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Separating Fact From Fiction in the Not-So-Normal Newborn Nursery: Pacifiers and Nipple Confusion

My first “real world” employment after completing residency was as a full-time newborn hospitalist in Houston. After spending 3 years in Space City, often rounding on as many as 30 newborn infants in the Level 1 and Level 2 units each day at the county hospital, I feel as if I’ve probably about seen it all when it comes to the nursery. I then left the babies behind while working as a pediatric hospitalist in Baton Rouge for four years, but now I’m back in the newborn business up here in Boston. While there have certainly been a few changes since 2009, many things remain exactly the same.

I help take care of a very vulnerable population in my current position: parents. Parents, in particular the young and first time variety, often approach parenting with a blank slate. Sure there is frequently a grandparent or four there for assistance, but the healthcare professionals working in the nursery are looked to for vital knowledge about how to care for the new arrival. Even some of the more experienced parents will still have questions, and most respect and follow the advice given during those first few days while at the hospital. These questions most commonly focus on topics such as feeding, vaccinations and vitamin supplementation, but I am regularly asked about a variety of routine parenting skills such as swaddling, and even baby “gear” like Angel monitors.

Parents love their children and want what is best for them, and they frequently express fear and anxiety over some of these topics. Love and fear are two powerful factors in the acceptance of pseudoscience and bad advice, which is why parents are set up to be fooled. Over the next few posts, I plan to cover some examples of newborn issues known to cause excessive parental anxiety and that sometimes lead to poor decisions, in large part because of bad information received from people who should know better.

First up is a concept that is well-known in the nursery, and strikes fear in the hearts of lactation consultants all over the world. I’m talking about nipple confusion. This is a concept that may seem silly to those unfamiliar with the world of parenting, but it is something that newborn doctors deal with daily and there is a great deal of controversy. Not “vaccines and autism” controversy unfortunately, but if after reading this post you find yourself feeling let down because I didn’t start with something sexier, take solace in the fact that winter is coming.

What is nipple confusion?

If you don’t know what nipple confusion is, don’t feel bad. Most people probably don’t. And many who think they understand the concept have fallen for what I believe is hype based on scant evidence. Beliefs regarding nipple confusion transfer from generation to generation propelled by misinformation and cultural momentum. And based on questionable recommendations from organizations like the WHO and the AAP, many healthcare professionals encourage these beliefs, which tend to be very firmly held. On many occasions I have witnessed intense arguments over the existence of nipple confusion and the degree of respect it deserves.

According to proponents, nipple confusion occurs when a breastfeeding newborn is given a bottle or pacifier. They believe that because the mechanics of sucking on bottle nipples and pacifiers are so different, it confuses the infant and causes them to pick up bad feeding habits. When they attempt to put these newly acquired skills to use on their mother’s breast it results in frustration, maternal pain, and premature cessation of breastfeeding.

La Leche League International, a group which (to put it nicely) strongly supports breastfeeding, has the following to say about nipple confusion:

Pacifier use in the early weeks may affect milk supply and lead to slow weight gain. It is important that nursing sessions are not delayed and that all sucking is done at the breast in order to establish a good milk supply.

Using a pacifier may also result in latch-on and sucking problems for the baby. This is because the shape of the pacifier is different from your soft breast and the baby may get confused as to how to suck. This may result in sore nipples for mom. In addition to sore nipples, introducing a “dummy” may lead to mastitis because baby is not sucking as much at the breast. Also, you may find your fertility returns more quickly if you use a pacifier as your hormonal balance is affected by less sucking at the breast.

There may also be an increased risk of ear infections for a baby if regularly sucking on a pacifier. Thrush can also be a problem, as it thrives on moist surfaces at room temperature. Not only can it cause thrush infection, but unless pacifiers are boiled each day for five minutes and replaced each week during an outbreak of thrush, the pacifier can cause reinfection, too.

Regular pacifier use has also been shown to affect the growth of teeth and the shape of the mouth, increasing the need for braces later on. Also, it can increase the levels of bacteria in the mouth that cause dental caries. Regular pacifier use is also associated with early weaning.

