kristen says:

    I breastfed my three children for about 18 months. Although I enjoyed breastfeeding very much and think it helped foster the strong bond I have with my children, I am cautious in speaking to other new mothers about this subject.

    I am sure my children and I would still have the same bond if I had formula fed them. It is not possible for all women to breastfeed and no new mother should be made to feel that she is ruining her child’s chances for success in life by using formula.

    Whether there are long-term health benefits or not is beside the point, in my opinion. Every mother needs to do the best she can and not be made to feel inferior for her decisions. A mother who feels bad about herself IS a detriment to her child.

    So by all means encourage breastfeeding, but don’t claim it is going to make or break the child’s future or the mother’s future health. There are just too many other factors that go into it.

  19. Robin says:

    Ironically, the people who freak out about the tiny amount of ethlymercury in vaccines, are silent about the tiny amounts of mercury in breast milk. It would be very amusing to watch Jenny McCarthy take on La Lache.

  20. galway says:

    ErikD – I think you’re referring to “Delivery Self Attachment”.

    Although I think the point of that video wasn’t just that the child could find the breast. But to show the difference between babies born after a medicated birth (including c-section) and babies born from unmedicated births.

  21. LindaRosaRN:

    “One of the frequent claims by you hear from them even the best of them is that breast feeding helps the infant bond or form an attachment to the mother.”

    That an unfortunate claim on two levels. First, it not substantiated by the scientific evidence. Almost all the studies that claim to show that breastfeeding increases “attachment” measure “attachment” by the researcher’s subjective view of each mother-infant dyad.

    Second, it is merely a way for some mothers to demean other mothers by essentially claiming that babies love breastfeeding mothers more.

  22. Enkidu:

    “I felt like the worst mother on the planet.”

    Feminist scholar Rebecca Kukla has written extensively on the ways in which mothering has been reduced to “performances.” In Measuring Motherhood, she writes:

    “As a culture, we have a tendency to measure motherhood in terms of a set of signal moments that have become the focus of special social attention and anxiety; we interpret these as emblematic summations of women’s mothering abilities. Women’s performances during these moments can seem to exhaust the story of mothering, and mothers often internalize these measures and evaluate their own mothering in terms of them. “Good”” mothers are those who pass a series of tests — they bond properly during their routine ultrasound screening, they do not let a sip of alcohol cross their lips during pregnancy, they give birth vaginally without pain medication, they do not offer their child an artificial nipple during the first six months, they feed their children maximally nutritious meals with every bite, and so on. This reductive understanding of mothering has had counterproductive effects upon health care practice and policy, encouraging measures that penalize mothers who do not live up to cultural norms during signal moments, while failing to promote extended narratives of healthy mothering.”

    Kukla situates “natural” childbirth within a larger pattern of judging women by their “performance” at key moments:

    “The rhetoric surrounding these moments suggests, on the one hand, that they will determine the success of the future mothering narrative (whether the mother will bond properly with her baby; whether the baby will develop a lifetime of secure relationships and healthy eating habits) and on the other hand, that they reveal the truth about a woman’s fitness to mother (whether she is sufficiently engaged, self sacrificing,risk-adverse, disciplined, etc.).”

  23. Erika says:

    I remember several years ago (5-6) the parenting magazine Brain, Child did a pro/con feature on “should women get more pressure to breastfeed?” (Or something to that effect–could have been “feel more guilt” but you get the idea.) My feeling, for a long time, has been “no, we don’t need more pressure/guilt/whatever.” We need accurate information and support–for whatever path we take.

    When I talk to expecting friends about it, I talk about the personal benefits (convenience, weight loss, etc.) as well as drawbacks (don’t be surprised if you feel glued to the rocker for a while there). And I talk about how lost I would have been if it hadn’t been for LCs, the PA at my OB’s practice, and my sister, who came to stay w/ us for a week and did nothing but cook. Unfortunately, emotional support isn’t enough in those first few weeks–you need physical help.

    I think many women think that they’ll do it (b/c of all the benefits they’ve heard of), and are unprepared for how hard it will be–and then feel guilty when they give up, b/c yes, it’s become a proxy for being a good mother.

  24. Helen Schwalme:

    “Breastfeeding is the biological norm for humans.”

    So is getting pregnant shortly after a girl’s first period, getting pregnant as often as biologically possible, bearing 8-10 children, having a lifetime risk of death in childbirth of 1 in 13 and having a life expectancy of approximately 35 years.

    Just because something is the biologic norm does not make is “better.”

  25. Helen Schwalme:

    “I am a woman and a mother and I demand to be given accurate, evidence based information by my heath care practitioners…not fed whatever they feel will make us feel better.”

    Great! Then you should be aware that the “risks” of bottlefeeding are grossly exaggerated (if they exist at all), no matter how much better it makes you feel to claim otherwise.

  26. Molly, NYC:

    “And breastfeeding is really convenient.”

    Not if you’re a single mother working a minimum wage job, with no money to afford a pump, and no time to pump.

    As Rebecca Kukla writes in the paper I mentioned above:

    “Thus to the extent that we take “proper” maternal performance during these key moments as a measure of mothering as a whole, we will re-inscribe social privilege. We will read a deficient maternal character into the bodies and actions of underprivileged and socially marginalized women, whereas privileged women with socially normative home and work lives will tend to serve as our models of proper maternal character.”

  27. Helen Schwalme says:

    To Dr Amy Tuteur

    Words fail me on your responses. I am thankful that you are not my Doctor! I am an IBCLC student, all of my information is the most up to date current evidence based information and you are trying to tell me that the research on the risks of formula is over stated???? Who are you getting your information from…the formula companies??/

    Health care professionals have a responsibility to their patients to provide accurate evidence based information that is NOT based on personal biases! The reason many women fail at breastfeeding is because they get no support and crappy information from the very same health care professionals!!

    Shame on you…so much for first do no harm!

  28. Erika says:

    Yes, you’re right, it’s a societal privilege. Breastfeeding is really convenient–until you have to go to work and pump, and the only place to pump is the bathroom, or you can’t afford a pump, etc. Or until you have to make dinner for your other children, instead of sitting in the rocker w/ the baby. This is where the support comes in–and if women don’t have the support they need to breastfeed, then they need support for other decisions.

    I don’t think we’ll ever be able to erase *all* the societal barriers to it, but let’s hope we can eliminate some.

    #Helen Schwalme, *one* reason so many women fail is b/c of bad information from h/c providers. There are a host of other reasons, many outlined above. Dr. Tuter seems to be trying to provide good, accurate information–and support. I wish my OB had been more like her, actually. When I told her I was planning to, she said “so many women beat themselves up over it, and it’s not that big of a deal.” Far better if she’d said “this is what the evidence shows. There are great reasons to do it, and if you’re going to try, this is what you need to be aware of, and here are resources for your success.” Instead, I felt like I couldn’t ask her any questions b/c of her dismissive attitude.

  29. Helen Schwalme:

    “all of my information is the most up to date current evidence based information”

    Really? What scientific papers have you read that support your claims?

  30. biguglyjim says:

    I have four kids, all of whom are fantastic. Shortly after my first daughter was born, she came down with RSV and was hospitalized. While there, they noticed that she was quite dehydrated. They strapped my ex-wife to a high-tech milking machine and waited. The quantity of milk she was producing was ridiculously small. They offered no reasoning behind this, but quickly moved the baby to formula. I don’t believe we were consulted on the increased risk of diabetes or cancer. Our primary concern was the increased chance of starving to death from the current scenario.

    Despite the very glaring medical need for formula feeding, we were regularly told that our “choice” to not breastfeed meant our child would be sickly and stupid. Neither is the case. We were routinely told by friends, family, and even a fill-in family doctor that we should have just waited for it to work, which is of course ridiculous. The baby was at risk.

    Obviously breastfeeding is a good thing, but there are plenty of situations where it simply isn’t possible for a variety of reasons. The cult of supermommies has got to learn that they do not have the right to shove their mean-spirited opinions so blindly.

    As it happens, we bottle-fed the first two and were able to breastfeed the last two. They are similar in both health and intelligence.

    I think that all of these statements on the long-term effects of breastfeeding are weak at best. There’s no conclusive science behind them, and there are far too many variables to ensure any reliable data without creating experiments that would be grossly damaging to the child subjects.

  31. stephend50 says:

    Funny thing breast feeding; why are all the studies trying to demonstrate if breast feeding is better? Shouldn’t the burden of evidence be on the formula manufacturers to prove their product is as good as?

    We experienced the reverse of the meme that many have described. My wife had trouble at first with breast feeding. Our daughter wouldn’t latch properly. The nurses in L&D refused to call the lactation consultant in spite of frequent requests and all but threw free samples of formula at us. The lactation consultants recommended by the hospital — where I am employed as a hospitalist — were independent contractors who weren’t much more than representatives of the leading breast pump manufacturer. Rather than help with the latch, they offered to sell us products. Our pediatrician bent over backwards to be supportive so she pushed formula. Funny enough the PhD and her husband the MD could only find meaningful help from a naturopath/dula and a group of dula/natural birth breast feeding “enthusiasts.” My wife finally found what she needed. A group of women, who all had had children, and who were willing and able to take the time to reassure and coach mother and daughter. There is something delightful about watching a 10 month old dance in her mother’s lap while she has lunch.

