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206 thoughts on “Are the benefits of breastfeeding oversold?

  1. tm says:

    I have to wonder, as a man (and a dad): How many fathers have been reproached by people for bottlefeeding (regardless of the contents)? Clearly we can’t breastfeed in public, so we won’t get hassled by the nitwits on that side of the debate. In my experience, I can’t recall a single person lecturing me on “breast is best” or giving me a dirty look for shaking up a few bottles of what was clearly formula. Maybe I was getting dirty looks, but a parent of twins like me isn’t going to notice or care. Or are the (Western/American) standards of fatherhood so low that the mere fact I was feeding them was enough? If it’s the latter, that is a sad commentary on the deep disparity between the impossibly high standard set forth for mothers and the absurdly low one for fathers.

    If fathers had a say, and we voted with our wallets, we’d prefer breastfeeding solely on those cheapskate grounds. Fathers of multiples, however, would find they would be drafted to help mothers breastfeed if she had no other help available.

  2. edgar says:

    “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.”

    I don’ think this is the correct way to phrase it, but there is some truth to this. We know that breastfeeding and the cascade of hormones DOES induce a feeling of wellbeing in the mother (I would go even further, for me it was like opiates in an IV, except no one called social services), so in an indirect way, I do think it helps to facilitate a bond between mom and baby (assuming that the BF is going well).

  3. laursaurus and tm,

    You wrote about different things but they are linked in an important way. For some reason, women enjoy criticizing and undermining other women over parenting decisions, but give fathers a free pass. Not only that, but fathers don’t seem to worry about how other fathers parent.

    I am reminded of a very funny article by Faulkner Fox, Judging Mothers, How and Why Feminists Can Stop (http://www.mothersmovement.org/features/05/f_fox_0504/judging_mothers_1.htm). She cites many examples, but my personal favorite is the following:

    “The woman who wrote to me, whom I’ll call Joan, said that her 20-month-old had been playing in the sandbox before stopping to ask her mother for a snack. Ever the prepared mother, Joan pulled out a Stonyfield Farms organic strawberry yogurt in a tube.

    Immediately another mother, whom Joan did not know, piped up from a nearby bench: “How can you give that to your daughter? It’s so full of sugar. What I do,” she continued, “is use a syringe to extract 1/2 of the sweet yogurt from the tube, then I use a second syringe to inject plain yogurt back into the tube. That way my daughter has the same yogurt as the other kids, but I know that it’s not too sweet.”

    Fox’s suggestions for possible responses are hilarious:

    “Let’s consider for a minute – just for fun – what an appropriate response could be in this situation…

    Here are a few choices I came up with:

    a) Thanks so much! Can I borrow your syringe?

    b) Would you like the name of my psychiatrist? Zoloft has done wonders for me.

    c) Do you realize that the President of the United States [George W. Bush] is an often incompetent, but still incredibly dangerous, warmonger? Why not use your yogurt time to fight any number of unethical and nonsensical policies that harm mothers, children, and everyone else? Here’s the phone number for the National Organization for Women. Or,

    d) the all-purpose response to strange statements – for feminists, as well as anyone else: Huh? Say What?”

    Fox deftly frames the problem:

    “When another mother makes a statement that feels like a judgment on our mothering – and Joan certainly took this yogurt-doctoring advice as a judgment rather than an innocent food hint – how do we answer back? … Why do mothers judge each other, sometimes on the pettiest details, in the first place? Why do mothers – at least in my experience and according to my observations – judge one another at a much higher frequency than other members of the population judge one another?”

    Fox’s assessment:

    “I believe that at least some of the time, even the tiniest judgments we make are really ways of asking these two questions: 1) Is that mother selfless enough? And more personally, 2) is that mother sacrificing as much as I am? If not, I’m not sure I like her, and I’m not sure I can refrain from saying something critical to her – just to see if I can get her to feel anxious, the way I feel anxious.”

    In other words, women concern themselves with the details of other women’s mothering because they are insecure and can feel more secure by demeaning another mother. There are two serious problems here. One is that some women are deliberately hurting other women. The other is that when it comes to most parenting choices there is usually more than one way that will work out fine.

  4. “but there is some truth to this.”

    No, there is NO evidence that there is any truth to this. It’s just another made up claim that breastfeeding proponents wield like a cudgel to beat up mothers who make different choices.

    I came across this quote about mothering that really resonates with me:

    “Before you were conceived I wanted you. Before you were born I loved you. Before you were an hour old I would die for you. This is the miracle of life.”

    No where does it mention breastfeeding as a prerequisite or even an adjunct.

  5. edgar says:

    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?

    Because clinical support and education is not the key. As I said before in is the knowledge and support within our culture that is key. The personal one-on one support that help to handle problems as the arise is key to success. You hear far more women say “I tried and I wanted to, but I couldn’t” than say “Eh I tried, it wasn’t for me.”

  6. edgar says:

    Huh, so no Oxytocin and prolactin release with letdown?

  7. “Huh, so no Oxytocin and prolactin release with letdown?”

    I didn’t say that, I said that there’s no evidence that they improve bonding.

  8. edgar says:

    Nor did I.
    You keep attributing things to me that I did not say. Try reading more carefully, please.

    What I said is that the feelings of well-being by the mother, induced by the Breastfeeding (assuming all is going well) hormonal cascade may indirectly facilitate bonding.

    http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WFS-4W6YK2J-3&_user=4335206&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000000150&_version=1&_urlVersion=0&_userid=4335206&md5=b4b769406a401a5ab9375ec06b43475d

    Hormones do facilitate bonding Amy. Why else would be feel so lovey dovey after sex?
    However, BF (or other reproductive hormones)is not the only way (in humans anyway) to do that. We are capable of fully bonding without them (such is the case with adoptees). Nor does it determine strength of bond or longevity of such bond. But those hormones do have their advantages (again assuming all is going well)

  9. edgar says:

    Nor did I.
    You keep attributing things to me that I did not say. Try reading more carefully, please.

    What I said is that the feelings of well-being by the mother, induced by the Breastfeeding (assuming all is going well) hormonal cascade may indirectly facilitate bonding.

    http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WFS-4W6YK2J-3&_user=4335206&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000000150&_version=1&_urlVersion=0&_userid=4335206&md5=b4b769406a401a5ab9375ec06b43475d

    Hormones do facilitate bonding Amy. Why else would be feel so lovey dovey after sex?
    However, BF (or other reproductive hormones)is not the only way (in humans anyway) to do that. We are capable of fully bonding without them (such is the case with adoptees). Nor does it determine strength of bond or longevity of such bond. But those hormones do have their advantages (again assuming all is going well)!

  10. keleton says:

    edgar said: “We know that breastfeeding and the cascade of hormones DOES induce a feeling of wellbeing in the mother”

    My experience with breastfeeding was difficult. I suffered from postpartum depression (almost to the point of psychosis at times), and whenever I nursed my daughter, at least for the first several months, I felt an overwhelming sense of impending doom.

    Despite this I was determined to continue. I breastfed her exclusively from 3 weeks of age once I finally got her to nurse (she was forced bottles of formula in the hospital due to low birth weight). I continued to nurse for 32 months. I can’t say I ever enjoyed it but it was my duty as a mother to feed my child and I would never consider formula feeding unless there was absolutely no alternative. I would even go as far as to say that formula should be a prescription only product.

  11. “I would even go as far as to say that formula should be a prescription only product.”

    Why? Because women should only be allowed to do what you approve? What kind of reason is that?

  12. OttawaAlison says:

    Formula by prescription would be an absolute disaster. As much as I would have loved to have my costs for formula reimbursed by my insurance, it would cause premiums to increase (even in Canada for those of us with extra insurance) and so much hassle.

    People would doctor shop wasting tons of time and resources. People would try other substitutes (such as Carnation Evaporated Milk… by Nestle!), homemade formula or just plain Cow’s milk.

    You would be so screwed if you got stuck somewhere or lost luggage containing formula and didn’t have the prescription with you.

    As someone mentioned formula is one of the most stolen items already…

  13. Réka Morvay says:

    “Huh, so no Oxytocin and prolactin release with letdown?”
    I didn’t say that, I said that there’s no evidence that they improve bonding.

    ****

    Prolactin has been shown to be involved in mediating parental behavior in all sorts of animals, from fish to birds to mammals. Maternal AND paternal behavior. Oxytocin is involved in affiliative behaviors, maternal behaviors, pair bonding and other social behaviors across a range of species, including humans.

    Both of these hormones are released when breastfeeding, and in fact, there have been studies that indicate that breastfeeding improves mother-infant attachment, which comes as no surprise given the release of these hormones during breastfeeding.

    Just one citation:
    Breastfeeding, Bonding and the Mother-Infant Relationship
    Journal article by Nicole M. Else-Quest, Janet Shibley Hyde, Roseanne Clark; Merrill-Palmer Quarterly, Vol. 49, 2003

    Human relationships are complex, and no one is suggesting that breastfeeding is the only way to form an attachment to a baby. But you also cannot deny its role.

  14. Réka Morvay says:

    With regards to breastfeeding success, motivation is clearly one factor, and but another, though related one is cultural attitudes towards motherhood and breastfeeding. Countries like Sweden have an astonishingly high breastfeeding rate because they not only retrained their health care staff to be effective in supporting breastfeeding, but also create the environment necessary to support breastfeeding mothers. To wit, Sweden has an extremely generous 16-month paid parental leave that allows mothers to stay home with their babies and not only not lose their jobs, but receive a monthly paycheck while they do it.

    I live in Hungary, where until recently, women were allowed 3 years (!!!) of paid maternity leave. The breastfeeding initiation rate in this country is close to 100%, with exclusive breastfeeding rates at 6 months close to 50%. And this with truly crappy health care support and a lot of formula companies blatantly ignoring the marketing codex that was meant to protect the role of breastfeeding. The fact that most women in this country do not need to return to work for up to 3 years after having their children obviously is a huge factor in achieving those numbers.

    In many (possibly most) societies, a mother is coddled in the post-partum period, with all responsibilities except for caring for her child lifted from her shoulders by members of her community. In Western civilizations that have adopted the nuclear family model, this type of extended family and community support is all but gone.

    So with no help forthcoming for many new mothers and the need to return to work weeks after the birth of a child and formula marketing pouring forth from every direction, it is a wonder the US breastfeeding rates are not any worse.

    Like Dr. Tuteur said, initiating breastfeeding is HARD for a lot of women, and at this time, they need support, both skilled and communal, to stick with breastfeeding. If neither of those are available, especially with the above difficulties of other responsibilities and financial stressors factored in, many women do not feel they have much of a choice but to turn to formula, which is widely available, if expensive.

    Clearly, breastfeeding success is an extremely complex issue that depends on a host of factors, some of which are mode of delivery (babies tend to be less successful at breastfeeding following a medicated delivery), health care staff attitudes and training (staff need to be trained not only in the importance of early contact, but given the practical and attitudinal skills to help new mothers with breastfeeding difficulties), cultural and environmental attitudes (partners’ attitudes, availability of help for the new mother, reprieve from other responsibilities, financial security, just to name a few).

    The problem is, the cards in the US seem to be stacked against mothers who want to breastfeed, and I think that is why some breastfeeding advocates get so frustrated and lash out at formula companies. It is a much easier target than, say, the concept of nuclear family or lack of a federally mandated maternity leave.

  15. keleton says:

    @ OttawaAlison – good point, I admit I haven’t thought through all the details.