There is almost too much misinformation in that quote to deal with in one post, but I will do my best. Moving on.

The Sears family, a group of pediatricians who (to put it nicely) are easily confused by scientific evidence and prone to things like alternative vaccine schedules, bad advice about SIDS prevention and poorly produced daytime talk shows, agrees with the LLLI:

There are some basic mechanical differences between how a baby gets milk from a bottle and how a baby gets milk out of the breast. Giving bottles or pacifiers to young, breastfeeding babies often leads to nipple confusion. Baby tries to use the bottle-feeding technique on the breast and has difficulty latching-on and sucking. Baby gets very frustrated, and so does mother. Nipple confusion can even lead to baby refusing the breast.

Though not a new concern, the real fuss over nipple confusion started when the World Health Organization’s Division of Child Health and Development and UNICEF issued a joint statement on breastfeeding in 1989. The statement included the now famous (infamous perhaps depending on whether or not you work for Ross or Mead-Johnson) Ten Steps to Successful Breastfeeding. The following year WHO/UNICEF policymakers released the Innocenti Declaration, which called upon the governments of the world to adopt the Ten Steps in all hospitals providing maternity services. We now live in a society where the hospital’s pacifiers are sometimes locked in cabinets that require a special code, fingerprint analysis and retinal scan to open. Okay, maybe not the retinal scan.

What are the Ten Steps to Successful Breastfeeding?

The Steps are pretty straightforward and reasonable with the exception of number 9, which is the source of the nipple confusion controversy.

Every facility providing maternity services and care for newborn infants should:

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within a half-hour of birth.
5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming-in — allow mothers and infants to remain together — 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

The American Academy of Pediatrics, in its 1997 policy statement on breastfeeding, did not mention the Ten Steps but made recommendations equivalent to number 6 and 9. In their reaffirmation of the policy in 2005, again there was no specific mention of the Steps. There was, thankfully, a somewhat more nuanced discussion of the use of pacifiers:

Pacifier use is best avoided during the initiation of breastfeeding and used only after breastfeeding is well established. In some infants early pacifier use may interfere with establishment of good breastfeeding practices, whereas in others it may indicate the presence of a breastfeeding problem that requires intervention. This recommendation does not contraindicate pacifier use for non-nutritive sucking and oral training of premature infants and other special care infants.

This change allowed some interpretation. A pediatric resident at the time, I felt that I could counsel families that pacifier use was okay if breastfeeding was going very well, even in the nursery. There was also a lot more data available at the time that questioned the concept of nipple confusion as an entity that should even be on our radar. Also that year, emerging evidence on the benefit of pacifier use for reduction of the risk of SIDS led to the AAP recommendation that they be used in all infants less than one year of age during sleep initiation.

The AAP officially endorsed the WHO/UNICEF statement and their Ten Steps in 2009, and reaffirmed their endorsement in 2011. Of note, the AAP does not fully accept the ninth step, as is made clear in the most current policy statement on breastfeeding:

The AAP does not support a categorical ban on pacifiers because of their role in SIDS risk reduction and their analgesic benefit during painful procedures when breastfeeding cannot provide the analgesia. Pacifier use in the hospital in the neonatal period should be limited to specific medical indications such as pain reduction and calming in a drug-exposed infant, for example. Mothers of healthy term breastfed infants should be instructed to delay pacifier use until breastfeeding is well-established, usually about 3 to 4 weeks after birth.

All of this has led to the current predicament when caring for newborn infants being exclusively breastfed. How do pediatricians and family doctors appropriately discuss the use of pacifiers with their parents? What does “well-established” even mean exactly? Can we support breastfeeding while also reducing the risk of SIDS? More to the point of this post, is the ninth step or even the more nuanced AAP stance even reasonable?