    This was a case where “conventional” medicine pushed a patient towards spending lots of money for useless products — lactation consultant / breast pump rep. Too much support for not breast feeding pushed a patient away from science based medicine into the arms of alt med types. My wife was capable, our daughter was just — and is — stubborn. We needed someone to say it’s ok, try this. Instead we go it’s ok, buy this.

    And yes single moms working hourly jobs often are not permitted to pump at work even if they could afford to buy or rent a pump. People have to make decisions and the rest of us should bind or own business. On the other hand, formula is the most stolen item at the pharmacy we go to. It is kept locked and you can only get it off the shelf if the store manager unlocks it for you. Formula is expensive.

    Now let’s talk about something non-controversial… cloth diapers vs. disposable — LOL.

  32. SF Mom and Scientist says:

    Helen Schwaime – wow, I don’t know where to start. First let me say that your attitude is what I have encountered with lactation consultants. I had such a hard time with breastfeeding, and every time I went to a lactation consultant I got a lot of eye-rolling and huffing about how I should be able to do this by now. Not exactly the most supportive environment. I almost quit, until I joined a moms’ group and got help there. Pressuring women and making them feel guilty is not the way to go. Providing accurate, science-based information and a supportive environment is.

    I know this is only anecdotal, but in my group of friends we have had similar experiences with lactation consultants. In my opinion, they do more to push women away from breastfeeding than anything. (I’m sure there are good ones out there, but they seem hard to find.)

    The emotion in your posts indicates a lot of personal bias on your part. You keep talking about the crappy information provided, but provide no detail about why you disagree exactly.

  33. Calli Arcale says:

    The importance of social support cannot be overstated, and given how crucial it is to successful breastfeeding, I have to wonder: with all the studies showing the superiority of breastfeeding, are they really looking at the breastmilk or the fact that the mother is getting better social support? Mothers who breastfeed are more likely to be highly educated, have stable families, come from stable families, have lots of relatives in the area, and be affluent. These are all, independently, associated with better outcomes for both mother and child, yet I’ve yet to see a “breast is best” study which adequately accounts for these massive confounders. Ms Schwalme, if you know of one, I’d be very interested to read it.

    I think that telling new mothers that they are child abusers if they bottle feed, or comparing bottle-feeding to smoking and drinking during pregnancy (as Ms Schwalme did above) is a great way of convincing new mothers that you are a total loon and can therefore be disregarded. Or, that you’re a controlling, judgmental jerk and should be avoided at all costs, in which case, even if they initially agree with you about breast, they may change their minds just because they don’t want to be associated with you.

    The real objective for all of us (including you, Ms Schwalme) is to get more women breastfeeding their babies. Formula is an acceptable substitute, IMHO, but breastfeeding really is a wonderful thing, in and of itself. It shouldn’t require lies to defend it. So how do we do that? How do we convince more women to do it?

    It’s not difficult, it turns out. In America, a very large majority of new mothers attempt to breastfeed their babies. The problem isn’t convincing them to start. Somewhere along the way, they’re stopping. If we want them to avoid formula, we need to address the reasons why they stop nursing and correct those. Just telling them they’re bad mothers if they stop won’t do the trick.

    And some of the reasons are out of their control. If a woman needs to work to support her family, and her job isn’t very understanding about the milk breaks, what is she to do? We can legislate stuff, and an increasing number of states are requiring that employers make reasonable accomodations for lactating mothers. But long-term, we really need to educate employers and colleagues to understand that the milk breaks are good for the mothers, don’t have to be disruptive, and are an appropriate benefit that should simply be expected. You expect your employer to provide a restroom; you should expect them to allow nursing mothers to do their thing as well.

    Restaurants eject nursing women; most states won’t allow you to breastfeed outdoors, so mothers have to find bathrooms or at least pray for a mother’s room or women’s lounge; breasts are seen as sexual objects and thus not suitable for view by children; women even get asked to stop nursing on airplanes when they’re covered. It’s not good. The real problem isn’t that there’s too much formula feeding. The real problem is that we have a social taboo about it. Our society supports it as long as it isn’t seen, which is a bit like supporting equal education for blacks 50 years ago as long as they don’t actually show up at your school. Which is to say, not helpful at all.

    The industrialized nation with the highest rate of breastfeeding success is Norway. I think the most amazing thing they have is a widespread acceptance of children in the worldplace. Many mothers bring their babies into the office with them, allowing them to nurse the babies as needed instead of using a pump. It’s no wonder that over 90% of Norwegian mothers are still nursing at six months.

    Rather than demonize formula, I think the answer is to concentrate on normalizing breastfeeding.

  34. Kylara says:

    @Alexander Han, I believe if you breastfeed them until they’re 9, they win gold medals in wrestling for Mongolia. ;)

    (The gold-medal winner attributed his strength to his extended breastfeeding, apparently a common belief in Mongolia.)

  35. Kylara says:

    @Helen Schwalme: Your attitude is one of the big reasons I almost didn’t TRY breastfeeding. Women like you made my mother cry when, because of an anatomical abnormality, her supply was unable to keep up with demand and who told her that adequately feeding her baby was child abuse (and this was in the 70s!). The hospital finally had one of the lactation “consultants” (they weren’t called that then, but I forget what) thrown out for urging women to malnourish their babies because it was BREAST OR NOTHING even if the infant was starving and/or failing to thrive. Women like you attack one of my best friends in the mall for feeding her infant formula — BECAUSE SHE IS A FOSTER PARENT TO HIGH RISK INFANTS.

    I did breastfeed, I’m at 7 months and still going, but I even hate to mention it, because the attitudes of *approval* I get are part and parcel of that whole judgmental line of attack on GOOD PARENTS caring for their children as best as they are able within the constraints of time, money, work, body, and so forth.

    The only bad part of my “birthing experience” was the lactation consultant at the hospital, who was in your mold, Helen: Mean, judgmental, and full of nonsense claims unsupported by the evidence. She also attempted to make decisions about my MEDICAL care despite having no MD or even nursing degree; I have a chronic condition requiring active management that my ob/gyn, my son’s pediatrician, my husband, and I had discussed in depth, researched, and made decisions about treatment during breastfeeding that would be safe for the baby and keep me healthy. She was literally try to call in different orders with no medical background at all! I finally told the nurses not to let her come back, and I would figure it out myself or with the help of the nurses.

    You, Helen, are part of the problem. You are not part of the solution.

    @Calli — MOST states — 43 of them — have laws protecting breastfeeding in public. That includes outdoors. And typically “places of public accommodation,” which are things like stores and restaurants. It’s misleading at best to say “most” states don’t allow you to breastfeed outdoors. 28 states specifically exempt breastfeeding from public indecency statutes. You can learn more here: http://www.ncsl.org/issuesresearch/health/breastfeedinglaws/tabid/14389/default.aspx

  36. phren0logy says:

    Thanks Dr. Tuteur. Your articles keep getting better and better. It’s nice to see a balanced take on an issue that, as you mention, seems to be “oversold.”

    As a child psychiatrist, the most problematic part of this situation (at least, that I’m exposed to clinically) is the pressure and guilt for mothers who opt not to breast feed (or cannot breast feed) but are still great parents.

  37. SomePapa says:

    I do think the benefits have been oversold, however I don’t understand the apparent backlash against breast feeding. (And, no, I wouldn’t put this piece in the backlash, although considering other pieces that I’ve seen, I would have been more careful with the headline, however accurate it may be — and is.) Yes, many states have some protections on the books, but breast feeding in public is still something with which many people are not necessarily all that comfortable. Education and support in that area continues to lag, IMO. Sure, there is a small minority of breast feeding advocates that go overboard and push guilt, but they are far outnumbered by those who don’t breast feed — and by those who do breast feed but are fine the choices other people make.

    We must remember that guilt is a funny thing. It can often come from within, but we are also quite good at blaming others for our own negative creations. I’m not saying this is the case all the time (I know it’s not!), I’m just saying that I think the “people making mothers who don’t breast feed guilty” line is also oversold.

  38. Harriet Hall says:

    I was a bit surprised at the emphasis on long-term effects. What about the short term effects – for instance of maternal antibodies in breast milk?

  39. SomePapa says:

    One question for Dr. Tuteur: This is based on supposition and old memory, and so it may be off base. But, I’m wondering about the theory that more mothers have difficulty with breast feeding today than they did in centuries past? (A claim I’ve read at least once or twice.) I know we can’t study that definitively, but is there any cultural anthropology or other evidence that even supports such a notion? Or did difficulty with breast feeding for some mothers throughout human history add to some of the high infant mortality historically known in humans?

    Or…?

    Thanks.

  40. Harriet Hall says:

    I strongly support breastfeeding, but I didn’t do it. My reasons were occupational incompatibility (I was an on-call flight surgeon) and personal preference. Whatever the reasons, no woman should feel guilty because she chose to bottle feed. It may not be quite as good but it’s close enough.

  41. icewings27 says:

    I am a new mother and have chosen to breastfeed. I am fortunate because I do not work, so breastfeeding is a convenient, inexpensive feeding option for my baby. I do not think mothers who choose to formula feed should feel guilty or inadequate!

    I do think that breast milk is best FOR ME, but not because of all the unconfirmed supposed benefits that have been mentioned already. I believe breastfeeding is more environmentally friendly.

    Formula requires resources and energy to be produced, packaged, and shipped. Formula feeding requires bottles to be produced, packaged, and sterilized. It also takes energy to heat the formula before feeding it to baby. Formula packages and bottles end up being thrown into the garbage.