    I’m exploring different lines of thought to make breastfeeding more normalized – and formula is a necessary product for babies who can’t get breastmilk, but should not be such a casual decision as it seems to be.

    I apologize for diverting the conversation from science to politics. This is a very emotional issue and I admit I probably can’t see it without bias.

    Many previous posts have mentioned that the burden of proof should be on the formula – that I agree with.

  16. OttawaAlison says:

    Keleton – no worries.. It’s something I have heard numerous times, and being a mom who ended up formula feeding it was something I have thought about. I was one of those women who researched breastfeeding, was very determined and then was unable to achieve a full supply (I have breast hypoplasia and some scar tissue). I combo fed until my DD was 3.5 months, then did just formula.

    It’s weird though, I always thought breastfeeding was the norm before I became pregnant. Me and my brothers were all breastfed (and we were born during the 70s) and many women I knew breastfed too.

    That being said, due to my experience I am very pro-choice on the issue of infant feeding.

    Next kid though, I won’t hesitate to supplement if I need to (my DD was still losing weight at 2 weeks). I also will line up all the help I can get with cooking, cleaning, looking after my daughter etc. I will get my prescription of domperidone before I give birth and do what I can. That being said, I refuse to let my mental health suffer the way I did after my first child (with all the guilt I had etc). In the end, to me anyway, the most important thing is that a baby is lovingly fed, either by breast or by bottle (or both!)

  17. tm says:

    “Why? Because women should only be allowed to do what you approve? What kind of reason is that?”

    Dr. Tuteur, I believe you answered your question already in response to my last comment ;)

    Another tangent: The marketing of so many baby products, preys upon anxieties about our children. From foam cushions you are exhorted to stick on any potentially sharp corner to the “perfect” car seat/sling/stroller/crib/etc… And the marketing is for women: Note dearth of diaper bags for men, and the prevalence of soft focus photographs with lots of pastels. The majority of these products are overpriced plastic junk: I once saw a “baby food kit” which consisted of nothing more than a cheap plastic food mill and an ice cube tray with a lid. For $25.

    Fathers could, to their great peril, argue that $25 for a balky food mill that will break anyway and a ice tray they could buy 3 for $5 is not money well spent. If they really wish to spend the night on the sofa, they can object to such purchases and find themselves right in the middle of what the Mommy Wars are about: “You don’t care about the children? You don’t want what’s best for them?”

    My friends nearly encountered one of the worst examples of marketing to new mothers-to-be. They signed up for a “Safety Convention”. I called up and was surprised to hear the tone of the automated message: “If your husband would *rather* watch some sports than care about their baby…” And it got worse from there. It also forbade children (and their parents) from this shindig. My friends arrived late and we met them at the local hotel where it was going down. The organizers had literally locked the doors to the hall where this was going on, preventing anyone from entering or leaving. It was one of those deals where they lined up speakers that would go on about the horrors of child safety, to get those women scared (with full bladders), but guess what! They just happened to have a bunch of products and services right there to sell you. The whole “convention” was based upon preying on a new mother’s anxiety, and heightening it to deplete her bank account.

    “Don’t you want what’s best?” is one of the most insidious questions that marketers and mothers can use on mothers. Whether it’s yogurt syringes, breastfeeding or the entire universe of overpriced baby goods, it’s used to raise a mom’s anxiety and have her worry whether she is on the one true way to raise children or not.

    Men do not ask each other this question. And if one dared to ask, they might get a knuckle sandwich for the answer.

    In the Perl programming language, there is a maxim that translates very well to the raising of children: There’s More Than One Way to Do It. Perl code, like raising children, is messy, fraught with errors, but somehow it manages to work in the end.

  18. desiree says:

    Clearly, breastfeeding success is an extremely complex issue that depends on a host of factors, some of which are mode of delivery (babies tend to be less successful at breastfeeding following a medicated delivery)

    is this true? i tried a pubmed search once, and all i found was one article stating one specific medication was associated with lower rates of breastfeeding (in the long term, not the short term). it sounds so mean (you failed because you got the epidural, you selfish, selfish woman!). but, i don’t have access to most studies, so i have no idea whether it’s really true (and if true, how significant the associations are).

  19. galway says:

    I recall reading about a study which appeared online March 19th in the American Journal of Public Health.
    I’ll quote from an article referring to it on medicalnewstoday as I don’t want to wait for approval by putting in a link.

    “A research team led by Eugene Declercq, PhD, professor of Maternal and Child Health, found a significant drop-off between the numbers of mothers who intend to exclusively breastfeed, and those who fulfill that intention one week after giving birth.

    Among first-time mothers, 70 percent reported an intention to exclusively breastfeed, but only 50 percent achieved that goal at one week.

    The study found that hospital practices were strongly related to those outcomes. Specifically, the practice of hospital staff providing formula or water to supplement breastfeeding was significantly related to the failure to achieve exclusive breastfeeding.

    Mothers whose infants were not offered supplementation were far more likely to achieve their intention to breastfeed – 4.4 times more likely among primiparas (first-time mothers), and 8.8 times more likely among multiparas.

    Other hospital practices also influenced outcomes. First-time mothers who delivered in hospitals that practiced at least six out of seven recommended steps to encourage breastfeeding — such as helping mothers get started and not giving babies pacifiers — were six times more likely to fulfill their intention to exclusively breastfeed than mothers who reported experiencing one or none of these practices.

    About half (49 percent) of first-time mothers who intended to exclusively breastfeed reported that their babies were given water or formula for supplementation, while 74 percent reported being given free formula samples or offers.”

    In my mind (which it might not be intentional by the hospital staff).. that’s sabotage.

  20. Reka Morvay:

    “Breastfeeding, Bonding and the Mother-Infant Relationship”

    What did the authors use to measure “bonding”?

  21. tm:

    “There’s More Than One Way to Do It.”

    Yes!

  22. Reka Morvay:

    “babies tend to be less successful at breastfeeding following a medicated delivery”

    That’s not true either. It is yet another made up claim used to berate women who make “unapproved” choices.

  23. galway says:

    Desiree:

    The only thing I can think of is “Delivery Self Attachment” which is a comparison (on video) of medicated and unmedicated babies after birth.
    When placed on the chest, most of the unmedicated babies crawled to the breast, found the nipple, latched on and nursed.
    Compared to the unmedicated babies who either 1) Didn’t move from the belly, 2)Did very lethargically find the breast… and from there either were too drowsy to latch on, or nursed very poorly.

    Women shouldn’t be shamed for doing what they needed to do during labor. But it does show how it can affect breastfeeding after such a delivery.

    Now, it’s not to say that ALL babies are affected this way. But some are. For instance a baby who’s mother used pain relief for two hours, compared to a baby whose mother used it for 15 might be affected completely different. (not stating facts, just my assumptions)

  24. galway:

    “A research team led by Eugene Declercq, PhD, professor of Maternal and Child Health, found a significant drop-off between the numbers of mothers who intend to exclusively breastfeed, and those who fulfill that intention one week after giving birth.”

    The study doesn’t show much of anything, regardless of what the authors claim.

    1. It is based on a phone survey carried out by The Childbirth Connection, a “natural” childbirth lobbying organization.

    2. It is retrospective. They asked mothers about what they had planned to do at the end of pregnancy, and what they were doing when the baby was 7 days old. They did not ask if breastfeeding continued beyond that point or for how long it continued.

    3. They never determined actual hospital practices. They asked the patients what they recalled of hospital practices.

    4. Those who were breastfeeding at one week differed substantially from those who were not.

    “Those most likely to intend to and actually exclusively breastfeed at1week were mothers who were non-Hispanic White, better educated, had higher incomes, had private insurance, or were employed part-time.”

  25. “The only thing I can think of is “Delivery Self Attachment” which is a comparison (on video) of medicated and unmedicated babies after birth.”

    Curiously, it appears to only occur on videos made by breastfeeding proponents. That’s because it is yet another mean spirited fabrication from breastfeeding advocates.

  26. keleton says:

    “They never determined actual hospital practices. They asked the patients what they recalled of hospital practices.”

    So do you think what actually occurrs at a hospital during delivery and recovery is more accurately gauged by what the hospital claims their practices are, or what the patient actually experienced?

    For example, I delivered at a supposedly very “baby-friendly” hospital that claimed to have lactation consultants available for every mother, but every time I would ask for one the doctor would say that she would set that up and the nurses would just change the subject and try to offer me advice but no one got me a lactation consultant.

  27. keleton says:

    Dr. Tuteur:

    I do agree the “one week” aspect of the study is misleading. I was not breastfeeding successfully until 3 weeks. I have always believed this was because my daughter was taken to the special care nursery and bottle fed formula. I didn’t get a chance to even try to nurse her until the next day. I was told by the doctors, nurses and my family that I should get some rest and let the nurses take care of her. I was too exhausted to argue. But I will never know if breastfeeding would have been any easier to establish if the circumstances had been different.

  28. Zoe237 says:

    “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, ”

    So if babies are allergic to soy and cow’s milk, what do they do? Surely they’re not on banked breastmilk until one year?

    “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?”

    This is a total 180 from your original comments wondering why women didn’t get breastfeeding classes instead of childbirth classes, Dr. Tuteur. I am thoroughly confused as to your disjointed, directly contradictory *opinions.* Maybe I’m missing something.

    Yes, some women try it and don’t like it. I totally get that, I didn’t like it many times myself.

    However,
    Why is so hard to believe that *some* women don’t breastfeed as successfully as they would like because they don’t have help? You yourself earlier said that bf is not easy for someone who does shift work and doesn’t get pumping breaks. The government public health effort (in their silly log rolling ads) pays lip service to bf, but doesn’t address efforts to make it easier for women to do so.

    And once again, your (former) colleagues disagree with you. On bonding and the cultural challenges to enabling women to bf (those who WANT to iow). (To be clear, I don’t personally find bonding to be a compelling reason to bf, because I have bottlefeeding friends who are just as bonded. But apparently many doctors and scientists seem to think it makes a difference).

    http://www.aap.org/breastfeeding/PolicyOnBreastfeeding.html

    “For the family
    Breastfeeding facilitates bonding. ”

    “Obstacles to initiation and continuation of breastfeeding include insufficient prenatal education about breastfeeding132,133; disruptive hospital policies and practices134; inappropriate interruption of breastfeeding135; early hospital discharge in some populations136; lack of timely routine follow-up care and postpartum home health visits137; maternal employment138,139 (especially in the absence of workplace facilities and support for breastfeeding)140; lack of family and broad societal support141; media portrayal of bottle feeding as normative142; commercial promotion of infant formula through distribution of hospital discharge packs, coupons for free or discounted formula, and some television and general magazine advertising143,144; misinformation; and lack of guidance and encouragement from health care professionals.135,145,146 ”

    “No, there is NO evidence that there is any truth to this. It’s just another made up claim that breastfeeding proponents wield like a cudgel to beat up mothers who make different choices.”\

    I’m sure you know that you are well known in the blogosphere for attempting to beat up women who make different choices than you. That’s why I find this whole original post slightly hypocritical.

    On a side note, the whole baby products industry strikes fear in me. Especially the jars of bananas… how ’bout just mush up a banana? Wipe warmers, waterproof carriers for carseat carrier, baby einstein videos… most of it is advertised to appeal to the neverending guilt of mothers. But then, I got berated once for letting my kids play outside by themselves (on my private suburban cul de sac). It’s exhausting. Oh, and apparently I wasn’t supposed to let them go trick or treating on Halloween because of H1N1, even though they are vaccinated.