But before I delve into whether or not pacifiers actually impact breastfeeding success, first a quick discussion about why this discussion even matters. Breastfeeding is, hands down, one of the most beneficial actions a mother can take in raising a healthy child. If proponents of Step 9 are correct, and pacifier use can impair the ability of a young infant to establish breastfeeding, then this issue should be taken very seriously.

Why breastfeeding matters?

Infants fed human milk, and the mothers that feed them benefit from a wide variety of well-established health outcomes, even in developed countries. In many areas, there is benefit even with partial breastfeeding. Here are a few of the improved outcomes seen in breastfed infants and their mothers:

1. Significant reductions in the risk of lower respiratory infections and hospitalizations for lower respiratory infections during the first year of life.

2. Significant reduction in the incidence of gastrointestinal tract infections while being breastfed and up to 2 months after breastfeeding is stopped.

3. Significant reduction in the risk of necrotizing enterocolitis (trust me, it’s as bad as it sounds) in premature infants. One surgery or death prevented for every 8 premies being fed exclusively with human milk. This is a big reason why human milk banks are being established in many areas.

4. Significant reduction in the risk of SIDS (#1 cause of death from 1 to 12 months of life in the US) and infant mortality around the world.

5. Reduced risk of asthma, eczema, celiac disease (the real kind) and inflammatory bowel disease.

6. Breastfed infants are less likely to become obese children and adults.

7. Reduction in the risk of type 1 diabetes, childhood leukemia and lymphoma.

8. Improved neurodevelopmental outcomes in premature infants (best supported) and likely even term infants (probably not significant enough to matter in most healthy kids) even when accounting for social variables.

9. Mothers who breastfeed have less postpartum bleeding, less risk of postpartum depression, are less likely to abuse their children even after accounting for social variables and have lower risk of breast and ovarian cancer.

10. Lactational amenorrhea helps to prevent subsequent pregnancy while still breastfeeding.

And I didn’t even get into the economic benefits. One possible benefit that is probably more fiction than reality, however, is improved postpartum weight loss. If there even is a difference, it probably doesn’t manifest until breastfeeding has lasted longer than 9 months and the effect is probably minimal.

While the benefits of breastfeeding are huge, please to not misinterpret my support of the practice. I love and encourage breastfeeding but I do not endorse tactics to coerce uninterested mothers into doing it. There are few medical contraindications to breastfeeding, but many personal ones, and I support those mothers just as much. Despite the long list above, formula fed infants do very well. The one possible exception for me is when it comes to extremely premature infants. I consider breast milk as vital to their health as I would an antibiotic in a patient with meningitis. Mothers should be strongly encouraged to provide breast milk to the best of their ability, and they should be made aware of the potentially lifesaving benefits in this population of newborns. And I strongly support the development of more human milk banks so that human milk is available for premature infants whose mothers are unable or unwilling to provide it.

Now back to pacifiers!

Is nipple confusion real?

From a plausibility standpoint, I don’t think that nipple confusion makes a whole lot of sense. Though I am often the first to point out that newborn babies are helpless (thanks evolution), and would not survive long without significant intervention from caregivers, I must admit that they are actually quite good at what they can do. They can’t see much of anything, control their movements, or communicate their specific needs very well but healthy babies know how to suck. It is, in fact, a reflex action that they do not control. Sucking is a natural means of soothing a crying baby.

Put anything in an infant’s mouth and it will suck on it. I use this to my advantage during every newborn exam, placing my gloved pinky finger in the oral cavity, not just to assess this normal reflex or to check for a cleft palate but also to quiet them down so that I might check their little hummingbird hearts for murmurs. Newborns suck on their hands, their feet, blanket edges, and essentially whatever they can get into their mouths. It is actually quite common to find self-inflicted suction blisters on various body parts that were acquired prenatally. Somehow this does not alter the mechanics of their suck and lead to early cessation of breastfeeding, but even intermittent use of a pacifier is felt to do so.