    Breastmilk, for the most part, does not use up resources and energy other than the few additional calories that the mom needs to eat each day, and there is minimal waste produced, assuming breastfeeding moms use far fewer bottles than formula feeding moms.

    So basically, I breastfeed for the same reason I use cloth diapers: overall the environmental impact is smaller. Having said that though, there are MANY ways moms can choose to conserve energy and reduce waste. Breastfeeding is only one small choice among many. It is not right or wrong. It’s a choice. It works for some women and not for others, depending on their lifestyle and many other factors.

  42. Zoe237 says:

    Recently, my state (Michigan) had a mom kicked out of Target for nursing in the electronics aisle. A few days later the judiciary committee in the House passed 11-2 a bill making it officially legal (it never was illegal) to breastfeed in public. Now it goes to the floor.

    As with childbirth, extremists on both sides annoy me- those that claim that breastfeeding has little to no benefits, and those who basically claim that formula feeding is child abuse. This post addressed the supposed long term benefits of bf (the only one I’d heard was obesity) but nothing about ear infections or diarrhea. And I’m very curious if c-sections hinder or help bf success (or neither)

    Advocates should focus on normalizing beastfeeding. There is also the issue of some obstetricians and pediatricians giving horrible bf advice- like only ten minutes/side, every 2-4 hours. This is a recipe for
    bf failure, since in the early weeks infants need to nurse on demand to establish a good supply. Another huge misconception I see is that you can’t combine nursing and formula feeding after the few weeks. It’s not an all or nothing proposition. And yes, pumping time and break time have been mandated by some states. Personally, I would like to see more maternity/ paternity leave time granted as well (if desired).

    IME, the mommy wars are mostly an online phenomenon. IRL, whether a mom bf or ff, gives birth vaginally w/o pain meds or by ECS doesn’t make a bit of difference. Online though we have hatred and loathing of mothers who breastfeed 2 year olds in public and who give birth in hospital tubs helped by CNMs. And others who seem to loathe moms who formula feed and have c-sections. They seem to feed off each other (we’ve seen examples of both extreme sides on this thread, and others in recent weeks). Motherhood is so political, and I’m not sure if SBM has all the answers (in general).

  43. Enkidu says:

    Helen: “I know of no doctor who would hesitate to tell a pregnant mother that her smoking and drinking are dangerous to her baby, why is the same not true of talking to mothers about the risks of formula?”

    What are these risks that you speak of? You throw formula in with smoking and alcohol, I want to see these studies that show formula is dangerous.

    As a mother who had no milk production, for me it was formula or hire a wet nurse (talk about an assult on my psyche if I had to do that, I would have been riddled with guilt and jealousy; I would not have been in a very good mental state to be a mom). Or the third option, not feed my 3 lb, 1 month old baby. I’ll take the formula, thanks modern technology!

  44. Zetetic says:

    Hmmm… So now Dr. Tuteur is just a shill for “Big Formula” ?

  45. Zoe237 says:

    I am also interested in how much breastfeeding decreases breast cancer risk. And why if it’s not all that good, why most large hospitals have breast milk banks for preemies.

    Helen: “I know of no doctor who would hesitate to tell a pregnant mother that her smoking and drinking are dangerous to her baby, why is the same not true of talking to mothers about the risks of formula?”

    @@@

  46. EricG says:

    wow

    first entry on this topic. I had no idea that bf had the same undertones as religion. heretics be warned! your baby will be a menace to society unless you agree that breast is best!

    the interesting thing is…

    unlike vaccines, religion, the environment etc. etc. bf has no implications for anyone else besides the individual…at all! It appears to be a falsely created “pandemic” that demands that “you act just as I do…OR ELSE!!!” And the social norms swiftly guilt you to death. The info is there; a dedicated parent can pick through it if they want. meanwhile, kids watch 3 hours of tv a day (or some insane amount) and primary education in the US is crumbling…what are you going to do? (relate it to bf feeding i suppose…)

  47. Ash says:

    As a father, I fully support breast feeding since it means it has to be my wife that gets up for those feedings in the middle of the night :)

  48. windriven says:

    @Helen Schwalme

    My gut tells me that breastfeeding is superior to bottle feeding, at least through the first days post partum. But my gut doesn’t mean squat. Neither does the nebulous assertion that, “all of my information is the most up to date current evidence based information”. This blog lives and breathes the scientific approach to medicine. So let’s have some citations to support your claims. If they’re good studies, you’ll find them warmly welcomed here.

  49. Julie says:

    I am a new mother, my daughter will be 5 months old this month. I had planned on breastfeeding. I did my research, had a birth plan, had everything all lined up. Then my induction (for medical reasons) didn’t go well and I needed an emergency c-section. Things went downhill from there.

    However, the second day, we started breastfeeding and after meeting with 3 LCs, we finally got her latched on and breastfeeding her well. I *almost* exclusively breastfeed her for the first 4 weeks (my allowed maternity leave).

    Then I had to return to work. I was NEVER able to pump well. Never. I tried 6 different pumps, ending with a hospital-grade pump I rent for a high monthly fee. Even at my peak performance, I could only pump 8 oz for the entire day, and as I am gone at least 12 hours a day, she still got formula. Eventually my supply dwindled, and now my daughter won’t take my breast. I had to work to support my family as my husband was laid off last year and it is next to impossible to stick to a pumping schedule at my job.

    I tried everything to build a supply. I spent hundreds of dollars on LCs, supplements, pumps, tea, oatmeal, anything anyone said would increase my supply, I would try.

    I was so devastated about not being able to exclusively pump and breastfeed, that I ended up with severe PPD and my doctor wanted me to start taking medication because she was worried I was a suicide risk. I would burst into tears at work for no reason, I would spend hours crying at home and drive my husband crazy by asking him how many ounces of formula my daughter had to have that day… I would stay up all night and pump every hour while my daughter was sleeping and still not get enough, and then be so tired the next day that my work suffered. I withdrew from my family and friends. I came close to being fired two months ago because I was so depressed and not functioning properly at my job.

    Right now I am shelling out the money for her formula, but I still am renting the pump so I can give my daughter some breastmilk. I have thought of just stopping altogether, especially now that she won’t take my breast, but I still feel so completely guilty about the whole thing that I still beat myself up for it.

    And do you know why? It’s because of people who tell me I didn’t do the best I could for my daughter. People who make generalized statements without knowing the particulars of a situation, or how hard it is to be a new mom and also be the sole financial supporter of your family, while having no support for breastfeeding. People who think that I am formula feeding my daughter out of selfishness, rather than understanding that I literally made myself sick trying to breastfeed, and still beat myself up over every bottle of formula she gets.

    It just makes me even more sick to think about these breastfeeding advocates who tell moms they are selfish, or poisoning their babies, or any of the other God-awful things I’ve heard the last 5 months.

    I wonder how much of my and my daughter’s well-being has been sacrificed because of my depression and breastfeeding struggles. I can’t help but think we both would have been better off if I’d formula-fed from the beginning.

  50. Dawn says:

    @Helen: As a midwife, I always encouraged women to breastfeed if they expressed any desire to do so. Yes, I believe breastfeeding is best. I breastfed my children (6 months and 3 months) and would have liked to do so longer but since in both cases work/daycare didn’t allow for it, I couldn’t.

    What would you suggest to a mother of a 3 month old who had a severe ear infection and was refusing to nurse for 8 hours? It hurt her a lot less to take a bottle than nurse so she refused to latch on. I worked with her for 3 days and finally, in tears, gave up and bottle fed her. (IIRC, in those 3 days, she lost about 2 lbs as she was eating much less frequently because I would work with her for hours trying to get her to nurse – not good for a baby on the 10th percentile for weight. Even expressing milk from my breasts into her mouth didn’t work. And even today, the remembrance makes me cry, how much I hurt my child because I insisted she breast feed. Thank goodness my pediatrician, father of 6, all whom breastfed for 1+years, talked sense into me and I gave her a bottle) She never nursed again.

  51. SF Mom and Scientist says:

    Helen: “I know of no doctor who would hesitate to tell a pregnant mother that her smoking and drinking are dangerous to her baby, why is the same not true of talking to mothers about the risks of formula?”

    Maybe this is because I live in San Francisco, but I felt much more pressure about breastfeeding than about not smoking or drinking during pregnancy. When my son was an infant and I’d be walking around with him in the stroller/carrier, I often would have someone (always a woman) walk up to me and say “you are breastfeeding, right?” Even though I was breastfeeding I found this extremely offensive. On the other hand, when I was pregnant I never had anyone walk up to me and say “well, you are abstaining from alcohol and cigarettes, aren’t you?”

    Again, its about giving information and support. Why would a stranger ask me if I was breastfeeding my months-old son. If I was not breastfeeding at that point, it is not like I could spontaneously start lactating.

  52. skepchick says:

    @ Amy Tuteur, MD

    Hurrah!

  53. Harriet:

    “What about the short term effects – for instance of maternal antibodies in breast milk?”

    There are short term effects such as a decrease in morbidity and mortality, but the magnitude of these effects is not clear. That’s because of the many confounding factors that could account for the differences.

  54. biguglyjim:

    “While there, they noticed that she was quite dehydrated.”

    When I was in training, I was taught that it was virtually impossible for a baby to get dehydrated by exclusive breastfeeding. Unfortunately, that was more wishful thinking than reality. Some women simply cannot produce enough milk. Not only do babies get dehydrated, but some die.