    Regarding epidurals and bf, I have only seen one study that shows a link between epidurals and bf difficulty. The rest have shown no such difficulty. I tend to doubt it. But I don’t think women who would rather avoid pain medication (for whatever reason) should be castigated either.

    “The authors conclude that this study adds to the growing body of evidence that the fentanyl component of epidurals may be associated with difficulty establishing breastfeeding.”

    http://www.sciencedaily.com/releases/2006/12/061211092622.htm

    The other side:

    “Purpose of review: To evaluate the effect of epidural analgesia on breastfeeding.

    Recent findings: Alarming messages were sent out following a retrospective study indicating that epidural analgesia caused more breastfeeding failures. The limitations of this study were reviewed as well as the critical importance of good lactation support.

    Summary: There is no good evidence that epidural analgesia causes reduced breastfeeding success. Good lactation support is critical.”

    Oops, is that another hurrah for good lactation support?

    http://journals.lww.com/co-anesthesiology/Abstract/2009/06000/Breastfeeding_and_epidural_analgesia_during_labour.3.aspx

  29. daedalus2u says:

    keleton, your experience is interesting to me and my nitric oxide research. It is my hypothesis that postpartum depression and postpartum psychosis are due in part to the metabolic stress of lactation and that it is a “feature”, an evolved feature for a mother in metabolic stress to shed metabolic load through infanticide. All other mammals exhibit that behavior (within some limits), we should expect humans to do so also. It is nitric oxide that triggers mitochondria biogenesis, and mitochondria in the liver are probably one of the limiting factors in lactation.

    A mother feeling she doesn’t want to breast feed any more may be her body telling her that she doesn’t have the metabolic capacity to do so. The capacity to produce milk is not unlimited, and is different for each woman, and with each pregnancy. I suspect there are multiple signals that a mother experiences that tell her she doesn’t have the metabolic capacity to continue nursing. If she is able to ignore the early signals, the later signals may be less controllable.

    The post partum period is unique, and there may be some tricky things going on in physiology that are trying to balance the different risks that women were exposed to in “the wild” during evolutionary time. The 1% maternal death rate per pregnancy must have put some terrific evolutionary pressure on physiology to adapt to minimize the death rate from the various causes. I suspect that some of the things that now look like problems may have been solutions to other problems that don’t happen now, for example blood loss may reduce death from strep infection. When strep infection is controlled essentially completely with antibiotics, the effects of blood loss are only adverse.

  30. keleton says:

    daedalus2u –

    That is an interesting hypothesis. I definitely had metabolic changes during and after my pregnancy. I don’t want to distract this thread any further but if you’re interested I would be happy to tell you more.

  31. Réka Morvay says:

    A collection of abstracts regarding breastfeeding outcomes across a range of topics:

    http://www.llli.org/docs/Outcomes_of_breastfeeding_June_2007.pdf

  32. desiree says:

    reka, dr. tuteur’s assertion is not that there are no benefits to breastfeeding, but that the benefits may have been overstated. without reading the research that the la leche paper is based on, we can’t evaluate the accuracy of their claims.

    as an aside, i think there are risks to breastfeeding moms that get TOTALLY glossed over. i’ve had 2 episodes of mastitis and both left me feeling dreadful. a nurse friend of mine told me about assisting with a woman who needed a breast abscess surgically drained who had come very close to losing her breast. my youngest is 18 months old (still nursing), and i still haven’t gotten my cycles back, which isn’t as fun as it sounds because it means my body is in a sort of pseudo menopausal state. i know la leche emphasizes how breastfeeding lowers your risk of osteoporosis in the long run, but in the short run it weakens your bones. i’m afraid i have a stress fracture in my wrist that i wouldn’t be surprised 5 consecutive years of pregnancy and breastfeeding my 2 girls contributed to. i’ll stop my ranting now but i could go on!! it’s a lot for a woman’s body, and i get irritated when advocates gloss over the downsides.

  33. Reka Morvay:

    “A collection of abstracts regarding breastfeeding outcomes across a range of topics:”

    A collection of abstracts does not substantiate any of the claims therein. Moreover, the issue is not whether papers exist. The issue is that the benefits claimed are actually very small, and that most of the studies suffer from serious issues with confounding that render their conclusions suspect. Some also suffer from serious issues of methodology. For example, can bonding be “measured”? What are the authors doing when they claim to be measuring bonding?

  34. keleton:

    “So do you think what actually occurrs at a hospital during delivery and recovery is more accurately gauged by what the hospital claims their practices are, or what the patient actually experienced?”

    No, I think it is sloppy and unjustified to skip gathering actual data and substitute patient recollections.

  35. icewings27 says:

    I don’t think the “free formula coupons or samples” argument is a very good explanation for explaining new moms’ failure to breastfeed, even when they intended to breastfeed. It’s insulting to our intelligence. I mean, you can hand me a free packet of cocaine but I’m not going to use it, no matter what.

    Women have brains and we can think and reason. Yes, even post-partum, we have these abilities! The hospital sent me home with several free bottles of formula and several formula coupons (all of which claim formula is “the closest thing to breast milk”, which I find ironic). We threw out the coupons and stowed the formula in a diaper bag in case of emergency.

    The hospital also provided excellent breastfeeding support and encouragement, by the way. They are not evil Formula-mongers.

    I suspect that one reason so many women give up on breastfeeding the first few days or weeks into it, is because it sure is nice to have someone else feed the baby sometimes to give mom a break, and formula feeding allows that. And no, I can’t cite a study to support that…just my opinion.

    You have to really have a support system in place, and too many new moms are home alone with baby, or only have their husbands home for a week or two after birth, and no other family to help out. AND they’re trying to learn how to breastfeed. That’s asking a lot of a tired new mom!

  36. Bonnie says:

    So I was thinking about those hormones that help relax women and help them bond during nursing. I wonder if they are there *because* a substantial number of women find nursing to some extent to be annoying/difficult/tiring, and need a little help from biology to relax and put up with it?

    IMO formula would have never taken over so much, no matter what the marketing, if there weren’t plenty of women glad to find an alternative.

    I was so glad to have accomplished my 1-year goal with my second. But I never felt exactly blissful about it. I mostly put up with it, and sometimes enjoyed it. But honestly, I enjoy bottle feeding more.

    I’m pretty pro-breastfeeding, but I think sometimes the pro-breastfeeding side glosses over the fact that many women just don’t really love it. Some do, and that’s great for them. Nothing wrong with not loving it though.

  37. Kylara says:

    @icewings: “The hospital also provided excellent breastfeeding support and encouragement, by the way. They are not evil Formula-mongers.”

    Yeah, I tend to be a little suspicious of claims that hospitals undermined breastfeeding … I gave birth at a conservative hospital in a somewhat rural, fairly conservative area that is NOT on the cutting edge of ANYTHING regarding childbirth.

    My son had two big stickers on his hospital bassinet that said, “I’m a Breastfed Boy! Do not give me bottles or pacifiers without specific parental consent.” Which I thought was a little silly, to be honest, but they were super-serious about baby only getting what mom and dad approved, mouth-wise. (I thought they were so funny that I actually stuck one in his baby book because it continues to amuse me.)

  38. KuneSSR2edPS says:

    Interesting post. As a new father, I read it the post and the comment that followed closely and I have to say I got pretty carried away. This is a seriously emotional issue!

    I did really appreciate the link Amy gave to “Measuring Motherhood,” which really seems to jive with all of the pressure and stress my wife is going through now and me to a much lesser extent. I wish that parenting style in our culture wasn’t subject to such huge pendulum shifts, it makes me distrust just about all the sources. We experienced a fair amount of encouragement to breast feed, but nothing inordinate– I’d say proportional to the modest benefits.

    My main problem with the current “orthodoxy” is the idea that “BF should never be painful/if it hurts you should stop.” For my wife and many women I have talked to some pain and discomfort at first was inevitable, so it seems to be a question of scale. We were routinely told to stop feeding even if it hurt a little. Sure, we tried many different positions and techniques to find the most comfortable method. But, I don’t think there is any chance my kid would be breastfeeding now if we had followed that advice.

  39. galway says:

    KuneSSR2edPS:

    wow, I’ve never heard the “if it hurts while breastfeeding you should *stop*” bit.

    What I was taught, and help other moms with… is if you’re feeling pain (and more than just an initial latch pain as baby sucks in the nipple) but continuing pain, then the latch is not correct. For myself it felt like continuous burning.
    It means something else should be tried. Whether it’s a nipple shield to protect the nipple/get baby to latch correctly. (hen take it off mid-session) or a different position. Or just plain watching how baby latches and correcting it as you go. Something is needing help. Lasting pain is a sign of something not quite right.

    Like I said, an initial “shock” or “twinge” of pain can be perfectly normal even later with an older breastfeeding child.

  40. ivywild says:

    <<>>

    No. Abnormally low blood pressure is not one of the side effects of breastfeeding. Breastfeeding produces a normal level of blood pressure. Formula use may lead to an increase in blood pressure levels over the norm in some individuals.

    <<>>

    No, breastfeeding does not result in abnormally low levels of cholesterol. It gives a NORMAL level of cholesterol based on each individual’s own genetics and subsequent diet. A diet consisting exclusively of breastmilk does not increase or decrease normal cholesterol levels.

    <<>>

    No, breastfeeding does not result in lower than average/normal weight gain over a person’s lifetime. It gives a NORMAL level of weight/health according to each individual’s own genetics and personal diet. Formula use may predispose some individuals to increased weight gain, but breastmilk does not prevent or contribute to unwanted weight gain.

    <<>>

    No, breastfed individuals get diabetes at a normal rate of occurrence for the human species. Formula fed individuals as a group have a higher rate of diabetes than normal.

    <<>>

    No. Breastfeeding gives a normal level of intelligence and school performance according to each individual’s own genetic potential. It does not increase intelligence beyond what it normal for any given human being with their own specific genetics. Formula use may decrease intelligence and school performance below the normal level for some individuals.

    <<>>

    Perhaps because breastmilk is the normal diet for human infants, not a super-food. The real question is, does the use of formula INCREASE any of these risks over and above the normal levels? Shouldn’t the burden of proof be on the substitute rather than the standard? Where is the proof that formula is AS SAFE AS the standard nutrition for infants? Where are the studies showing that it gives at least comparable results? Why should breastmilk have to prove that it is so much “better” than formula in any way? If it is AT ALL better than formula, that is because formula falls that much short of the STANDARD. Unless formula gives either exactly the same or better results than breastmilk, then it is SUB-STANDARD nutrition and introduces risks over and above what is normal.

    Maybe the real issue is not that breastmilk is being “oversold”, but that no one wants to acknowledge that formula may be in any way substandard or risky? If you bring the “benefits” of breastmilk down to the point of being insignificant, then formula looks acceptable by comparison. But if the general public ever understood that breastmilk has NO “benefits”, but that formula is sub-standard nutrition that increases the health risks to their children, they might FEEL BAD. The real issue is not infant health at all, but the manners and feelings of the general public. If Suzie FF’er gets accosted by Jane BF’er in the mall, that is a POOR MANNERS issue, it has absolutely nothing to do with whether formula is good, bad or indifferent as a nutritional supplement. If Suzie FF’er reads in an article that formula may put her baby at a higher risk of X illness, then she needs to own her own feelings about her choice (or non-choice, as the case may be, since many moms do not have a choice). We should not have to water down the facts in order to make formula feeding parents FEEL better about the substance they are feeding their children. Suzie FF’er and Jane BF’er need to deal with their own issues and learn how to interact politely, and Suzie needs to find a way to deal with the TRUTH about formula. It’s not “rat poison”, but it’s still not risk-free. It is the best alternative nutrition for an infant when breastmilk is not available. It is NOT equal in content or in health results.