In addition to the argument that pacifier use alters feeding mechanics, the claim is often made that choosing the pacifier instead of putting the baby to the breast will cause a delay in milk let down and increase the likelihood of breastfeeding cessation. There is some truth to this. It is a definite issue when it comes to bottle feeding, again not because of altered mechanics but because formula feeding leads to satiety.

The more that a baby feeds from the breast, the faster the milk will come in, and a baby full of formula will feed less from the breast. A pacifier will not appreciably space out breastfeeding because hungry babies will rarely be soothed by one. If anything, lack of a pacifier would seem to be more likely to encourage turning to formula in the nursery because many babies spend much of their 2nd day of life crying. The 2nd day is often the hardest because it is the time between the sleepy 1st day of life and mom’s milk coming in. A pacifier can help between feeding attempts, but formula works much better. But to be clear, a pacifier should not be used as a substitute for feeding a hungry baby.

In my opinion, any strict ban of pacifiers is unreasonable and even cruel considering how effective pacifiers are, particularly when combined with sucrose, in alleviating pain during procedures such as heel sticks, venipuncture and circumcision. Furthermore, I do not accept that use of pacifiers interferes with breastfeeding at all. It probably hurts breastfeeding efforts. So what does the evidence reveal?

When WHO/UNICEF handed down their Ten Steps in 1989, the evidence for Step 9 was very poor. The available studies were small and did not account for a variety of variables that might affect breastfeeding other than pacifier use. And according to their own 1998 paper discussing the evidence in support of The Ten Steps, while the evidence suggested that pacifiers may be to blame for breastfeeding difficulties, “their use may be a marker of the desire to stop breastfeeding early rather than a cause of discontinuation.” So are mothers neglecting breastfeeding in favor of the pacifier, or grabbing the pacifier because breastfeeding is going poorly for some other reason?

The WHO paper also outlines a number of other reasons why pacifiers are evil, which were also in that earlier statement from the LLLI on nipple confusion. These included concerns of tooth decay, dental malocclusion (misalignment of teeth), ear infections, thrush, toxic chemicals and choking. Most of these concerns are overblown by nipple confusion proponents.

Tooth decay is primarily an issue of propping a formula-filled bottle in the crib, but pacifiers can contribute somewhat to the development of caries. This can easily be avoided by not dipping a pacifier in honey or other sugary liquid. Also parents should avoid “spit cleaning” pacifiers, which can allow for the transfer of cavity causing bacteria and lead to caries. According to the American Academy of Pediatric Dentistry, concerns of malocclusion should not scare parents away from using the pacifier as a SIDS risk reduction strategy, stating that “Dental effects are generally reversible and unlikely to cause any long-term problems if the habit is discontinued by the age of 5.”

Children who use a pacifier are more likely to develop ear infections, but not by much and not typically during the first six months of life when the risk of SIDS is highest. There appears to be about a 1-2 fold increased risk in older infants and children. Pacifier-using infants are also more likely to be colonized with the species of yeast that causes thrush, although many children who don’t use them are as well, and colonization does not equal infection. Many exclusively breast fed infants develop thrush. It is not uncommon for the nipples and areolae of breastfeeding mothers to become infected as well and, like pacifiers, serve as a source of reinfection. Pacifiers can be cleaned and mom’s nipples can be treated. This should not deter pacifier use.

But what about the impact on breastfeeding? There have been a number of larger and better controlled studies that have come out in recent years, and they have not supported the concerns of nipple confusion advocates. A Cochrane review of pacifier use in breastfeeding term infants looked at the three best available studies through 2012 and found no detrimental effect up to four months of age. There isn’t enough good data to make a conclusion about longer term problems, but I would be very surprised if there were any. This more recent 2013 paper in Pediatrics looked at over 2,000 newborns both before and after pacifiers were literally put under lock and key in a hospital nursery. It raises serious concerns that restricting pacifier availability in the newborn period may even increase the likelihood that breastfeeding mothers will reach for formula. It appears that, as the old saying goes, correlation does not equal causation in this case and pacifiers may even be protective.