  55. Calli Arcale:

    “It’s not difficult, it turns out. In America, a very large majority of new mothers attempt to breastfeed their babies. The problem isn’t convincing them to start. Somewhere along the way, they’re stopping.”

    I wish that were true, but I suspect that it is not.

    First of all, breastfeeding IS hard. It can be painful, tiring, and often takes some time and serious effort to establish. It amazes me that we insist that women take childbirth education classes and then neglect breastfeeding education. The baby is going to come out one way or another; a class makes no difference. However, breastfeeding is not necessarily going to work out. In my judgment we should be spending more time preparing for breastfeeding than for childbirth.

    Second, the key factor in successful breastfeeding is probably motivation. Women who are motivated to make it work usually (but not always) can make it work. Unfortunately, there are very few people more psychologically fragile than new mothers. They are both physically and emotionally vulnerable. They easily feel overwhelmed, and breastfeeding may simply add to the those unpleasant feelings.

    I suspect that many women start out breastfeeding because of the psychological pressure to do so, but then give it up when they are no longer being judged by the nurses or others.

  56. SomePapa:

    “But, I’m wondering about the theory that more mothers have difficulty with breast feeding today than they did in centuries past? (A claim I’ve read at least once or twice.) I know we can’t study that definitively, but is there any cultural anthropology or other evidence that even supports such a notion? Or did difficulty with breast feeding for some mothers throughout human history add to some of the high infant mortality historically known in humans?”

    Human beings are not inherently perfect. Things go wrong all the time. For example, 20% of all confirmed pregnancies end in miscarriage. Approximately 1% of mothers and 7% of babies will die in childbirth. There is no reason to expect that breastfeeding is any more “perfect” than other functions.

    There is likely a range of characteristics (quantity of milk, quality of milk, anatomy of the nipple and areola) that affect the success of breastfeeding. It doesn’t make sense from an evolutionary standpoint to imagine that breastfeeding, among all human functions, is innately perfect.

  57. Zoe237:

    “IME, the mommy wars are mostly an online phenomenon. ”

    I can assure you that it existed long before the internet did.

  58. windriven says:

    @Zoe237

    “Motherhood is so political, and I’m not sure if SBM has all the answers (in general).”

    SBM has never claimed to have all the answers, only the best way yet discovered to search for all the answers.

  59. Zoe237 says:

    IME, the mommy wars are mostly an online phenomenon.

    “I can assure you that it existed long before the internet did.”

    The politicization of motherhood has existed for hundreds of years, probably longer. In literature before the internet. And the pendulum has swung many many times between nature and science/technology. Currently, one trend is to become more and more child centered. For many years, formula was seen as superior. Hopefully, at some point, we’ll settle on a happy medium. It’s interesting that something that is “natural” (bf, sans pumps of course) is not necessarily *always* seen as deficient by SBM.

    But, I doubt even then that individual mothers paid attention to who they should judge based on what the “experts” were saying. I’m sure that there is some judgement of formula feeding mothers as putting their child’s health at risk, and I’m sure there is some judgement of breastfeeding mothers as being sick nipple nazis who bf for their own sexual pleasure. But the vast majority of moms support each other, despite “experts” who want to capitalize on a mother’s fear of hurting her child.

    “Approximately 1% of mothers and 7% of babies will die in childbirth. ”

    Just to clarify, I’m assuming you meant in the past.

  60. Zoe237 says:

    “SBM has never claimed to have all the answers, only the best way yet discovered to search for all the answers.”

    I dunno, you’d have to convince me of that. What if there are answers that science CAN’T answer, by definition? Value judgements, for example.

    Or maybe I’m misunderstanding you.

  61. EricG says:

    Zoe237 said:

    “I dunno, you’d have to convince me of that. What if there are answers that science CAN’T answer, by definition? Value judgements, for example.”

    an example would be interesting. if by “value judgement” you mean something like culture, sprituality, morals or ethics, then you are probably right. But, I would venture to say that science based medicine is probably not terribly interested in the afforementioned value-equivalents’ take on bf save for what can be contributed by sbm to begin with…right?

    yea…definately need an example, I don’t want to put words in your mouth.

  62. SomePapa says:

    Dr. Tuteur,

    I never said humans were perfect, in any way. Thanks for the answer, and it’s probably all anyone can offer on that topic, but the tone of your answer, and the use of the notion of “perfect,” does make it seem like you were answering a rewording of my question.

    Anyway, cheers!

  63. SomePapa:

    “the tone of your answer, and the use of the notion of “perfect,” does make it seem like you were answering a rewording of my question.”

    Sorry about that. I guess I didn’t express myself very well.

  64. tm says:

    @Kylara: Brava. Good luck with your adventures.

    Doing a quick google on Helen, she runs her own little echo chamber where Big Bad Formula Companies are trying to poison and kill their customers (“Just like Big Tobacco”, hence her Big Tobacco comparison). It’s conspiracy theory nonsense, evidenced by the fact she can’t actually cite actual scientific studies backing up her claims. Conspiracy theorists, when faced with the dearth of actual evidence, respond with the tried and true ad hominem attack:

    “I am thankful that you are not my Doctor! Who are you getting your information from…the formula companies??/ … Shame on you…so much for first do no harm!”

    See how quickly she moves to label Dr. Tuteur as nothing more than a Big Formula shill. And that final insult, referring to the Hippocratic Oath, casting Dr. Tuteur as no better than Mengele. That’s a real classy touch. I’m sure she’ll nitpick and say, “But I didn’t mention the Nazis!” Yeah, but how many high profile oath breakers can you name? Mengele is top of that list, by miles.

    It’s not surprising that Helen would fail to see the irony of her own zealotry in a discussion that covers motherhood and the eternal Mommy Wars. She is a zealot, and zealotry blinds people to actual reality. Children and their parents are like snowflakes: No two family situations are alike. Yet people like Helen attempt the same one-size fits all condemnation upon those who don’t breastfeed that the La Leche League had to fight a generation ago from the opposite direction (when almost all American children were bottle fed, because of the whole “better living through chemistry” era). Despite the progress made in society to accept a new mantra (“breast is best”), La Leche zealots like Helen still play the victim card. Still claiming they are the only ones who Know the Truth and the only ones who will Save Humanity from the Evil Conspiracy.

    Wait, I thought it was the Moon Landing Hoaxers who did that, or was it the 9/11 deniers, or the JFK people, or the Jewish Bankers theorists, or the Hidden Nazis ones, or was it Hidden Communists, or was it the CIA theorists? Or what about theorists uncovering the Bavarian Illuminati, or the Queen of England’s conspiracy, or the Roman Catholic church’s conspiracy? So many Defenders of Humanity out there these days…

    Just as alt-med has a billion Truths, so do conspiracy theorists. Certainly, formula companies have behaved badly, and some continue to do so. The same criticism could leveled against any industry, and does not, at any rate, constitute actual scientific evidence of one feeding method over the other. Oh I know what Helen would say: “But Big Formula has suppressed all of the evidence showing risks!” In her universe, every doctor is bought, every nurse is an accomplice, and the only ones who can “Truly” protect our children are lactation consultants.

    Helen is an extreme example of the tenor of how motherhood is judged. Pragmatic considerations are tossed aside in favor of strictly ideological ones. And those ideologues cast about for “evidence”, where every shred of even the slightest benefit is magnified and put into the “Good Mother” list, and those that have even a whiff of risk are put into the “Bad Mother” list. But with the judgments, the intolerance of differing viewpoints, and the shaky scientific foundations, what we have here is not a guide to parenting, but a secular religion: A system of beliefs that cannot be challenged.

  65. Geekoid says:

    Why do people think breast feeding is above reproach?

    Looking at it’s effects is the responsible thing to do. Even if someone takes the incorrect stand that breast feeding is natural and therefore perfect, you STILL need to study it’s effects to compare formula. Why someone would get so emotionally upset about having a society that gives mothers the ability to have health children even when breast feeding isn’t possible boggles my mind. Are people ally that mean?

    @Helen – A rational thinking skeptic site may not be the best place to make arguments and statements without any back up. It really seems that you are arguing from arrogance of ignorance.

    Now some humor. Warning, it’s a little…blue.

    If Someone who looks at Breast feeding studies to evaluate it’s effects is a shill for ‘Big Formula’ is someone who religiously accepts that it’s better because its natural a shill for “Big Boobs*”?

    If so I have no idea who to root for~

  66. Geekoid says:

    @Zoe – It’s science based medicine, not philosophy based medicine…just saying~

  67. galway says:

    Kylara:
    Anecdotal, but my eldest sister was born in ’69. My mother was a “lamaze” mom as she calls herself, who was determined to breastfeed. In her area – formula feeding was the social norm. She was accused of starving my sister (who was quite healthy being breastfed) and was repeatedly told by outsiders and family alike that she just needed to bottle feed her baby because that was what was best.

    Interesting where time takes us.

    My mother was my support system during the 4 long weeks it took to teach my son a proper latch. She bought me my breast pump when I was dealing with engorgement issues. She was encouraging and understanding of what was going on – having been there herself.
    It’s this kind of support that I feel helps women the most.

  68. daedalus2u says:

    In response to the first comment in this thread by jcwelch, I think you both made a very wise decision. I think that a lot of the distress that occurs in the postpartum period, postpartum depression and postpartum psychosis is exactly due to the metabolic stress of lactation and is a “feature”.