    Formula is far more “oversold” than breastmilk. It is actively advertised and promoted not only by manufacturers but by physicians and others in the medical community as being “just fine” or “safe”, and the risks are generally downplayed or completely dismissed, in spite of the fact that the worldwide medical community has known for years that this is a LIE. Millions of babies die worldwide due to not being breastfed. That is hardly a “slight” difference. Just because the difference is less noticeable in “developed” countries does not mean that there is no difference. I think it is insulting to lie to parents and tell them that what they are feeding their child has NO health risks. If they are fully informed and still choose to use it, then that is their business, but convincing parents that they are making a risk-free choice just to avoid potentially hurting their feelings is deceptive and not in the best medical interest of the CHILD. (remember, there is a CHILD involved in this, not just a parent with sensitive feelings.)

    Maybe we should stop trying to make breastmilk prove that it has super powers and start making formula prove that it can at least measure up to AVERAGE.

    Just a thought…

    Stephanie
    mom to seven sensational kids!!!

  41. ““Measuring Motherhood,” which really seems to jive with all of the pressure and stress my wife is going through now and me to a much lesser extent.”

    I find that article very thought provoking. It is an attempt to analyze why and how women judge and undermine other women. Parenting is a multi-decade endeavor involving countless interactions. The idea that it can be reduced to “performances” at signal moments is absurd on its face. Yet some women insist that mothering is about vaginal birth, no pain relief, extended breastfeeding, baby-wearing, organic babyfood and nothing else.

  42. criticalthinker says:

    From an evolutionary standpoint, how long has cow-based infant formula been available for infant consumption?

    Why is there a universal acceptance of consuming a product derived from another species, and deemed acceptable based on limited data?

    Does the evidence show a positive association with breastfeeding, or are you misinterpreting the evidence (that really shows a negative association with formula feeding) to justify the use of formula?

    Do I care if a woman chooses to formula feed their child? Well… no, but I’m not advocating for anything. I think it’s probably best to stick with nutrition / food that humans have been eating for longer than 100 years ( and realistically, it’s a heck of a lot longer than that ) … because we all know how long that really is – don’t we?

    Am I going to tell you that if you breastfeed your kid, they’ll go to Harvard while their counterpart doesn’t and ends up being a janitor? No, I’m not. Addressing the long term effects appear to be a distraction from what is important, and that’s the immediate effect – to which I hope no one will deny.

    This post appears to be a distraction from those benefits, by claiming them to be ‘small’. Rather than focus money and energy on long term effects (while significant) shouldn’t we be addressing the moment the child is born, until they are able to not only appropriately consume, and actually (hopefully) correctly digest solid food? What are the health outcomes (with more meaningful endpoints) through secondary schools? I actually agree that counfounders will limit data to a degree (true for everything really).

    The differences in microflora between the two respective groups should be enough to give pause, at least one would hope. We should be willing to accept that we will be rewarded for being a good host (appropriate colonies of microflora, etc…) truest to our original design (within reasonable limit). Shouldn’t humans be consuming food that they’ve been consuming for longer than 100 years? I’m thinking yes. Call me old-fashioned. I just can’t help NOT think in evolutionary terms. Ever.

  43. sohare 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? ”

    I love comments like this. It really shows you why we need better science education.

  44. “The real question is, does the use of formula INCREASE any of these risks over and above the normal levels?”

    No, that’s just another way of saying the same thing: instead of claiming that the the benefits of breastfeeding are oversold I could have said that the risks of formula feeding have been grossly overstated, and for the same reason.

  45. Dawn says:

    Formula, of one version or another, has been used for hundreds of years. Wet nurses were often the norm, IF the mother had the money to pay for one. Or, in a communal society, the baby might have been given to another, lactating woman, to tandem nurse. (Different from wet nursing. Often, wet nurses were forbidden to nurse their own children, who were put on “alternative” forms of nursing). If a wet nurse was not available or the family could not afford one, and communal nursing was not an option, then an alternative had to be found. For most rural people, that alternative was either goat’s milk or cow’s milk. Bottles for feeding babies have been found way back in archeological digs.

    We tend to romanticize the past: all women breastfed successfully or their babies would have died. Well, no. Not all women breastfed successfully. Alternative options have been known for thousands of years. Yes, breast may be best for a human child, but let’s not pretend that other choices are only new within the past 100 years.

  46. “From an evolutionary standpoint, how long has cow-based infant formula been available for infant consumption?”

    From an evolutionary standpoint, how long has dental floss been available? Not very long, right? Yet you still (should) floss everyday.

    Your claim is an example of the “naturalistic fallacy” also known as the “is-ought” fallacy. The naturalistic fallacy is the assumption, without evidence, that what occurs in nature is always superior to everything else.

    It also represents a misunderstanding of what evolution is capable of achieving. It cannot and does not achieve perfection. Natural selection leads to the most successful outcome in the current situation given the tools that nature has available. If the environment changes, the adaptation that previously was superior might become inferior or even dangerous.

    Consider the color of bear fur. Bears in temperate climates have dark (usually brown) fur. Bears in the Arctic have white fur. Neither color is “better” than the other. White fur gives bears in the Arctic a competitive advantage in their current environment. It allows them to blend into their surroundings, probably advantageous when trying to approach prey. Yet if global warming continues, and the ice cap melts and bears are forced farther south into more temperate climates, the white fur will make them stick out dramatically. It will no longer be an advantage, it will have become a liability.

    Moreover, while being white and blending into Arctic surroundings is advantageous, it would be far better to be invisible when stalking prey. But invisibility is not within the power of our DNA to achieve, regardless of how advantageous it might be. Evolution occurs extremely slowly and uses the only thing available, the DNA that the animal has. Evolution doesn’t produce the “perfect” outcome, only the best outcome possible for that environment within the constraints of existing DNA. It would have been “perfect” if we had evolved a way to floss our teeth, but that didn’t happen.

    Given the constraints of our DNA, breast milk may have represented the best available solution for feeding infants in hunter-gatherer societies. But we know longer live in hunter-gather societies and we are no longer constrained to only what our DNA can manage.

    The history of human beings in the past 10,000 has been one of spectacular success in population growth. That success occurred because we left the constraints of nature behind. We are no longer limited to foraging for grain and fruit; we can farm it and create large quantities. We are no longer limited to meat that we can catch; we can domesticate animals and raise large numbers of animals.

    It’s not enough to insist that because something is natural (because we’ve “always” done it that way), it must be superior. Sometimes there are non-natural alternatives that are equal; and often there are non-natural alternatives that are better.

  47. edgar says:

    Sarah Blaffer Hrdy writes about many of the issues people have raised in this thread in
    Mother Nature: A history of mothers, infants and Natural Selection.

    Excellent book.

    Also, :I find that article very thought provoking. It is an attempt to analyze why and how women judge and undermine other women.:

    I am the only one who finds this ironic?

  48. criticalthinker says:

    “From an evolutionary standpoint, how long has dental floss been available? Not very long, right? Yet you still (should) floss everyday.”

    What is the basis for comparing food to dental floss? Dental floss is needed now, because of the agriculture you address later in your post. As for this viewpoint (at least as it relates to breastfeeding) being a naturalistic fallacy – I don’t think there is a fallacy, as breastfeeding is the biological norm as far as infant nutrition goes. Consuming cow based products is not something humans have done for a very long time, and many people suffer ill-effects. Some overt…. others less.

    I think I have a pretty good grasp on evolution, and thank you for taking the time to illustrate it to those that might not. My point, is that a food that has been a round for a very, very, very short evolutionary period of time is the one that is taxed with the burden of proving to be a better product for human babies.

    Your view and mine have some similarities as it relates to the last 10,000 years. But while I agree that we have experienced population growth on a rather extravagant level due in part to agriculture, that certainly doesn’t mean that we’ve adapted to the modern diet and the consumption of grain (at least to the tune of 12 servings a day). We may certainly be able to consume it, but an item that was available in rare form prior to this time period that turns into something we consume as the majority of our diet will certainly affect some in a negative manner. Something that starts out with good intention (monocultural farming, wide-scale animal factory farms) also have their own repercussions to both animals (including humans) and planet. Massively farming a corn derivative crop and turning every molecule of its harvest into every imaginable shape of “food” – has the burden of proving that to be superior of something less manipulative, not the other way around.

    While I certainly am capable of recognizing that this domestication afforded for my existence, I would be remiss if I only focused on the positive aspects and abandoned what actually took place during the Paleolithic Era. I’d also be naive if I believed that this domestication did not also create opportunities for man to insert his own greed and place it before everything else (Nestle comes to mind here). The burden of proof is upon those claiming that non-natural alternatives are better (within reason, at least when it comes to infant feeding). The fact that human babies have sustained on human milk for hundreds of thousands of years is evidence in its own right.

    Of course, this is simply my opinion and my perception of this issue. This is actually the first time I’ve been compelled enough to comment here, though I read material regularly. I appreciate the exchange.

  49. criticalthinker says:

    Sorry for the forum flood (two posts in a row, I didn’t see Dawn’s post)

    I actually am okay with raw goat’s milk as an alternative to human milk (for a number of reasons), or at least would prefer it over cow’s milk. Infant formula is certainly not the same as the raw milk collected from an animal on a farm that is carefully taken care of, surely you can recognize the difference.

  50. “I don’t think there is a fallacy, as breastfeeding is the biological norm as far as infant nutrition goes.”

    I’m afraid I wasn’t as clear as I might have been. Naturalistic fallacy is not my personal opinion. It is a recognized fallacy in logical argument. It is also known as “appeal to nature.”

    Here’s what Wikipedia says:

    “Appeal to nature is a fallacy of relevance consisting of a claim that something is good or right because it is natural, or that something is bad or wrong because it is unnatural. In this type of fallacy nature is often implied as an ideal or desired state of being, a state of how things were, should be, or are: in this sense an appeal to nature may resemble an appeal to tradition.

    Several problems exist with this type of argument that makes it a fallacy. First of all the word “natural” is often a loaded term, usually unconsciously equated with normality, and its use in many cases is simply a form of bias. Second, “nature” and “natural” have vague definitions and thus the claim that something is natural may not be correct by every definition of the term natural; a good example would be the claim of all-natural foods, such as “all-natural” wheat, the claimed wheat though is usually a hybridised plant that has been bred by artificial selection. Lastly, the argument can quickly be invalidated by a counter-argument that demonstrates something that is natural that has undesirable properties (for example aging, illness, and death are natural), or something that is unnatural that has desirable properties (for example, many modern medicines are not found in nature, yet have saved countless lives).”

    So when you say that breastfeeding is the biological norm, you are suggesting that it logically follows that breastfeeding is superior. That’s the naturalistic fallacy. If you want to claim that breastfeeding is superior, you have to show that it is superior, not merely rely on the fact that it is natural.

  51. Calli Arcale says:

    Zoe237:

    “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, ”

    So if babies are allergic to soy and cow’s milk, what do they do? Surely they’re not on banked breastmilk until one year?