Conclusion

Newborns may lack orientation to person, place, time and situation but they do not become confused simply because of having a pacifier placed in their mouth. Pacifiers are an effective means of soothing a crying infant and treating their pain during brief procedures, and they protect against SIDS. The evidence to date does not support concerns that pacifier use will interfere with breastfeeding and they may even help exhausted mothers say no to formula. Additional health concerns blamed on pacifiers are overblown and should not serve as a reason to miss out on the benefits of their use.

There is a lot of bad information out there that unfortunately will not be going away anytime soon, so I expect to continue to have to reassure parents that the pacifier is perfectly appropriate. Breastfeeding is a wonderful endeavor with myriad benefits to both mother and child, and it should be encouraged, but not with the use of propaganda and misinformation. Hopefully the American Academy of Pediatrics will take this new evidence into account when the time to reaffirm their breastfeeding policy comes around again in a few years.

Posted in: Science and Medicine

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130 thoughts on “Separating Fact From Fiction in the Not-So-Normal Newborn Nursery: Pacifiers and Nipple Confusion

  1. Tuck says:

    Pity the medical profession so diligently discourages breast-feeding… Actions speak louder than words, as your big caveat in the middle of this piece indicates.

    I guess it’s better now than it was when I was born, when my mother’s doctor advised against breast-feeding… Thanks, Doc. Asthma, check; allergies, check; IBS, check, colon resection, check…

    “According to the American Academy of Pediatric Dentistry, concerns of malocclusion should not scare parents away from using the pacifier as a SIDS risk reduction strategy, stating that ”Dental effects are generally reversible and unlikely to cause any long-term problems if the habit is discontinued by the age of 5.””

    This was not our experience. I wonder if they have evidence to support this?

    “This study confirms the findings of others that, compared to habit-free children, children with a history of pacifier use have a significantly higher occurrence of increased overjet,4, 16,312 a greater mean overjet, and reduced overbite. 13 As in other reports, the prevalences of posterior crossbites4. 45,,14 and openbites 6,12 were also higher among children with a habit history.”

    http://www.aapd.org/assets/1/25/Adair-17-07.pdf

    (The AAPD website, btw)

    1. I was breastfed. I have allergies, asthma, and other issues. Examples of one are not proof of anything.

    2. Young CC Prof says:

      You gotta love these nuts. The piece states that breast-feeding helps reduce illness in babies, and can prevent life-threatening complications in preemies. The author also (accurately) states that for healthy newborns, any long-term difference between breast and bottle-fed babies is pretty minor. The main purpose of the piece is to analyze the evidence on whether pacifiers interfere with breastfeeding.

      Tuck says, “The medical profession diligently discourages breastfeeding.”

      Not in at least 20 years, my friend. Climb back out of the hole you’re hiding in, and go visit any hospital in the developed world.

    3. @Tuck – Huh? Are you reading the same article? The whole piece was tittering on the edge of “oh no, another pediatrician causing me guilt* over my children not being breast-fed” until it was modified by some sensible reality**. I really can’t imagine how the article could have gotten MORE pro-breast feeding without being overbearing, judgmental and overstating the evidence.

      Possibly some form of maternal slavery would be your preference?

      *Yes, I can feel guilt over something that I have no control over. Because everyone knows that a GOOD mother is prescient and capable of inventing a time machine***, etc to insure that her child has EVERY advantage.

      **Thanks for that, Clay Jones.

      ***Oh wait, if I invent a time machine, I don’t need to be prescient. What a relief.

      1. Clay Jones says:

        I’m not sure if I should say “you’re welcome” or defend myself. I detest certainly any intentional measures to make parents feel guilty for the choice to not breastfeed their children, and I feel bad about the fact that even with reasonable discussion of the benefits some feelings of guilt are inevitable in some situations.

        1. Chris says:

          You’ll love Tina Fey’s take on those she calls “Teat Nazis” in her book Bossy Pants. I listened to the audiobook where her description of the Teat Nazi mind when it comes to adoptive parents was just hilarious.

          1. @Chris – Cool, I think that’s on audiobook. I could use some funny listening.