    Lactation is extremely energy intensive. If a woman does not have the metabolic capacity to lactate, she is incapable of producing sufficient milk of sufficient nutritive value. An important component of milk is lactose, which is the major osmolyte and which must be made as fast as the milk is produced. Lactose is made from glucose, and glucose is made by the liver from 3-carbon substrates. Glucose cannot be made from fatty acids (which are metabolized in 2-carbon bits).

    My hypothesis is that one of the metabolic stresses of the postpartum period is primarily due to insufficient liver mitochondria to support the level of glucogenesis that is necessary to support lactation. Evolution has configured lactation physiology to maximize the sum of survival from enough milk to feed the infant and too much milk which wastes maternal resources (which could be used to make additional babies). The regulation of lactation balances this trade-off as best as evolution has configured it. This balancing act includes maternal metabolic resources, but also maternal stress (which integrates environmental stressors), maternal anxiety (which integrates environmental anxiety producing agents), and maternal support systems (which modulate environmental stressors). Too much stress, or too little support systems, will tend to shift the balance toward insufficient resources to sustain the infant until it is weaned. I think that nitric oxide status (which is what triggers mitochondria biogenesis) is one of the mechanisms that integrates the large number of factors important in determining where the optimum lactation setpoint is from an evolutionary standpoint. A setpoint that we do not fully understand how to manipulate.

    In the absence of other sources of milk, other lactating females willing to wet-nurse, domesticated animals available for milk, or synthetic formula, a child that could not be sustained until it was weaned was a child that would die.

    In the “mommy wars”, the mommy who contributes more children to the next generation “wins”. Subtle competition, psychologically undermining one mommy’s ability to nurse her own infant but keeping her around so she could act as a wet-nurse for another might be an effective strategy. I suspect that a lot of the disapproval of the mothering style of others fits into this type of undermining strategy. Disapproval of breast feeding in public would fit into this strategy.

  69. Zoe237 says:

    “an example would be interesting. if by “value judgement” you mean something like culture, sprituality, morals or ethics, then you are probably right. But, I would venture to say that science based medicine is probably not terribly interested in the afforementioned value-equivalents’ take on bf save for what can be contributed by sbm to begin with…right? ”

    Well, ethics… yes. Like with the new mammography guidelines. How can we put a price or a number on certain unquantifiables? How many false positives (and their associated consequences) is worth a life saved? Or with bf vs. ff. There are certain advantages and disadvantages to each that can’t be easily defined by research studies. Formula feeding can have the advantages of convenience, ease of use, etc (at least in the early days). Or the pain scale, eliminating or reducing chronic pain seems to be a failure of modern medicine in some ways. So many well meaning doctors are afraid of addiction in their patients. Or women who would like to have a good childbirth experience *in addition to* a healthy baby and mom. Or end of life issues. Or abortion. There are many, many examples.

    Medicine (as an applied science) is different than pure science in many ways, in that value judgements and politics enter into play a great deal more than say physics.

    I’m not the least bit religious or spiritual personally, but I am very interested in why people turn away from science.

  70. “My mother was my support system during the 4 long weeks it took to teach my son a proper latch. She bought me my breast pump when I was dealing with engorgement issues.”

    Your difficulties are not unusual. That’s why so many women give up on breastfeeding: it’s not easy to get started.

  71. Zoe237:

    “Medicine (as an applied science) is different than pure science in many ways, in that value judgements and politics enter into play a great deal more than say physics.”

    You appear to be conflating two different things: empirical claims and philosophical claims. Science offers empirical claims: X number of mammograms will save Y number of lives. Science makes no pretensions to determining whether X number of mammograms is “worth it” to save Y number of lives.

    Judgment is not the same as philosophy, either. Judgment is: this lump should or should not be investigated by mammography. Philosophy is: we should ration mammography to save money.

    As a general matter, those who reject science based medicine do so because it’s empirical claims threaten their philosophical beliefs. For example, they reject evolution because that means that the Bible must be wrong, and in their religious world view the Bible can’t be wrong. They have no choice but to reject one or the other.

    Science gives us facts. Everyone is entitled to their opinions. No one is entitled to their own facts.

  72. Zoe237 says:

    “Medicine (as an applied science) is different than pure science in many ways, in that value judgements and politics enter into play a great deal more than say physics.”

    “You appear to be conflating two different things: empirical claims and philosophical claims. Science offers empirical claims: X number of mammograms will save Y number of lives.”

    Maybe I am. I’m just not sure it is possible to separate the two out. Medicine is not practiced in a laboratory.

    And I think it’s baloney that doctors aren’t influenced by philosophical claims or confirmation bias.

    For example, your use of the word “small” benefits to breastfeeding. Who can define small? Is this is a value judgement or a scientific one? 21% drop in postneonatal mortality for bf infants doesn’t sound “small” to me.

    The American Academy of Pediatrics in their “Breastfeeding and the Use of Human Milk” policy statement asserts that :

    “Research in developed and developing countries of the world, including middle-class populations in developed countries, provides strong evidence that human milk feeding decreases the incidence and/or severity of a wide range of infectious diseases23 including bacterial meningitis,24,25 bacteremia,25,26 diarrhea,27–33 respiratory tract infection,22,33–40 necrotizing enterocolitis,20,21 otitis media,27,41–45 urinary tract infection,46,47 and late-onset sepsis in preterm infants.17,20 In addition, postneonatal infant mortality rates in the United States are reduced by 21% in breastfed infants.48

    Other Health Outcomes
    Some studies suggest decreased rates of sudden infant death syndrome in the first year of life49–55 and reduction in incidence of insulin-dependent (type 1) and non–insulin-dependent (type 2) diabetes mellitus,56–59 lymphoma, leukemia, and Hodgkin disease,60–62 overweight and obesity,19,63–70 hypercholesterolemia,71 and asthma36–39 in older children and adults who were breastfed, compared with individuals who were not breastfed. Additional research in this area is warranted.

    Neurodevelopment
    Breastfeeding has been associated with slightly enhanced performance on tests of cognitive development.14,15,72–80 Breastfeeding during a painful procedure such as a heel-stick for newborn screening provides analgesia to infants.81,82

    Important health benefits of breastfeeding and lactation are also described for mothers.83 The benefits include decreased postpartum bleeding and more rapid uterine involution attributable to increased concentrations of oxytocin,84 decreased menstrual blood loss and increased child spacing attributable to lactational amenorrhea,85 earlier return to prepregnancy weight,86 decreased risk of breast cancer,87–92 decreased risk of ovarian cancer,93 and possibly decreased risk of hip fractures and osteoporosis in the postmenopausal period.94–96 ”

    And for things that some obstetricians do NOT do because of their own philosphical bias against things like skin to skin and delaying of medical procedures:

    “Healthy infants should be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished.156–158
    The alert, healthy newborn infant is capable of latching on to a breast without specific assistance within the first hour after birth.156 Dry the infant, assign Apgar scores, and perform the initial physical assessment while the infant is with the mother. The mother is an optimal heat source for the infant.159,160 Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed. Infants affected by maternal medications may require assistance for effective latch-on.156 Except under unusual circumstances, the newborn infant should remain with the mother throughout the recovery period.161

    Supplements (water, glucose water, formula, and other fluids) should not be given to breastfeeding newborn infants unless ordered by a physician when a medical indication exists.148,162–165 ”

    http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496

    But maybe the AAP themselves is guilty of overselling the benefits of bf for some philophical reason, I don’t know.

  73. Zoe237 says:

    “But maybe the AAP themselves is guilty of overselling the benefits of bf for some philophical reason, I don’t know.”

    Ugh, that should be philoSOphical.

    daedelus:

    “In the “mommy wars”, the mommy who contributes more children to the next generation “wins”. Subtle competition, psychologically undermining one mommy’s ability to nurse her own infant but keeping her around so she could act as a wet-nurse for another might be an effective strategy.

    Are you serious? I guess the Duggars win then! (The ‘quiverful’ family who just had their 20th kid).

  74. jcwelch says:

    “The alert, healthy newborn infant is capable of latching on to a breast without specific assistance within the first hour after birth.156″

    ‘capable of’ and ‘can do so easily’ are two very, very different things. any human is capable of running a sub-4 minute mile. Roger Bannister proved this decades ago.

    The number of humans who can actually run a sub 4-minute mile at all is rather small, and the ones who can do it without immediate deleterious health effects is even smaller. The number of people who can do it without regular training, smaller still.

    Just because a baby is capable of doing something, doesn’t mean the will easily. i know, I’ve watched new mothers have astoundingly difficult times with breastfeeding, and i’ve watched others have none.

    However, i have a 6′+ 16-year old who, other than some ADD, (both of us have it bad, so him having it is no shock at all), a smart mouth, is neither sickly, stupid, or any of the other things that formula will supposedly cause him to be. And i wish I had his resistance to colds and flus. Kid’s never bloody sick, it’s disgusting. So much for formula killing your immune system.

    (Although, if i thought formula was responsible for his nuclear reaction-like metabolism, *I’D* be shoveling it down.)

  75. Kylara says:

    @galway — my mom (who came to stay with us the first couple weeks) was a little nervous about me breastfeeding because she’d always been able to track how many ounces we each got when we were bottlefed … and of course you can’t do that with a boob. I certainly understood her anxiety because I shared it! But my son turned the weight-loss corner on his fourth day and started gaining and his weight gain was so ginormous at each of his early pede appointments that I felt better quickly.