    Alternatives are few. Goat’s milk is an option, but AFAIK, formulas aren’t made with goat’s milk, and I don’t think you’d want a newborn to be on straight goat’s milk. (The proportions would be wrong for a human infant. Though I know a guy who was breastfed but supplemented with goat’s milk in an effort to help him gain weight.) You can keep the kid on banked breastmilk until they’re able to take solids, and then transfer them to goat’s milk. It’s not cheap, but it’s not impossible to find either. I have a friend who’s daughter has both allergies; she drinks goat’s milk. She was adopted, though; I don’t know what was done for her as an infant.

    Or, you could create your own formula. In fact, the word “formula” is interesting, because originally, when a baby was put on formula, they didn’t mean a powdered instant formula. They meant the doctor would give you a formula written down on paper which you would use to make the child’s drink. My mother was fed on this sort of a formula, and apparently it involved raw eggs. (Eww!)

    Dawn:

    We tend to romanticize the past: all women breastfed successfully or their babies would have died. Well, no. Not all women breastfed successfully. Alternative options have been known for thousands of years. Yes, breast may be best for a human child, but let’s not pretend that other choices are only new within the past 100 years.

    It’s kind of like how people think natural stuff must be good because we wouldn’t have evolved to a form which would die most of the time. It betrays a misunderstanding of how things worked when we were living in the bush thousands of years ago, which is to say, lots of people died, usually in childhood. A woman having 12 babies isn’t a sustainable rate of population growth — unless most of them fail to reach adulthood. Women tried to nurse. When they failed, they either sought a wet nurse (human or animal), or the babies starved. And that’s *still* what they do. It’s amazing how many people romanticize the past but fail to realize that there are living examples of this lifestyle, examples who could show how difficult the life is. It’s not a joyless life; it’s a wonderful life. People are amazingly adaptable, and can learn to deal with that level of adversity and even find joy. But it involves accepting a certain rate of infant mortality, and that’s something I, for one, am not comfortable with.

  52. “I find that article very thought provoking. It is an attempt to analyze why and how women judge and undermine other women.:

    I am the only one who finds this ironic?”

    One of the things that interests me about the sociology of “natural’ childbirth, breastfeeding, etc. is the fact that proponents equate disagreement with judgment. Among lactivists, questioning the magnitude of benefit of breastfeeding is often interpreted as “disrespecting” women who breastfeed.

    Questioning the claims of “natural” childbirth advocates, lactivists, etc. is not judging them. It is holding them to the same standard as anyone else who makes an empirical claim.

  53. edgar says:

    Believe it or not, I am NOT a NCB advocate. I myself had an epidural.

    But you consistently pass judgment of women who do chose that route, quoting from MDC and pointing fingers. You consistently call into question the ethics of researchers like J&D and make unfounded allegations against them like ‘knowingly mislead’. This is not science, Amy.

    As far as this post goes, a truly scientific approach without bias or judgment would be
    “Breastfeeding, what is the evidence of long term benefits?”

    And then stating the evidence, and the fact that long term-effects is still pretty new to the literature.

  54. Kylara says:

    @critical thinker: “Call me old-fashioned. I just can’t help NOT think in evolutionary terms. Ever.”

    You know that the “that’s what natural” and “that’s how humans raise babies” and “it’s evolution” arguments are exactly how anti-homosexual bigotry is justified, right? Homosexuality is “unnatural” — there’s the natural fallacy again, harking back to natural law theory of the middle ages — because it doesn’t lead to reproduction and evolutionarily, we’re meant to reproduce. Formula feeding is “unnatural” because it’s not how we evolved and we should do what we evolved to do.

    You’re standing on the corner of Bigotry Way and Eugenics Street there. The view isn’t pretty.

  55. Kylara says:

    (Of course natural law theory had nothing to do with evolution in the middle ages, but evolution often makes a convenient updating mechanism for anti-gay bigots these days who find natural law theory a difficult row to hoe in the modern world.)

  56. edgar says:

    You know that the “that’s what natural” and “that’s how humans raise babies” and “it’s evolution” arguments are exactly how anti-homosexual bigotry is justified, right?

    Yes, but that would be a case in which this argument would be wrong, right? Because it is found in nature.

    Regardless, everyone is in agreement that Breastmilk is best for babies. On that point it is undeniable.

    However when we factor in other things like maternal satisfaction and wellbeing, politics, and culture, things aren’t so clear cut.

  57. Zoe237 says:

    “One of the things that interests me about the sociology of “natural’ childbirth, breastfeeding, etc. is the fact that proponents equate disagreement with judgment. Among lactivists, questioning the magnitude of benefit of breastfeeding is often interpreted as “disrespecting” women who breastfeed.”

    Em, no, it’s just your particularly abrasive, less than objective tone about any subject you write about, not just motherhood. Surely you must realize this, and of course, you’re entitled to your opinions. But don’t call them facts.

    Titles like “the tragic death toll of homebirth” (despite the fact that you presented ZERO studies to back this up) “midwives and the assault on scientific evidence,” (despite the fact that your arguments apply to a miniscule proportion of midwives known as direct entry midwives, when certified nurse midwives deliver 8% of babies in the US) and “the mother is the factory” (despite the fact that many advocates of any argument in the
    40s were sexist, ad hominem) tend to belie more than scientific presentation.

    Edgar is absolutely right that if you had any interest in science and truth, you would say: “Breastfeeding: what are the potential long term benefits?”

    “You know that the “that’s what natural” and “that’s how humans raise babies” and “it’s evolution” arguments are exactly how anti-homosexual bigotry is justified, right? Homosexuality is “unnatural” — there’s the natural fallacy again, harking back to natural law theory of the middle ages — because it doesn’t lead to reproduction and evolutionarily, we’re meant to reproduce. Formula feeding is “unnatural” because it’s not how we evolved and we should do what we evolved to do.”

    It’s interesting that you should bring that up, because Dr. Tuteur judges single parents and homosexual parents on her previous blog, calling them selfish and self indulgent. And calling hetero “normative” in the comments. Is this the same as natural? I dunno.

    “Actually I believe that women should we stigmatized if they want to have children without marriage, because it is a self indulgent, selfish choice. ”

    “Children deserve a resident father. Women do not deserve to have children simply because they want them.
    AmyTuteurMD
    February 23, 2009 08:44 PM”

    And yes, that was mostly a strawman, but so have been a lot of comments on this story.

  58. Zoe237 says:

    Oops, here’s the link.

    FEBRUARY 23, 2009 8:30PM
    Are fathers optional?

    http://open.salon.com/blog/amytuteurmd/2009/02/23/are_fathers_optional

  59. Harriet Hall says:

    Homosexuality is natural. It has been documented in over 400 species of animals.

    As for evolutionary arguments, how about this? Technology is now part of evolution. Humans have evolved the ability to do things like developing an artificial formula. Humans have evolved the ability to prevent many of the deaths that would have occurred without technology. The evolutionary survival value is obvious.

  60. edgar says:

    No one is debating that Harriet. But the claim is “is formula better that breastfeeding.”

    We all know the answer is no. To what degree, we don’t know, but it is probably safe as long as you have a safe water supply. We do know that if you do not have a safe water supply the answer is ‘not at all’.

    Because it is probably safe, and millions of babies can and do thrive on formula, mothers are free to use formula for a myriad of reasons, not just milk insufficiency.

    We also know that science does not exist in a vacuum and formula throughout our history has been touted as the better way to feed (my mother’s generation). Thousands of babies considered malnourished when in fact the growth charts reflected formula feeding as the norm. In the span of 2 generations, are knowledge of breastfeeding was wiped out, leaving women today, unsure, unsupported, and often pressured to use formula. There baby is always hungry, or keeps crying, or whatever.
    You hear it over and over again. With proper support (as one poster said) professional and communal some of the problems can be manged. Some won’t for whatever reason, and that’s OK.

  61. Harriet Hall says:

    edgar,

    “is formula better than breastfeeding” is a question, not a claim. I don’t think anyone today is claiming that formula is better than breastfeeding. Breastfeeding is clearly better: the only question is “how much” better. The evidence shows that the benefits are real but small, and that formula is a viable option that is “almost” as good.

  62. TsuDhoNimh says:

    The idea that it can be reduced to “performances” at signal moments is absurd on its face. Yet some women insist that mothering is about vaginal birth, no pain relief, extended breastfeeding, baby-wearing, organic babyfood and nothing else.

    Because thats what they can control. When the child gets mobility and learns how to talk, it turns into diplomacy and negotiation.

  63. edgar says:

    “Yet some women insist that mothering is about vaginal birth, no pain relief, extended breastfeeding, baby-wearing, organic babyfood and nothing else.”

    Again with the judgment. WHO CARES?

  64. Calli Arcale says:

    Some do care, mostly the ones who want to say that mothering is about those things. They can indeed be quite judgmental. If you haven’t run into them, you’re fortunate. I don’t believe anyone here is alleging that “natural” childbirth is worse. What Dr Hall is particularly arguing against is those who claim that natural childbirth is *better* when that’s not true at all. It can be done successfully by many women, but it isn’t going to uniformly result in better outcomes. It’s not birth without interventions that Dr Hall rails against. It’s those who misrepresent the science to encourage women to reject interventions before they have the chance to find out if they’ll need them.

    We also know that science does not exist in a vacuum and formula throughout our history has been touted as the better way to feed (my mother’s generation).

    I don’t think our mothers’ generation counts as “throughout our history”. It was a relatively short period in which formula supplanted breastfeeding. (Yes, alternatives have existed through history, but largely, breastfeeding has been the default.) My parents were both formula fed; their parents had done a lot of reading and educated themselves and learned that a “scientific” upbringing was best. Don’t just trust to nature — do BETTER than nature! Be a MODERN woman! You’d only breastfeed if you were too poor or uneducated to do something better.

    Given that, it shouldn’t be too surprising that a) so many seniors are heavily drugged up today (they grew up believing that the answer to everything would eventually be available in pill form) and b) our parents’ generation rebelled against it just as they were rebelling against everything else in the Greatest Generation.

    Note: formula feeding was the norm in cities in the first half of the 20th Century, but not universally. Although my parents were bottle-fed, my inlaws were breastfed, as were most of the kids they knew growing up. Maybe things were different in rural South Dakota than in downtown Minneapolis; less drive to be “modern”. Of course, father-in-law grew up on a farm, and mother-in-law grew up at a rustic lakeside resort; breastfeeding was compatible with those lifestyles. A working woman in the city in 1945 couldn’t even think about expressing her milk all day while a babysitter took care of her infant.

  65. “Because thats what they can control.”

    I agree. I think that this comes in part from our anxiety over motherhood and our anxiety over achievement. Motherhood brings very little in the way of awards and kudos. Your kids don’t often turn to you and say, “Mom, thanks for not letting me have that candy I want. I know you are only thinking of my well being.” But many of us are used to getting good grades, and awards, and praise and we have created these artificial “goals” of mothering so we can tell ourselves that we have met them and feel superior to those who have not.

    My philosophical views about “signal moments” are, of course, informed by my years of practicing obstetrics. I spent way too much time trying to prepare women to be realistic about the pain of labor after others had encouraged them to be unrealistic, and way too much time trying to comfort them when they felt that “failed” by “giving into the pain.”

    My philosophical views are also informed by my years of mothering. I have four children, young adults and teenagers now, but I still remember the competition among mothers at the playground and the admonitions that mothers must do this or that in order to produce happy, healthy children. Since my children are older now, I have the opportunity to see how they and their peers are turning out. And I can tell you unequivocally that it makes no difference if their mothers had epidurals; it makes no difference if their mothers had C-sections; and it makes not difference if their mothers breastfed.