          2. Chris says:

            Definitely listen to the audiobook. It is read by her, and makes note of the fact you are listening and not reading. The CDs from the library came with a pdf of the pictures.

          3. WilliamLawrenceUtridge says:

            I just finished reading Is Breast Best? by Joan Wolf, it’s a very interesting, and pretty short (150 pages) scholarly take on breastfeeding. The author is a women’s studies professor, and she goes into the benefits of breastfeeding (which are surprisingly scanty and the evidence base markedly shaky – of the claims listed by Dr. Jones, only perhaps the first three are given unequivocal endorsement), the culture of “total motherhood” that demands women (specifically, not men) give up anything and everything if it reduces any risk to their child, and the borderline-unethical position taken by most authorities to promote breastfeeding. I’d love to see a specialist in breastfeeding go through it, but no matter what – extremely interesting. If it’s factual, and not based on polemics (with 40 pages of detailed endnotes and another 40 pages of bibliography, it’s at minimum well-referenced) then it rather strongly undercuts the case for breastfeeding, and in particular all the resources and guilt that modern first-world societies pump into the topic.

            Interesting book.

        2. Sorry, I was afraid it would come across as back-handed and it did. It was a genuine thanks, though.

          1. ^^last apology should have been addressed to Clay Jones.

  2. Kate McAfee says:

    I breastfed my daughter for 13 months and used a pacifier from Day 2. She was never confused as an infant even after I went back to work and she drank pumped milk in a bottle during the day and breastfed in the evenings/ nights. She first saw a dentist when she got her first tooth and he was unconcerned about her pacifier use until her 4th birthday when we made her give them up. She had a small overbite at that point but within 6 months her teeth went back to a normal perfect alignment.

    By contrast my mom breast fed me and did not use pacifiers. Instead I sucked my thumb and as I am one of the most stubborn people I know (besides my own daughter) I refused to give up the practice despite my parents best efforts (including hot sauce, horrible bitter crap, gloves, etc) until WELL past my fifth birthday. I also had 18 ear infections before I was two.

    I am not a lactivist by any means, I breastfed and plan to do so with #2 as well but I don’t believe it should be forced on unwilling women. Short of giving women the information to make an informed decision, what are doctors supposed to be doing to further encourage breastfeeding? It’s not a decision that you can force or shame someone in to doing successfully.

    1. Hakainokami says:

      My mom breast fed me and didn’t use pacifiers. I only gave up sucking my fingers when the dentist put a cage behing my upper teeth to physically prevent me. So there was a lot of orthodontia later. I tried to prevent this in my son, but he mostly has rejected pacies for his fingers- and I can already see it messing up his teeth at not quite 2.5 – and so far he’s been as stubborn as I was about giving it up.

  3. Clay Jones says:

    The site ate my longer reply. In brief, old cross sectional study but appears to support current stance. If stop using pacifier, problems improve. Benefit outweighs risk.

  4. Four children, no pacifiers, demand breastfeeding for three, bottle for one–I simply think they are artificial and unsightly, and there was no SIDS issue at the time. I never heard of “nipple confusion” even though I did read through LLL materials (among other sources) and found them supportive. An older and wiser critical eye makes me wince at that, but as I had little other support, I am still grateful to them.

    I insisted on breastfeeding during venipuncture and had to go to three hospitals sometimes to get it. It was amazing the way some technicians rudely refused this request, as if I had requested something that would harm the baby instead of easing her discomfort. Once in the lab, the doctor’s view didn’t seem to carry any weight.

    I stopped seeing the doctor who insisted that I use supplemental feedings to “give myself a break”. Nor did I ever accept that babies should cry themselves to sleep. Some things are better left to parental love. If I am willing to lose sleep to accommodate my baby’s sleep pattern, why should anyone care?