    I feel like Murphy’s Law was at work because I wasn’t super-invested in breastfeeding — it wasn’t clear if my mom’s abnormality was heritable and if I’d be able to — so I was keeping an attitude of, “I’ll try it, but I won’t worry if it doesn’t work.” So of course my son latched on on his second attempt during our first try at breastfeeding (after a C-section, no less) and never looked back. Two of my close friends who had babies within a couple months of me (on either side) BADLY wanted to breastfeed and both of them had terrible problems of all sorts.

    Which just goes to prove my very scientific theory that CHILDREN ARE CONTRARY FROM BIRTH! :)

  76. Sid Offit says:

    Cent Eur J Public Health 2007; 15 (4): 143-146

    THE EFFECT OF BREASTFEEDING AND ITS DURATION ON ACUTE OTITIS MEDIA IN CHILDREN IN BRNO, CZECH REPUBLIC

    Results: The results of our study show that breastfeeding for a period of up to 11 months can play a significant preventive role against AOM

    ————–

    PEDIATRICS Vol. 91 No. 5 May 1993, pp. 867-872
    Exclusive Breast-Feeding for at Least 4 Months Protects Against Otitis Media

  77. Sid Offit:

    “Cent Eur J Public Health 2007; 15 (4): 143-146″

    Listing a citation is not enough. You must read it and make sure that the conclusions are supported by the data. In breastfeeding studies, in particular, you must check to make sure that confounders have been addressed.

  78. mmjconlon says:

    Wow. What an exchange!

    I’m a board certified lactation consultant (IBCLC). I had extensive education, practice hours, and I had to take a day-long exam to get my license. I am not a nurse who “calls herself a lactation specialist” as was mentioned in a previous post.

    However, I am not a lactation nazi. I realize that many women have physical and psychological/emotional issues that prevent them from breastfeeding “successfully”. We cannot know what is in someones emotional makeup. I’ve had women end up in tears when I assure them that their “failure” to breastfeed was not going to result in a damaged, sick baby.

    This is such an emotional issue. We feel like failures every time we don’t feel that we’ve lived up to a standard that is laid out in the parenting manuals. I always tell new parents in my classes that there will be nay-sayers for every decision they make. They’re damned if they do, damned if they don’t. Trust me, for every woman who doesn’t breastfeed and feels guilty, there is a breastfeeding woman who is getting a dirty look for nursing in the mall, or a wise crack about breastfeeding too long. Neither side is safe.

    The real point should be, why the words “shame” should be used here at all. If you are confident in your informed decision, you should stand tall and proud. Don’t let the mommy-police make you feel like a bad parent. Defend your decision, or, better yet, don’t! Just smile and say “thanks for your concern, but we know what we’re doint” even if you feel like you don’t.

    I don’t think we can honestly say that breastfeeding carries no real benefts. I believe that the above posts are correct when they state that we should be referring to formula feeding risks as opposed to breastfeeding’s benefits. It is formula that should be carrying the burden of proof, not the opposite. Is formula healthy? Does it confer health risks? What are they? Shouldn’t we want to know that if we are implying that a woman’s sense of guilt over-shadows the choice of feeding? Are we absolutely sure that formula feeding is safe enough to heartily recommend to nervous new mothers? I’m not sure.

    Thank you for the exchange. I always look forward to your thoughtful posts, Dr. Tuteur. We should never be afraid to examine even our most beloved positions. I will never be afraid to be proven wrong!

  79. Dawn says:

    @Dr Tuteur: thank you for mentioning confounders. In fact, both of my children had severe problems with ear infections, thanks to the genetics that gave them very short eustachian tubes (as it turns out, my husband, myself, and my brother all had numerous ear infections as infants also; my husband was bottle fed, my brother was exclusively breastfed for several months, and I was breast and bottle). Nothing but growth ended the problem for my kids (and having my eldest’s tonsils/adnoids removed at age 5 since at night her airway was being obstructed!)

  80. edgar says:

    Since we are talking about “Evidence Based Medicine” and not “Evidence Based Medicine in the US and Places with Safe Water” let us remember that formula feeding can indeed the the ‘poison’ that some make it out to be.

    That is my main concern about FF….The marketing of formula in places where breast feeding is the ONLY safe option, is in my opinion criminal.

  81. edgar says:

    As for the guilt of not breastfeeding, I am beginning to think that the guilt is just par for the course. No matter what, new moms will get heat from an opposing view point.

  82. edgar says:

    Oh,
    and finally, I think that I would use the term ‘cultural’ as opposed to ‘natural” (even if it is a biological function) when referring to breastfeeding.

    We as a culture seems to have lost our knowledge of how to breastfeed successfully. We have lost out knowledge about how to handle problems. We do not get that mothers shouldn’t be separated from babies. We believe that pumping is just as good as breastfeeding, when it isn’t (either for mother and baby).
    Not that women who have this knowledge always successfully breastfeed and raise healthy kids, because we know that is not true. But it does seem that we have a disproportionate amount of breastfeeding difficulties. WHY is that?

    I think this is a prime example of ‘overmedicalizing’ our lives when we try to break it down into only looking at risk/benefit.

  83. Plonit says:

    That is my main concern about FF….The marketing of formula in places where breast feeding is the ONLY safe option, is in my opinion criminal.

    ++++++++++++

    I stopped breastfeeding at ten months with both my children (with the first due to needing to take medication incompatible with breastfeeding, with the second because he refused the breast after I had been away at a conference for a few days – preferring EBM in a bottle. I couldn’t be bothered to reinitiate his interest in the breast, or express enough milk for him to have from a bottle).

    I actively looked for a product from companies that marketed their formula products ethically on a global basis, and couldn’t find a single one that wasn’t guilty of some aggressive or dishonest marketing tactics in the developing world (not to mention the pseudoscientific nonsense in the advertising to western markets).

  84. Calli Arcale says:

    Kylara:

    @Calli — MOST states — 43 of them — have laws protecting breastfeeding in public. That includes outdoors. And typically “places of public accommodation,” which are things like stores and restaurants. It’s misleading at best to say “most” states don’t allow you to breastfeed outdoors. 28 states specifically exempt breastfeeding from public indecency statutes. You can learn more here: http://www.ncsl.org/issuesresearch/health/breastfeedinglaws/tabid/14389/default.aspx

    Oh, that is fabulous news!!! The last time I researched the issue (admittedly, I’ve not been following as closely since Baby #2 was weaned) it was a smaller number. Of course, just because there is a law doesn’t mean it will be followed. Minnesota specifically exempted breastfeeding from public indecency laws, but that wouldn’t stop a waiter from telling you to move to the bathroom. It never happened to me, but there were reports of it happening. You could sue, of course, but that would be a significant expense for very little practical gain. Progress is clearly still being made, so I am optimistic that there will be widespread public acceptance of breastfeeding throughout America within my lifetime. ;-) As it is, I know plenty of women who bottlefeed simply because they’re embarassed to nurse. (And I was much more sheepish about nursing #1 than #2; there is a certain modesty threshold that one needs to break on one’s own.)

    Regarding your last post in the thread, that’s amazing, because it’s so reminiscent of my experience! Both of mine were c-section, which was actually fortunate in that it meant a longer hospital stay for me, and more time for the nurses to help me learn to breastfeed. I was still in the hospital when my milk came in, which was nice. Baby #1 (two weeks overdue, emergency c-section) was losing weight for several days. Actually, that’s not unusual even with bottlefed babies; it takes a while for them to figure out how to suckle. By day four, she finally got it, and it got sooo much easier. Baby #2, who was astonishingly strong at birth (held her head up within an hour of birth), latched on instantly at her first attempt and suckled vigorously. I couldn’t believe how much difference there was *already* between these two girls!

    Zoe237:

    I am also interested in how much breastfeeding decreases breast cancer risk. And why if it’s not all that good, why most large hospitals have breast milk banks for preemies.

    Some babies can’t handle formula. Donor breast milk is VERY limited, so I think they generally save it for the babies who don’t have other alternatives.

    Amy Tuteur:

    “It’s not difficult, it turns out. In America, a very large majority of new mothers attempt to breastfeed their babies. The problem isn’t convincing them to start. Somewhere along the way, they’re stopping.”

    I wish that were true, but I suspect that it is not.

    First of all, breastfeeding IS hard.

    I meant “not that difficult to keep women breastfeeding”, not that it’s a total breeze to breastfeed. I breastfed both of mine; I remember crying to myself when I was struggling to get my first baby to latch on, there in the hospital, feeling terribly alone. The nurses told me I should page them the next time that happened, and not to suffer by myself, and that made all the difference. Also, I got cracked nipples, thrush, and several bouts of mastitis . . . and I don’t think I had a bad experience overall, so I know there’s stuff that can definitely put people off of it.

    But I believe that if we can give women enough education and support while they’re starting out and then support over the next year, they can do it. You’re right that many stop when they leave the hospital (and get away from the helpful/bossy nurses) but many more stop when its time to go back to work. These two events can be seen as opportunities for intervention, places where there is a problem that may be fixable. Or maybe I’m just overoptimistic. ;-)

    It amazes me that we insist that women take childbirth education classes and then neglect breastfeeding education. The baby is going to come out one way or another; a class makes no difference.