    What I have learned from both experiences, practicing medicine and mothering, is that there is more than one way to do things. People make life decisions that I disagree with all the time and things turn out just fine for them. It has made me cognizant of the fact that there is no “right” way to give birth, no “right” way to handle labor pain, no “right” way to feed a baby, etc. Each woman must find what is right for her and her family.

    Mothering is a long term project that involves many complex interactions. It is about being there emotionally when your child needs you. It is trying to provide guidance while at the same time promoting independence. It is learning to separate your ambitions for your child from his ambitions for himself. And it is so much more. To suggest to women that mothering or womanhood can be reduced to signal moments is to demean women and make them caricatures. Children are not created by recipes. There is no right way to raise a child. I have four children and each of them required different things from me. How could I possibly insist that what I did for any of my children applies to someone else’s child?

    I think “signal moments” can best be understood by situating the idea in the context of historical views of women and pain, women and “duty,” women as little more than uteri and breasts, whose “noblest” task is to fulfill their biological potential. I am very distrustful of biologic essentialism, the idea that a woman should be judged by how she fulfills biological roles. Just as I have no right to tell a woman she “must” have children, I have no right to tell her how she must give birth to them, how much pain she must endure, and how she should feed her infant. No one has that right.

  66. ivywild says:

    “The real question is, does the use of formula INCREASE any of these risks over and above the normal levels?”
    Amy Tuteur:

    “No, that’s just another way of saying the same thing: instead of claiming that the the benefits of breastfeeding are oversold I could have said that the risks of formula feeding have been grossly overstated, and for the same reason.”

    By that logic, the “benefits of not smoking have been oversold”, and the “risks of smoking have been overstated” also mean the same. The problem is, there are not “benefits” to breathing without smoking… that’s just the standard. Sure, there will be some variables in air quality, but everyone pretty much understands that you don’t get “benefits” from doing something normal like breathing the available air. You never read studies that say “NOT smoking REDUCES your risk of lung cancer”… because you don’t REDUCE the NORMAL rate at which people get lung cancer. Smoking INCREASES the rate of lung cancer over and above what is normal for humans.

    The real problem isn’t that the “benefits” of breastfeeding are being oversold, but how the general public is interpreting them. When a study is released that shows that formula use results in a loss of up to 6 IQ points, people often interpret this to mean “formula-fed babies are STUPID”. NOT what was said or even implied by the study, but that doesn’t stop people from taking this info and passing it along in their new, improved version. When someone mentions that breastfeeding encourages “bonding”, someone else is going to HEAR “they think that formula fed babies don’t bond with their mothers”. Again, NOT what was said. “Formula fed babies are at a higher risk for ear infections” does not mean “all formula fed babies will get chronic ear infections” or “breastfed babies NEVER get ear infections”. The problem is NOT that the info is wrong or overstated, but that it is not being understood correctly. Stating that breastfeeding “REDUCES” risks for this or that is a big part of this misconception. It makes it sound like it gives a BETTER THAN NORMAL level of health, and this is simply not the case. This is why you hear so many people saying that they don’t believe the info on breastfeeding because not all breastfed babies are 100% healthy. Well duh… they are not getting “super food”., they’re just getting a normal diet. They don’t get FEWER INFECTIONS THAN NORMAL… they get a normal rate of infections. Formula fed babies, as a group, get MORE INFECTIONS than what is NORMAL for babies. BF’ed babies get SOME, but FF’ed babies get MORE.

    It seems that the only ones doing the “overstating” are the misinformed and the formula companies, NOT the scientific community. Perhaps if the information were more accurately presented, (keeping breastfeeding as the baseline instead of framing it as “reducing” risks) people would be less likely to “overstate” the case for breastfeeding? Maybe when the public finally figures out that breastfeeding is nothing more than NORMAL/AVERAGE nutrition, they will stop inflating it as some kind of super-food? Then again, if the public ever acknowledges that breastmilk is nothing more than standard, that will put formula in a more realistic, if less positive, position.

    Formula is the best alternative when the standard is not available, but like any other man-made alternative, it carries more risks, and parents need to be made aware of these before they make their choice. Once you remove the non-existant “health benefits” of breastfeeding from the picture, (breastfeeding will give your baby a normal level of health) what is left to “inform” parents of besides the risks of formula? Unless you deny that formula has ANY risks, then this is really the crux of the issue, and not trying to make breastfeeding prove how superior it is.

  67. tm says:

    ivywild: “When a study is released that shows that formula use results in a loss of up to 6 IQ points, people often interpret this to mean “formula-fed babies are STUPID”. NOT what was said or even implied by the study, but that doesn’t stop people from taking this info and passing it along in their new, improved version.”

    Like this?

    “No. Breastfeeding gives a normal level of intelligence and school performance according to each individual’s own genetic potential. It does not increase intelligence beyond what it normal for any given human being with their own specific genetics. Formula use may decrease intelligence and school performance below the normal level for some individuals.”

    That “may decrease intelligence” sounds way too much like one of those rapid fire drug disclaimers. “Supramyoplaxomin MAY result in spiderman like powers, other side effects MAY include increased appetite for bugs, and increased sensitivity to insecticides…” So, assuming that a “normal” mother is going to read your blurb, do you think she’s going to risk her kid’s IQ with formula after reading “may decrease intelligence”?

    Despite the fact that as a society we actually don’t like smart people (we call them “elitists”), as parents, we feel like we are in Lake Woebegon: “Every child is above average” So, given that you’re telling them that formula MAY make their kids dumb in a knowledge-based economy, what idiot is going to take the risk when you put it like that?

    Let me guess: A formula fed one!

    It’s odd that the actual risks of formula are rarely mentioned:
    1. Formula should not be used in places where the water quality is bad, as it will carry any toxins or water borne diseases straight into an infant. Zealots would like to tell us that this is how formula companies kill millions of babies (where do they find these numbers?). How is a product that can be considered relatively expensive in the developed world be sold at all in the developing world for a profit at a price the local mothers can afford? It likely wasn’t sold, but distributed by the WFP or an NGO (see WFP specs for formula: http://foodquality.wfp.org/FoodSpecifications/CodexAlimentarius/tabid/112/Default.aspx?PageContentID=480 ) But clean water has been a tough nut to crack in the poorest countries, where just having a reliable supply of water alone is a blessing. And if the mother herself is having trouble getting enough to eat and drink, that will make efforts to support breastfeeding very difficult. And to make things even more difficult, poor nations are often hard hit by HIV/AIDS: http://www.wfp.org/photos/maryknolls-hospice-mother-and-child-0 And that’s if the country isn’t torn apart by armed conflict. But this doesn’t have the neat little answer wrapped in a bow like “formula kills kids dead”.
    2. Formula is subject to the same tampering and manufacturing defects risks as any other pharmaceutical product. Expect to see the China melamine scandal brought up over and over again here, coupled with the FDA’s recent misses. This is certainly one area where we should be vigilant re: FDA’s processes for ensuring the purity of formula.
    3. Formula has a bigger impact on your family’s budget than breastfeeding (on average), and since the price of formula is not adjusted for income, lower income families are hit harder. Of the risks, this is one that does get some mention, but only after you’re told formula will make your kid fat, diabetic, have hardened arteries and a drooling moron. Of course, many moms have to work. Action is needed to provide working mothers with more resources (free pump rentals, supplies, support network) and work towards more flexibility from employers. A few dollars here and there can make or break a budget in the lower income brackets, which can affect a child’s well being in far more serious ways than this ivory tower debate over breast or formula.
    4. Formula has a bigger carbon footprint than breastfeeding (a wild, unscientific guess, but likely right). Another way for breastfeeders to rub it in the faces of formula addicts. Make sure you do it from your hybrid car.

  68. Bonnie says:

    @ivywild:

    “Formula fed babies are at a higher risk for ear infections” does not mean “all formula fed babies will get chronic ear infections” or “breastfed babies NEVER get ear infections”

    That’s exactly one of the most grating things about this whole debate. The mothers all over internet parenting message boards who say things like “My child has never had an ear infection, and I know it’s because she’s breastfed.” Or, “my nephew has chronic ear infections, and I feel so bad for him that his mother formula feeds him.” It seems that a lot of people out there are choosing to breastfeed out of some idea that it, being superior, breastmilk makes their children superior, and by extension makes them superior mothers. For those people, breastfeeding has been oversold!

  69. edgar says:

    “Some do care, mostly the ones who want to say that mothering is about those things. They can indeed be quite judgmental. If you haven’t run into them, you’re fortunate.”

    Oh yes, I have run into it, and I personally resent the judgment (I supplemented, BTW). But what I am saying, is that that Amy seems to be throwing the same judgment their way. If we want to stop the mommy wars, we need to stop them. If they want to think the unmedicated homebirth is the way to go, more power to them. If they want to think breastfeeding is the be all and end all, so be it.
    Judging the judgmental(and lumping people together) right back is not helpful solution. Saying to someone who you feel is being judgmental “you are being a bit sanctimonious here, and I don’t appreciate it. II am doing the best that I can, same as you” is.

    And back to the original post “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.”

    1. A bit if hyberpole, since Amy has not practiced in some time.
    2. Of course you would counsel on the advantages of breastfeeding. It is the healthiest thing to do. That it would take some finesse because it is such a loaded issue goes without saying.
    3. As one poster mentioned several times, Amy makes no mention of the short term benefits, which are more dramatic that the long term.
    4. Offer the mother support with whatever decision she makes.

  70. Zoe237 says:

    That’s exactly one of the most grating things about this whole debate. The mothers all over internet parenting message boards who say things like “My child has never had an ear infection, and I know it’s because she’s breastfed.” Or, “my nephew has chronic ear infections, and I feel so bad for him that his mother formula feeds him.”

    You see that the other way too, and we’ve actually seen it in this thread a few times. Formula is fine because my baby was on it and never sick. Or whatever.

    Again, this is because people are confusing causation and correlation and relying on personal anecdotes.

  71. ivywild says:

    “That “may decrease intelligence” sounds way too much like one of those rapid fire drug disclaimers. “Supramyoplaxomin MAY result in spiderman like powers, other side effects MAY include increased appetite for bugs, and increased sensitivity to insecticides…” ”

    Then perhaps you may want to actually read the study. The effects of breastmilk on intelligence are at least partially dependent on a specific gene (FADS2) that effects brain development. Approx. 90% of all humans have this gene, which is only triggered by specific compounds found only in human breastmilk. If this gene is not triggered, brain development is hindered. For the 10% who do not possess this gene, there is no difference in brain development between formula and breastfed infants. Unfortunately, until gene mapping becomes more accessible, you cannot tell which infant will be effected by this and which will not. So choosing not to breastfeed MAY result in lower IQ scores IF your child is one of the 90% who have the right gene. You’ve got a 1 in 10 chance that it won’t matter… and a 9 in 10 chance it will. It helps if you actually do a little reading to know how these things work before dismissing them out of hand.

    ” So, assuming that a “normal” mother is going to read your blurb, do you think she’s going to risk her kid’s IQ with formula after reading “may decrease intelligence”?

    Despite the fact that as a society we actually don’t like smart people (we call them “elitists”), as parents, we feel like we are in Lake Woebegon: “Every child is above average” So, given that you’re telling them that formula MAY make their kids dumb in a knowledge-based economy, what idiot is going to take the risk when you put it like that?

    Let me guess: A formula fed one!

    Of the risks, this is one that does get some mention, but only after you’re told formula will make your kid fat, diabetic, have hardened arteries and a drooling moron.”