    By the way, you didn’t follow up on swaddling after mentioning it? Is it harmful and how do you advise parents who are culturally accustomed to it? I remember when I had my first, that my mother was horrified that my daughter came home from the hospital without a “belly band”, which was standard when I was born. She was sure “something awful” would happen to my baby’s umbilical stump. It seems belly bands were a form of swaddling, perhaps.

  5. LDM says:

    I agree that newborns are unlikely to be “confused,” but what about the many anecdotes on mommy forums of babies having a preference for a bottle because they don’t have to work as hard or wait for a letdown? I’d be curious to know if introducing even “one bottle” as LLLI claims really leads to breastfeeding cessation.

    1. Clay Jones says:

      That is all that they are: anecdotes. Claims such as the introduction of one bottle ruining breastfeeding are not evidence based. I can easily counter these anecdotes with stories from families with babies that breastfed beautifully despite frequent pacifier use and bottle feeds of formula or expressed milk.

      1. Julia B says:

        Actually, limited use of formula during the first few days after birth was associated with increased breastfeeding at 1 and 3 months in a recent study. They compared exclusive BF with early limited formula feeding in the hospital. Perhaps a little formula reassures parents and makes them less likely to give up on breastfeeding? Or the infants nurse better because they are less hungry from getting a bit of formula? It was from a small study but the differences are striking. Published in Pediatrics. http://www.ncbi.nlm.nih.gov/pubmed/23669513

    2. Chris says:

      No it doesn’t. My first newborn was taken from the hospital he was born in to Children’s Hospital due to seizures. I had injuries from his birth and could not be released from the hospital until a day later. It was then that a nurse introduced me to a breast pump and I spent a terrible night in the hospital.

      So during the next week when my infant was in the hospital I pumped lots, but when I was finally able to hold him without so many tubes and wires he breastfed just fine. After a he a few weeks old I had to give him his medication in an ounce of formula twice a day. He was breastfed as much as possible until he was about a year old.

      I went to one La Leche League mom/baby gathering. It was there that I met my first self-righteous anti-vax mom. (my son needed community immunity for one disease so I always asked) This experience has always colored by attitude towards LLLI. When I do think of them, it is not kindly.

      Especially since I knew one mother whose medication kept her from breastfeeding, others who tried very hard, and finally several who adopted their kids.

      1. WilliamLawrenceUtridge says:

        Look into the history of the La Leche League. It’s actually a religious organization masquerading as a breatfeeding organization. The Conflict by Elisabeth Badinter goes into its history and overall goals, and it’s not pretty.

        1. Karen says:

          The original founders of La Leche League were Catholic —a fact which has no relevance whatsoever to the present organization. I’ve worked with LLL for over 10 years now, and I can promise you there is no religious agenda. Come to think of it, I don’t think I personally know any Catholics in LLL. There are lots of atheists and pagans and Unitarian Universalists in my circles though.

          LLL has one goal only: to support mothers who want to breastfeed.

          That being said, LLL does tend to attract ultra-crunchy types who unquestioningly accept any manifestation of the appeal to nature fallacy. LLL as an organization doesn’t promote any brand of pseudoscience, but since so many of the meeting attendees and volunteers believe in chiropractic, homeopathy, naturopathy, anti-vax, anti-GMO, etc, that stuff too often creeps into LLL meetings and discussions. It’s excruciating. I do my best to counter it with better information wherever I can.

          1. DugganSC says:

            Thank you for addressing the point. *sigh* Sometimes I think we ascribe too much importance to the source of an idea and not enough to its content. Leads to arguments that consist of “You know who thought that was a good idea? Stalin (or insert whatever hated group/person)!”

          2. WilliamLawrenceUtridge says:

            Having never attended a LLL meeting, I don’t know either way – I’m just going by Badinter’s book. I do wonder about the upper eschelons versus the front-line groups, but I could be completely off-base. A search of even the history page of the LLLI turns up no mention of the religious roots of the organization, though upon this blank slate I project my own nefarious imaginings. If they’ve secularized, great! But if not…dun-dun-DUNNNNNNNNN!!!

            Ahem.