    The childbirth class still has value; it helps to know ahead of time what the various interventions are for and what to expect so it’s not so scary. “You’re gonna stick that WHERE???” :-P

    But yes, breastfeeding classes are absolutely important. Luckily, I had an awesome hospital, and they provided classes for new mothers and fathers. The ones that applied to me were the parenting class (how to bathe the baby, how to change diapers, etc — it *seems* obvious, but it’s still nice to get pointers) and, most of all, the breastfeeding class. Taught by a maternity nurse who actually had also taught the childbirth class, and who was wonderfully supportive *and* nonjudgmental, this was probably the best class I took while I was there. You bring your baby, and sit with several mothers and fathers, learning how to do it. One couple also had a bottle; they were trying both to see what would work out best. That was United Hospital in St Paul. Even though I didn’t score one of the awesome birth center rooms either time (it’s first-come first-serve), it was a wonderful experience overall, and I really felt they prepared me for what was to come. They also gave out a complimentary book about childbirth and parenting which was quite awesome as well — particularly because it covered everything from conception through the introduction of solid foods, with extensive advice for both breastfeeding and bottlefeeding. How to burp your baby. How much weight loss/weight gain can be expected as the kid learns to feed. Tips for soothing a fussy baby. When to call the doctor. It was an invaluable resource well after the baby was born.

    And you’re absolutely right about motivation, and I think a mother who is totally freaked out about the idea would be far better off concentrating on getting to know the kid than on forcing themselves to breastfeed.

  85. “We as a culture seems to have lost our knowledge of how to breastfeed successfully.”

    No, many women don’t have the desire to breastfeed, and that’s an entirely different situation.

    Breastfeeding is hard.
    It ties the mother to the nursling (which is fine if that’s what you want, but not, if you don’t want to be tied down).
    It is not particularly compatible with full time work.
    Some male partners resent it.

    It is important that we acknowledge these realities and not pretend that women would breastfeed if we hadn’t “lost our knowledge.”

    Since the medical benefits of breastfeeding are small, there is no reason to claim or imply that breastfeeding makes a woman a better mother.

  86. edgar says:

    Amy, please point to where I said “that women would breastfeed if we hadn’t “lost our knowledge’.” Also, nowhere did I say that this makes a better mother.

    I was speaking of the many many women who initiate and do not continue BF because of problems. Having specialists and lactation consultants are great, but not enough. They are unable to address peer to peer knowledge, which is fundamental to motherhood. A clinical expert is often not enough. Handling BF problems should be common knowledge much like treating scrapes and bruises, but it isn’t. We don’t see it. It is still somehow shrouded in mystery.

    For those who don’t want to, fine with me. And for those whose partners will resent it, well, their partners suck, but none of my business.

  87. Zoe237 says:

    “Some babies can’t handle formula. Donor breast milk is VERY limited, so I think they generally save it for the babies who don’t have other alternatives.”

    Why can’t they handle it? Allergies? I know at our local milk bank, breast milk is big business, and if you want to buy it, it’s something like $4 for an ounce. The bank itself is non profit though.

    “We as a culture seems to have lost our knowledge of how to breastfeed successfully. ”

    This seems to be changing though. Breastfeeding is really something you should “see” somebody else doing. It’s not absolutely necessary, but knowledge out of a book about it doesn’t always help. Now enough moms bf that we can get help from other moms who have btdt.

    I have to point out that bf isn’t *always* hard, although that I agree that it often is in the first few weeks. For me, I was sore and was tied to the baby 24-7 in the first couple of weeks (except for a couple of hours/day for one class). Plugged duct at 13 months with my oldest. That’s it for 3 kids. My youngest, a one year old is still nursing. Many of the moms I know work f/t and manage to pump exclusively. If I had to work f/t, I imagine I’d use formula… pumps suck… literally lol. I did it p/t and hated it. I also know other moms who work f/t and nurse their babies at night while giving formula at daycare.

    There’s also the issue of the Chinese formula contaminated with melamine. 6 babies died and thousands were hospitalized.

    http://en.wikipedia.org/wiki/2008_Chinese_milk_scandal#Victims

  88. Plonit says:

    No, many women don’t have the desire to breastfeed, and that’s an entirely different situation.

    ++++++++++

    Can you provide any evidence to support that statement? (Beyond the circular argument that if they had *really* desired it *enough* then they would have continued to breastfeed – a moralist argument if ever there was one).

    There’s plenty of research showing that women who intend to breastfeed initiate breastfeeding but discontinue because of factors such as concerns about milk supply, that baby is not getting enough milk and sore/damaged nipples. Many of those issues stem from lack of information about the physiology of breastfeeding and practical implications of that physiology. For example, how to know if you baby is getting enough milk, the normal feeding patterns and whether you need to wake your baby to feed (“demand-feeding” has been oversold to the detriment of very sleepy babies), attachment and positioning to prevent nipple damage.

    Until there is adequate support and accurate information to assist women who say they intend to breastfeed to do so, I don’t think it is reasonable to attribute low breastfeeding rates to “women don’t desire to breastfeed”.

  89. mmjconlon:

    “I don’t think we can honestly say that breastfeeding carries no real benefts.”

    Please don’t misunderstand. I’m not saying that breastfeeding has no benefits, merely that the medical benefits are much smaller than its proponents claim.

    And we haven’t even considered the risks, which though small, are also real. For example, there is a risk of dehydration or even death from inadequate milk supply, and there is evidence to suggest that certain environmental toxins are concentrated in breast milk.

  90. “Can you provide any evidence to support that statement?”

    Sure. There are a number of studies on breastfeeding commitment and duration of breastfeeding. Including:

    Relationship between prenatal infant feeding intention and initiation and duration of breastfeeding: a cohort study (Acta Paediatrica, Volume 92, Number 3, 2003 , pp. 352-356):

    “This large population-based study confirms the strength of the relationship between maternal prenatal intention to breastfeed and both breastfeeding initiation and duration. Maternal intention was a stronger predictor than the standard demographic factors combined. This should be taken into account in future research, and trials should be undertaken to establish whether interventions could alter maternal intention and thereby increase rates of breastfeeding initiation and duration.”

    Other studies show that maternal education programs don’t have much effect on breastfeeding.

    Effect of an extended midwifery postnatal support programme on the duration of breast feeding: A randomised controlled trial, Midwifery, 2008:

    “Intervention

    participants were allocated at random to EMS, in which they were offered a one-to-one postnatal educational session and weekly home visits with additional telephone contact by a midwife until their baby was six weeks old; or standard postnatal midwifery support (SMS). Participants were stratified for parity and tertiary education.
    Measurements

    the main outcome measures were prevalence of full and any breast feeding at six months postpartum.
    Findings

    there was no difference between the groups at six months postpartum for either full breast feeding [EMS 43.3% versus SMS 42.5%, relative risk (RR) 1.02, 95% confidence interval (CI) 0.87–1.19] or any breast feeding (EMS 63.9% versus SMS 67.9%, RR 0.94, 95%CI 0.85–1.04).
    Conclusions

    the EMS programme did not succeed in improving breast-feeding rates in a setting where there was high initiation of breast feeding. Breast-feeding rates were high but still fell short of national goals.”

    Moreover, almost most studies show that women who breastfeed for longer periods differ substantially from those who don’t. Those who breastfeed for longer durations are much more likely to be married, have higher incomes and have higher levels of college and graduate degrees.

  91. Sid Offit says:

    Listing a citation is not enough. You must read it and make sure that the conclusions are supported by the data. In breastfeeding studies, in particular, you must check to make sure that confounders have been addressed.

    ———————–

    Thanks Amy, but I know how to read a study. Anyway since I have access only to the abstract perhaps you could point out the confounders about which you’re concerned. And should I expect to find these same confounders in the numerous other studies finding the same protective affect of breastfeeding?

  92. Calli Arcale says:

    Zoe237:

    Why can’t they handle it? Allergies? I know at our local milk bank, breast milk is big business, and if you want to buy it, it’s something like $4 for an ounce. The bank itself is non profit though.

    Yep, allergies. Most formulas are made from cow’s milk, but you can be allergic to bovine casein. (That’s different from lactose intolerance, of course.) The usual “hypoallergenic” alternative is soy based (Isomil, for instance, which we actually dabbed on my nipples to try to persaude baby #1 to suckle; didn’t work; she just had to figure out how to do it successfully). But soy allergies exist too, so what’s an allergic baby to do, if his/her mother’s milk isn’t available for whatever reason? That’s where donor milk comes in. If donor milk were cheaper, I expect more people would use it, but right now, it’s strictly a non-profit thing. It’s a body fluid, so it’s covered by the same rules that goven blood donation. The donor cannot be paid. If you donate an organ or egg cells, you can be reimbursed for your medical costs, but the intent is to make sure donations are purely altruistic. Perhaps if women were paid (as wet nurses were/are), more would donate. But there are ethical implications there.

    As far as women who do well with pumps, it worked very well for me. There were times, especially when the kid was close to starting solids and thus had a large appetite, when I’d have to switch bottles during a pumping session because the first ones filled up halfway through! I estimate my peak production at about a quart a day, extrapolating from what I produced at work. Mileage definitely varies from person to person, and I suspect it’s a bit like trying to predict which astronauts will get space sick — utlimately, it’s a total crapshoot.

    Plonit:

    Can you provide any evidence to support that statement? (Beyond the circular argument that if they had *really* desired it *enough* then they would have continued to breastfeed – a moralist argument if ever there was one).

    Dr Tuteur has already responded with a study correlating intention to breastfeed with ultimate breastfeeding success; I think it’s pretty safe to say that the mother has to decide it before she gives birth. Afterwards, she will have only a very small window to make this decision before circumstances make the decision for her.