    Thank you for so eloquently illustrating my point. Neither the original study nor my “blurb” said anything about making children “dumb”, much less a “drooling moron”. A slight decrease in intelligence is not the same as causing a serious mental handicap. However, you do have a point. Most parents will not knowingly give their child a substance that has been show to decrease intelligence to ANY degree. As you said, this is a highly competitive society, so every little bit helps, and most parents are not willing to risk seeing just how big of a difference that might turn out to be.

    So why NOT inform parents that formula has the potential to reduce their child’s IQ by even a SLIGHT amount? That if weight is an issue in their family, formula use may contribute to it? That if diabetes runs in their family, this may increase the risk for their child? The answer? Because we don’t want to make them FEEL BAD. Oddly enough, we do not take the same approach with other supplements or medications that are medically necessary for children. A doctor will not tell a parent that the medication they have to give their child to treat their illness is “risk free” and has “no side effects” simply to spare their feelings about having to give their child a substance that puts them at risk. I know, I’ve had children with medical issues, and the risks of some of the medications and procedures were downright scary… but I never had a doctor try to tell me that they did not exist just to save me from worrying or feeling bad about what needed to be done. If you have no choice, then the risks are necessary and unavoidable, and it is important to understand what they are and how to deal with them. If you DO have a choice, then it is important to understand the risks so you can make an INFORMED choice. But lying to parents in an effort to spare their feelings? How is that respectful or even medically responsible?

    Formula has risks, that is an indisputable fact… it should be up to each individual parent to find out what they are and whether they personally feel comfortable with them. Denying that the risks even exist benefits no one. (except the formula manufacturers)

  72. edgar says:

    I think putting it it simpler terms may be better than details. Some mothers will be interested in the how’s and why’s. Most won’t.

    It is a fine line, but since we do know that all other things being equal, breast IS best, saying somethings like “formula does not have the all components that breastmilk does to to support OPTIMAL brain development.”

  73. ivywild:

    “So why NOT inform parents that formula has the potential to reduce their child’s IQ by even a SLIGHT amount?”

    Because that’s not what the scientific evidence shows.

    Publication of a study does NOT mean that it is true. It ONLY means that it is worthy of being evaluated by other doctors and scientists. One of the points of my original post is that breastfeeding proponents oversell the benefits and oversell the risks of formula feeding (exactly as you are doing right now) because they don’t understand the limitations of the studies.

    Children who are breastfed generally come from families of higher income and higher educational attainment. It is hardly surprising that such children might have higher IQs than their non-breastfed peers. The authors may say that they have controlled for these variable, but it is not always clear that they have. And that does not even address the fact that much of this research has never been reliably reproduced.

    One of the ironies of the breastfeeding debate is that the same people who would be appalled to have their own children characterized by IQ — who strongly believe that there are “different styles” of learning and that the IQ test isn’t necessarily accurate in accounting for these different styles — are only too happy to proclaim a few IQ points as “proof” that breastfeeding improves intelligence.

  74. “It is a fine line, but since we do know that all other things being equal, breast IS best, saying somethings like”

    Why do you feel compelled to say anything?

    We also know that the all other things being equal, never putting your child into a car is safer than driving them. Does that mean we should say that women who walk with their infant to the grocery store are doing something “better” than women who drive with their infant in the car?

  75. edgar says:

    I thought we were speaking of patient education, Amy.

  76. “I thought we were speaking of patient education, Amy.”

    We are. I’m asking why you think it is so important to educate patients on the “risks” of formula feeding, while you don’t seem to care about educating patients about the risks of driving to the store instead of walking, which are potentially far more devastating.

  77. Bonnie says:

    “But lying to parents in an effort to spare their feelings? How is that respectful or even medically responsible? ”

    I think that is minimizing the issue. First, I think there’s no one out there who hasn’t heard that breast milk is better than formula. So often, mothers who use formula are already feeling guilty. The question is, are the risks of formula as great as the extreme pro-breastfeeding side would make it seem? If not, if the difference between formula and breastfeeding is less than what we have been led to believe, then mothers deserve to hear that truth. Hopefully that does spare their feelings some! They shouldn’t be feeling mountains of guilt over something that turns out to be not as significant as they thought.

    Second, any other medical conversation you are having about a child, where the doctor is presenting the risks, tends to be centered much more around the child alone. Whether you feed your child certain foods, or strap them into a carseat, or get them outside to exercise sufficiently, does not involve a parent’s body and well being nearly to the extent that breastfeeding does. The mother is half of the breastfeeding pair — her concerns and well being matter too. There are La Leche League types out there who will never abandon nursing no matter what the cost to them in pain, no matter what the obstacle. For the rest of us, there is a line beyond which we can not or no longer wish to continue. When deciding whether or not to throw in the towel, a mother needs to have *accurate* information on the risks she is taking, not information so biased as to create unnecessary guilt. With *accurate* information, she can balance whether the benefits of quitting (to both her and the baby) or the benefits of continuing weigh more heavily.

  78. edgar says:

    Good God Amy,
    why are you being so obtuse? Are you advocating not doing any counseling around infant feeding choices? Car seat use is the gold standard for child safety, as is breastfeeding. Would it be better if the kid never left the house? Maybe, but it isn’t reality.
    The goal is to keep the kid as safe and healthy as possible, while still keeping with reality.

    You have to feed the kid. There are one of two ways of doing that. That is reality. Between the two ways, Breastfeeding is the gold standard. It should be presented that way, as presenting risk/benefit is a must for good patient education. At the same time the mother should feel that which ever method she decides on is supported and honored. As I said before, that takes some finesse.

  79. edgar says:

    Bonnie:
    in keeping with my previous post I find this to be sanctimonious and judgmental. Please stop.
    There are La Leche League types out there who will never abandon nursing no matter what the cost to them in pain, no matter what the obstacle.

    “First, I think there’s no one out there who hasn’t heard that breast milk is better than formula.”

    There are many many people who do not believe it to be true. A provider would be remiss in not providing this education. in the same way a provider would be not to counsel a healthier diet and exercise.

    Not addressing something because ‘everyone already knows’ is never a good public health strategy.

  80. Bonnie says:

    edgar:

    I don’t see how it is “sanctimonious and judgmental.” I didn’t say they are bad for being that way. All I’m saying is, not everyone can live up to that standard of breastfeeding no matter what, and if they can’t they shouldn’t be made to feel worse than the evidence warrants.

    Nor am I saying it shouldn’t be addressed. I am saying that it should be addressed accurately, and that women’s feelings *should* be taken into consideration. (I felt that the other poster was minimizing the importance of that.)

    I don’t see what I said that warranted being told “please stop.” I’m very interested in this debate and thought I would participate. You can feel free to skip over my posts if you don’t like them.

  81. “Would it be better if the kid never left the house? Maybe, but it isn’t reality.?”

    When you say “it isn’t reality,” you mean it’s too inconvenient. Yet you don’t condemn mothers (including yourself) for putting your convenience ahead of your baby’s safety (driving instead of walking). Why do you feel the need to “educate” women about the theoretical, trivial and possibly non-existent risk of loss of IQ points of not breastfeeding? It certainly cannot be justified by the magnitude of the (theoretical) risk.

    Ultimately, it is your personal value judgment. You value the convenience of driving over the risk to your baby’s safety. You don’t value the convenience of not breastfeeding (in order to work, or simply because a woman doesn’t like breastfeeding) over the theoretical “risks” of bottlefeeding. The fact that you value one over the other does not make your choice the correct one, and does not mean that other women need to be “educated” about certain trivial (and possibly non-existent) risks and not others.

  82. edgar says:

    But Amy, the difference is the data IS there. It is negligent not to tell them about the data that is currently available. And you should address infant safety seats in your practice. Again, these two things are the gold standard. We can take these arguments ad infinitum, it is safest to leave the kid in the house for the next 18 years, but that is neither productive nor realistic.

    Why do you put risks in quotations? We know that breastfeeding IS better. There consequently there must be something that is worse, riskier. That is the duality of science.

    But it is good to know that you skip over patient education in your ‘practice.’

  83. edgar says:

    Bonnie,
    I was referring to this “There are La Leche League types…” Again with the lumping and categorizing of people trying to do the best they can.

    Women should not be made to feel bad no matter what.

  84. Dawn says:

    @tm: just one minor correction. If a woman is very low income, she probably will be on WIC and food stamps. In that case, formula is available at very little or no cost to her until the child is 1 year old. So, in a sense, for some women, formula IS “adjusted for income”. And many of those women would rather bottle feed to someone else can take care of the baby rather than be tied down with breastfeeding. (I worked several years in inner city clinics. Still shake my head in bafflement over some of the mothers I saw)

  85. Dawn says:

    Darn fat fingers…the sentance should read:…would rather bottle feed SO someone else can take care of the baby….

  86. Zoe237 says:

    @Amy Tuteur MD:

    “The fact that you value one over the other does not make your choice the correct one, and does not mean that other women need to be “educated” about certain trivial (and possibly non-existent) risks and not others.”

    Nice leap. I agree about intelligence- possibly trivial and non existent (although formula makers have added dha and rha). Certainly not true about chronic ear infections, respiratory infections, diarrhea, bacterial meningitis, sepsis, and a host of others risks associated with not breastfeeding. And apparently only single and lesbian mothers are worthy of your judgement and derision.

    Edgar is correct that the better comparison would be between infant car seats and seatbelts, if you are stuck on making such a comparison. Or rear facing vs. forward facing.

  87. Zoe237 says:

    “Whether you feed your child certain foods, or strap them into a carseat, or get them outside to exercise sufficiently, does not involve a parent’s body and well being nearly to the extent that breastfeeding does. ”

    I agree with this. It is hard in the beginning, and I don’t like the current “mother as martyrs” attitude that I see so much. I hate seeing stories like one above where moms nearly killed themselves trying to bf out of guilt. For me, bf was easy and enjoyable and I think that women (who don’t have a negative association) could at least try it and be educated to how to avoid possible problems with milk supply etc. But again, I don’t think we ought to use fear, guilt, or any other manipulation as a tactic. Some women don’t want to and that’s fine too. There are way too many women who start off trying and can’t because of bad advice.

    RE: WIC. The good news is that they now give away pumps and extra food to those who bf. Now that we have really good pumps, bf doesn’t necessarily tie you down to the baby, dads can give bottles, you can even pump exclusively and never actually nurse. I hated the pump personally, but I’m glad it’s available as another option.

  88. ivywild says:

    Ivywild:
    ““So why NOT inform parents that formula has the potential to reduce their child’s IQ by even a SLIGHT amount?”

    Amy:
    “Because that’s not what the scientific evidence shows.

    Publication of a study does NOT mean that it is true. It ONLY means that it is worthy of being evaluated by other doctors and scientists. One of the points of my original post is that breastfeeding proponents oversell the benefits and oversell the risks of formula feeding (exactly as you are doing right now) because they don’t understand the limitations of the studies. ”

    So you are willing to advise parents on the health of their babies based on the off chance that a published study might not be completely accurate? And how, exactly, is stating that formula use may SLIGHTLY decrease brain development “overselling the risks of formula feeding”??? Apparently, in your view, ANY mention of risk is “overstating the risks of formula”. And it’s pretty hard to “oversell” the benefits of breastfeeding when THERE AREN’T ANY. Biologically normal diets do not have “benefits”, they give normal, baseline levels of health.