    But as far as whether or not there are women who really don’t desire to breastfeed — that’s certainly true. And I would think it would be self-evident that not wanting to breastfeed would correlate to not breastfeeding, or discontinuing very early. If you don’t want to do it, what’s going to carry you through the pain and nuisance? (Breastfeeding is both easier and harder than formula feeding.) I’d be more surprised if the reverse were true, and women who didn’t want to breastfeed generally were successful at it. It’s like anything else. Women who don’t want to ski are generally poor skiers.

    Amy Tuteur:

    For example, there is a risk of dehydration or even death from inadequate milk supply, and there is evidence to suggest that certain environmental toxins are concentrated in breast milk.

    Of course, environmental toxins also get concentrated in cow’s milk, from which formula is made. My personal hunch is that as long as the mother is taking care of herself and not doing drugs or something, it’s probably a tossup as far as which is more contaminated. But that’s just a hunch.

  93. Dawn says:

    @Zoe237: Yes, there are some babies that can’t tolerate any formula. It’s a very difficult situation, especially in the case of babies with this issue who have mothers who have no interest in breastfeeding, pumping, whatever. As much as they love their baby, the reasons they have for not breastfeeding (sexual abuse, psychological reasons, needs for medications totally contraindicated in the nursing mother) override the infant’s needs. In another world, or generation, that child’s needs would be met by a wet nurse, lactation extended family member, or whatever. Here we have milk banks.

    @Plonit: I don’t know of any studies regarding women who refuse to breastfeed. However, in my 20+ years of being a nurse, midwife, and mother, I met several women who refused to breastfeed. In fact, for a good friend (and another nurse), the idea of breastfeeding her infant made her physically ill (she vomited every time we talked about breastfeeding – even if it was not regarding her and her baby. She nearly failed nursing school during her OB rotation.) No, she did NOT work on a maternal-child unit but she was a fantastic surgical nurse. She told us that she would not allow her husband to touch her breasts at any time, either. She wore a bra unless she was in the shower. Psychological issues. In most of my sexually abused patients, breasts were associated with the abuse. The few who were able to nurse had worked for years with therapists regarding their sexual issues and also had rewarding sex lives with their partners. The others usually didn’t. Other women didn’t want to start breastfeeding because they knew they would not be able to keep it up once they returned to work.

    Again: I DO feel that breastfeeding is best for baby but a happy, healthy mother/baby diad is more important than how the baby gets his/her calories for growth.

  94. Plonit says:

    Women who don’t want to breastfeed don’t breastfeed. That’s straightforward and not really my concern.

    Women who do want to breastfeed also end up not breastfeeding for a variety of reasons. The reasons why are not straightforward, and that is my concern.

    The fact that there is a correlation between breastfeeding intention and duration (which is not surprising, if you don’t intend breastfeeding at all then the duration of breastfeeding will be 0 days!) doesn’t mean that low breastfeeding rates can be attributed to “many women don’t want to breastfeed” – unless you discount the research on why women who do intend breastfeeding discontinue.

  95. Bonnie says:

    @Sid Offit:

    “Thanks Amy, but I know how to read a study. Anyway since I have access only to the abstract perhaps you could point out the confounders about which you’re concerned. And should I expect to find these same confounders in the numerous other studies finding the same protective affect of breastfeeding?”

    Actually, the article Dr. Tuteur linked near the beginning does discuss that. How it could be a result of how the baby is positioned, more or less supine. I have also heard that, that if you have a baby prone to ear infections, to make sure to keep the head & shoulders more elevated while feeding.

    Dr. Tuteur, thank you, great post! I had to register just so I could comment.

    For me, breastfeeding my first was hard — no big problems, but continuous small ones. Switching to formula at 6 months was such a relief and a pleasure. I got to enjoy feeding my baby, instead of just facing it with grim determination! Breastfeeding my second was easy and we went for a year. If I were to have another, I would set out to breastfeed for numerous reasons, but if we ran into trouble I would quit it much easier than I did the first time. Personally, the benefits are outweighed when there are problems by the need to enjoy taking care of the baby.

  96. Plonit says:

    Totally true that women who don’t want to breastfeed don’t breastfeed. I care for many of these women, and they formula feed – usually without problems, and sometimes with (formula-feeding isn’t the magic solution to sleepy babies that don’t wake to feed, reflux or a whole host of other issues). Their feeding choice is not really my concern beyond ensuring that they have the information to feed safely (regarding sterilising and making up feeds etc…)

    However, it is also true that many women initiate breastfeeding, hope to breastfeed, but discontinue earlier than they would like because of problems. Addressing those would seem to be a worthwhile endeavour.

  97. Kylara says:

    @Calli: “Of course, just because there is a law doesn’t mean it will be followed. Minnesota specifically exempted breastfeeding from public indecency laws, but that wouldn’t stop a waiter from telling you to move to the bathroom.”

    I know it … although personally, I was a lawyer in my former life, so I would just invite them to call the police after politely informing them of the law. I JUST DARE THEM TO TRY IT!

    I’m pretty discreet too, and I haven’t been hassled for breastfeeding in public or semi-private. I have been hassled for bottle-feeding (how do people even know if that’s expressed breast milk or formula? man people are rude!) but fortunately I was far enough post-partum that I wasn’t an emotional wreck (which I was at first!) and was able to summon the look of death and move on with my day. :D

    @Dr. Amy: “Maternal intention was a stronger predictor than the standard demographic factors combined.”

    That’s probably why my (horrible, referenced upthread) lactation consultant went all crazy on me when she asked if I was “committed” to breastfeeding and I said, “I’m going to give it a try and see how it goes” and told her I had a series of goals — while in the hospital (4 days), then two weeks, then six weeks, then 3 months, then 6 months. Which is how I handle every monumental task in my life, breaking it into manageable bites so I can say, “Okay, today’s awful, but if I just go three more days, I’m at my two-week goal.” (“Okay, this paper is making me bang my head on the table, but if I just grade three more I’m at my 10-paper goal …”)

    She went nuts about it, saying unless I committed to a FULL YEAR of breastfeeding RIGHT NOW TODAY (the day I had a C-section) I was not going to successfully breastfeed at ALL. Because women have to be COMMITTED to breastfeeding or they fail. Always. Every time. She kept insisting. God she was crazy.

    Anyway, my system worked really well for me in those early weeks when it was painful and I was exhausted, and when things were better, I was able to say, “Well, I’ll go ahead to three months and re-evaluate then” so it never felt open-ended and therefore (to me) oppressively endless. I know what kinds of mind-hacks work for me, so I never felt “trapped” by breastfeeding because I’ve always had concrete, short-term goals for it. So contra the crazy consultant’s insistence I was going to fail, I’m at 7 months, aiming towards 9!

    Next time I give birth, though, I’m telling them when I check in that I definitely do NOT want to see a lactation consultant. If I have trouble, I’ll ask the nurses, and if the nurses can’t help, THEN I’ll call the lactation consultant. But not if it’s the same lady, she was so mean and crazy.

  98. Plonit:

    “doesn’t mean that low breastfeeding rates can be attributed to “many women don’t want to breastfeed” – unless you discount the research on why women who do intend breastfeeding discontinue.”

    Such as?

    We can argue the empirical evidence, and I’m happy to do so, but I have a non-empirical question. As far as I know, there’s not much evidence to show that education and support efforts make much difference in long term breastfeeding. So why do you assume that women should and would want to breastfeed but stop for lack of support? Why is it difficult to accept that some women don’t want to breastfeed and that many women try it and don’t like it?

  99. Bonnie:

    “Personally, the benefits are outweighed when there are problems by the need to enjoy taking care of the baby.”

    Thanks for commenting. I agree that each woman needs to make the decision that she feels is best for herself and her baby in her unique situation.

  100. laursaurus says:

    Wow! Breastfeeding is a very emotionally charged issue. The pressure from society acting squeemish at the site of a nursing child vs. the pressure from the zealot advocates. In one way or another, a mother ultimately finds herself practically defiantly protesting against someone else’s expectations of what is the proper thing to do. Growing up, my mother often expressed regret and anger, that she didn’t breastfeed us because she caved into the prevailing attitude against it during the early 60′s. This planted a firm resolve in me to nurse my babies as nature intended.
    I have 3 kids. For a number of reasons, I failed to establish breastfeeding my first child. This was a tremendous disappointment. You pretty much get one shot initially to succeed. Once it passes, it’s too late. My resolve was more determined with number 2, with initial great success only to taper off once I went back to work. Pumping produced less and less gradually. By 5 months, it was over.
    Then number 3! This kid was going to self-wean! I went back to work only part time and faithfully pumped on every break, plus a quick trip during my lunch hour to nurse in person. Even then, he was finished by 18 months, preferring the sippy cup in his newly active lifestyle.
    I guess my point is that there are a number of obstacles to overcome. Although it’s pretty much common knowledge that breast is best, since mammals evolved this way. New mothers are emotional and sleep-deprived; many are additionally suffering with post-partum depression.
    The ideal approach is to encourage, support, and facilitate breastfeeding. When unsuccessful, we also need to provide emotional support particularly to the woman who really desired to breastfeed, but failed. Remind her that her child will never feel she loved them any less. Heck, I feel “bonded” with the dog we adopted in July, so I offer this anecdote. LOL
    Encourage women, but don’t brow beat them.
    I relize this is a”science-based” blog, but this is an issue where emotions seem to play a more prominent role. I hope the disappointed mothers read this article and feel reassured that baby will still thrive and know he/she is well-loved.

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