    “One of the ironies of the breastfeeding debate is that the same people who would be appalled to have their own children characterized by IQ — who strongly believe that there are “different styles” of learning and that the IQ test isn’t necessarily accurate in accounting for these different styles — are only too happy to proclaim a few IQ points as “proof” that breastfeeding improves intelligence.”

    But that is the whole point, breastfeeding does NOT improve intelligence! It gives a NORMAL level of intelligence based on a person’s own individual genetic potential. The thing that concerns me is not trying to INCREASE my child’s intelligence to some superior level, I just want them to be able to develop to whatever NORMAL level of intelligence they have been naturally gifted with, in whatever area that may be. Anything that hinders normal brain growth does not strike me as something I want for my child.

    Even the formula companies are claiming that their new ARA/DHA formulas IMPROVE vision/IQ over their old product, making it “even closer to breastmilk”…. that must mean that their original product REDUCED these factors. (and there is no evidence that the substances they are using even have the effects they are promoting it for, talk about unsubstantiated claims!!!) Perhaps you are privy to some information that the formula companies are not? Or perhaps the formula companies themselves are actively trying to trick parents into buying a more expensive product that doesn’t actually do what it says? If there is no real difference in the first place, why pay extra for snake oil?

  89. edgar:

    “But Amy, the difference is the data IS there.”

    That’s not a difference; that’s a similarity. If anything, the data about the risks of putting your infant into a car are far more compelling than the data about the “risks” of bottlefeeding. So if that is your trigger for “educating” women, they should ertainly be counseled about the risks of putting an infant in a car and not necessarily counseled about the “risks” of bottlefeeding.

    If you want to make the case that women should be counseled about the “risks” of bottlefeeding but not counseled about the risks of putting an infant in a car, you have to show how those situations differ in a meaningful way. You haven’t done that yet.

  90. Zoe237:

    “I agree about intelligence- possibly trivial and non existent (although formula makers have added dha and rha). Certainly not true about chronic ear infections, respiratory infections, diarrhea, bacterial meningitis, sepsis, and a host of others risks associated with not breastfeeding.”

    But the risk of infant death in an auto accident is HIGHER than the purported additional risk of those infections, some of which are minor in any case.

    If you want to counsel parents about risks, you’d counsel them not to put them in a car long before you’d counsel them not to bottlefeed.

  91. ivywild:

    “But that is the whole point, breastfeeding does NOT improve intelligence!”

    No, you seem to have missed the point. The point is that NOTHING about an association between breastfeeding and intelligence has been proven.

  92. rachelleavitt says:

    I’m just wondering if anyone has any article links to look at. Or even just references so I can look them up myself.

    Personally the decision for me was easy. Formula is expensive and I found it much easier to just nurse then have to prepare bottles, plus I did enjoy the time I was forced to spend just sitting and reading or being with my baby. The fact that science shows an association is wonderful, but I would never try to make another women feel inadequate because she choose differently.

    It is important to make sure a woman is informed in her choices, though. Thus, I for one would like to make sure I understand the research first hand. If there is a slight association, I would tell the woman that. If it appeared that there is a definite direct cause, then I would tell here that. Either way, it’s the woman’s choice, and we don’t really know what is going on in their lives that are directing that choice.

  93. tm says:

    @Dawn: Ah, I stand corrected. But WIC covering the costs of formula for the 1st year would tilt the balance in favor of formula feeding for low income mothers, would it not? It would be nice for LLL and other breastfeeding advocates to press for vouchers or vendor programs for free/reduced pump rentals, since this is the primary demographic in the US that breastfeeds the least.

    “And many of those women would rather bottle feed to someone else can take care of the baby rather than be tied down with breastfeeding. (I worked several years in inner city clinics. Still shake my head in bafflement over some of the mothers I saw)”

    Was that due to the need to work for most of these mothers or they didn’t work and simply wanted to hand their children over to someone so they could get some “me” time (which is a phenomenon common across all income levels)?

    @ivywild: “Then perhaps you may want to actually read the study. The effects of breastmilk on intelligence are at least partially dependent on a specific gene (FADS2) that effects brain development.”

    One study does not make scientific consensus. Science is slow in this regard. And while we have made great strides in understanding how the brain works, it still remains the most complex and least understood components of the human body.

    “Because we don’t want to make them FEEL BAD.”

    No, because we know it doesn’t make a measurable difference above statistical noise in studies conducted up to this point.

    Unless a mother has some dinosaur OB from the era when all children were formula fed, the guidelines that any sensible doctor and hospital would follow would be to prefer breastmilk over formula. The peds groups are pretty clear that infants should be breastfed exclusively for the first months of life. I keep bringing up “better living through chemistry” because that era is long past in the United States. It is gone the way of black and white TVs. The La Leche League is not some fringe group fighting the mainstream: They have become the mainstream.

    “If you have no choice, then the risks are necessary and unavoidable, and it is important to understand what they are and how to deal with them.”

    Well, one certain result of bottle feeding for women is having judgmental women approach bottle feeding mothers uninvited to lecture them on why breast milk is better.

    “If you DO have a choice, then it is important to understand the risks so you can make an INFORMED choice.”

    The risks you cite are not scientifically proven. Frustrating? Sure. But we’re not running a particle accelerator here, we’re dealing with thousands of unique individuals in all sorts of situations. It’s hard stuff to separate out the particular affects, and so far, the linkage is not there statistically speaking.

    “But lying to parents in an effort to spare their feelings? How is that respectful or even medically responsible?”

    To reiterate, the “medically responsible” thing (yay, hippocratic oath attack again) that is set in professional guidelines is clear: Breastfeed exclusively for the first months of life, preferably continuing through at least the first birthday. In fact, the medical establishment cites many of the same studies and statistics that LLL does. Do you have solid evidence that a majority of doctors are “lying”? That’s a very strong accusation there.

    “Even the formula companies are claiming that their new ARA/DHA formulas IMPROVE vision/IQ over their old product, making it “even closer to breastmilk”…. that must mean that their original product REDUCED these factors. (and there is no evidence that the substances they are using even have the effects they are promoting it for, talk about unsubstantiated claims!!!) Perhaps you are privy to some information that the formula companies are not? Or perhaps the formula companies themselves are actively trying to trick parents into buying a more expensive product that doesn’t actually do what it says? If there is no real difference in the first place, why pay extra for snake oil?”

    Ironically, DHA/ARA are found most commonly in fish oils. But this is an honest attempt by formula makers to make the formulas closer to breastmilk (which also contain these substances). But: current studies have shown that any IQ boost provided by DHA/ARA is temporary and does not affect long term educational outcomes. Who knows how many fish farms have been setup just to add this to baby formula. Of course, pregnant or nursing women are generally advised not to consume fish because of the mercury content.

    Seriously, three exclamation points, random caps? What is the point of this zealotry? Why can’t these claims be questioned scientifically? Why is that so threatening? Why, when breastfeeding is clearly the default preference in medical guidelines is there this fear that we’ll suddenly be back in the age of formula feeding? Is there a conspiracy I’m not aware of here? Will I need a tinfoil hat and corkboard to keep track of the connections?

  94. Bonnie says:

    Here’s another thing I was wondering last night. I wonder how many, if any, of the studies that have been done took into consideration length of breastfeeding? Like, when they look at “breastfed” infants, does that mean babies who never had a drop of formula? Or those who were breastfed for 6 months? 3? Were some of them supplemented while being breastfed? Did they start rice cereal at 2 months? Or no solids until 12 months?

    How much breastfeeding is necessary to reach the benefits? (Yes, turn that around to “how much formula does it take to increase risks?” if you want.) I think a lot of people assume the more breastmilk the better. But is that true? Does the IQ benefit, if it exists, all come within the first 6 weeks? Or do you need a solid year of breastmilk to achieve it? Something in between? How much formula does it take to increase your risk of diabetes? I think that’s completely unanswered by the studies.

    My first had some formula, maybe 1-2 bottles a day, for 6 months, and then was weaned completely from the breast at 7 months. Did he get enough breastmilk to protect his IQ? Enough formula to increase his risk of obesity?

    I think it would be very difficult for a study to account for things like that, unless it excluded all infants who were not exclusively breastfed or exclusively formula fed. I would be curious to see if people smarter than me have thought of ways to account for those things.

  95. Dawn says:

    @Zoe237: Nice to learn that about WIC. At the time I worked the clinics, they didn’t support breastfeeding in that way (except for premature births…and then you had to jump through multiple hoops to get one). Glad to learn that it’s possible to get a pump/support with WIC now.

    @tm: For the majority of my bottle feeding mothers, it was for the “me” time. Few if any of them worked, either due to young age or lack of interest. Many of the mothers were young, teens and early 20s, and it was often a struggle even in the hospital to get them involved in infant care. The grandmother/senior adult female in the household would generally be the person doing all the child care. We would encourage all of them to try breastfeeding. Occasionally we would get one to try it, and out of that bunch, a few would continue on. But they were a rare breed, and generally from a household that was more stable, with at least 1 employed person in it, and grandma/great-grandma/auntie had also breastfed and wasn’t having any of this bottle feeding nonsense!

  96. Jean Mercer says:

    I notice several people have used the term “bonding” here. I would be very much interested in knowing how those who used the word would define it. In particular, when you use this term, are you referring to the mother’s feelings about the baby, or the baby’s about the mother, or both? Also, when you say “bonding”, are you thinking of a phenomenon that is in some way time-limited– that can only occur within a certain period relative to birth? Finally, what do you think of as the consequences of the occurrence or failure of “bonding” ?

  97. Jean Mercer says:

    People interested in breastfeeding might like to read some comments I’ve made on my Psychology Today blog:

    http://www.psychologytoday.com/blog/child-myths/200906/breastfeeding-speculating-wildly

    http://www.psychologytoday.com/blog/child-myths/200906/more-breastfeeding-more-speculation

    http://www.psychologytoday.com/blog/child-myths/200907/breastfeeding-true-or-false-test-yourself

    http://www.psychologytoday.com/child-myths/200907/breastfeeding-part-2-test-yourself

    I was surprised to see that very few people read these, compared to other topics I’ve written about. I consider breastfeeding one of the most fascinating topics in existence, with its combination of biological, psychological, innate, and learned aspects. But my experience in teaching developmental psychology is that most students think it’s disgusting…. go figure!

  98. edgar says:

    “I thought we were speaking of patient education, Amy.”

    We are. I’m asking why you think it is so important to educate patients on the “risks” of formula feeding, while you don’t seem to care about educating patients about the risks of driving to the store instead of walking, which are potentially far more devastating.

    Well, if that is the way you want to approach patient education, from the ‘riskiest’ to the ‘least risky’ of all factors more power to you. But most providers stick to general topics and work around this…Major categories…..’feeding’ ‘bathing’ ,’first aid’ etc.

    I suggest you screen all women for the presence of a man that is not the babies father, and warn them against infanticide.

  99. ChrisvV says:

    Are the benefits of breastfeeding oversold?

    No.

    1) It’s way cheap. Breastmilk is free. Formula, bottles, nipples aren’t.

    2) It’s way easy and it’s time-saving. With breastfeeding, you don’t have to stop what you’re doing and go to the kitchen to assemble paraphernalia. You don’t have to sterilize paraphernalia. You don’t have to heat anything up. You don’t have to pack up paraphernalia and lug it around with you.

    3) It’s way natural. We’re animals. This is what mother animals do to feed their young. Assuming that nursing mothers are eating properly, and not taking anything that can affect their breastmilk, then nutritionally the baby will thrive.

    If, for some reason, you are unable to breastfeed, then give your baby formula.

    End of story.

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