          3. LDM says:

            “LLL has one goal only: to support mothers who want to breastfeed.”

            I disagree. I recall they trashed this study when it came out, the one Julie B linked to: http://www.ncbi.nlm.nih.gov/pubmed/23669513

            Limited formula use can increase breastfeeding rates, but they didn’t like it. Why? Because they are breastfeeding purists.

            Now that I know the “one bottle” thing is BS, I’m even more convinced of that. I was so scared to give my baby a bottle early on. At 2 months when I needed to go back to work she would not take one.

          4. LDM says:

            LLL = LaLa Land

        2. mousethatroared says:

          DugganSC “Sometimes I think we ascribe too much importance to the source of an idea and not enough to its content.”

          I believe it’s called poisoning the well. (This is not a correction, it’s just that I get really excited when I can actually remember the name of a logical fallacy.)

    3. Nova Squadron says:

      Yes, they are anecdotes. But I would argue the delayed letdown leads to increased baby/maternal stress and increased use of formula would be equivalent to studying this:
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/#!po=0.735294

      1. Chris says:

        Would that baby/maternal stress be more or less than having the newborn in the Intermediate Infant Care ward of a Children’s Hospital? Just curious, because I kind of know what the latter is like.

        How do you measure baby/maternal stress? Every new parent is under stress, and there is even stress with the younger children. Especially when there is lack of sleep.

        And who advocating increased use of formula? It gets used often when it is needed, and I suspect the babies Dr. Clay takes care of would sometimes need formula if the mother was not able to pump.

        1. Chris says:

          Oops, Dr. Jones.

          Actually there has been significant rise in stress lately for second child who lives in a house with other students just north of the college campus. There have been two armed robberies within a block of the house in last four days. He, his housemates and all of their parents are pretty worried. Especially since many, like my son, come home from their evening jobs at about the time the robberies take place.

          Really, there are so many things about children that come into play between birth and when they become adults than how they are fed as infants.

    4. WilliamLawrenceUtridge says:

      And while it seems cruel to some, hunger is a strong motivator. Want your baby to breastfeed while also bottlefeeding at times? Make sure they are hungrier when you give them the breast. The idea that a baby can be “confused” over such a trivial thing always struck me as absurd – that a baby can only retain one pattern of muscle use at a time.

    5. corky says:

      As a mother of two who went back to work full-time when each was 2 months old, I can tell you that they both breast-fed and got bottles. My first so hated the bottles that for the first week back, she would refuse the bottle (of pumped breast milk–before there were these nicer pumps) and cry until I rushed home. The second was less picky, but was ALWAYS eager to see me the minute I walked through the door. I could never give either of them a bottle, nor could I be around when they were fed with a bottle as they always wanted the breast. I never used a pacifier (they both didn’t like them and I hated having to keep track of them) and just allowed them to suck my finger or their fist or hand. Neither sucked their thumbs.
      And both of them had ear infections constantly, the older one was diagnosed with celiac disease a few years ago, and both have lots of allergies. but then so do I and I was exclusively breast-fed (back in the 50s when it was rare).
      Yet more anecdotes….

  6. Clay Jones says:

    There are no official recommendation but it appears that aggressive swaddling, particularly if done so with arms tightly held down by the side and especially if combined with prone sleep position, is probably a risk factor for SIDS. We already know that swaddling for extended periods of time that limits movement at the hip joint is a risk factor in hip dysphasia. I am personally fine with some swaddling for when a baby is fussy but would be careful with tight wraps used during sleep. The downside is that a right swaddle will absolutely help prolong sleep and decrease duration of crying, which may be more meaningful in some families than others. As with everything there is a need to weigh risks and benefits.

  7. WilliamLawrenceUtridge says:

    Pity the medical profession so diligently discourages breast-feeding… Actions speak louder than words, as your big caveat in the middle of this piece indicates.

    Are you an idiot? What action speaks louder than locking up formula and pacifiers? The borderline punishing approach to formula that exists today is repellent to me, the last thing parents need is something else to worry about. The benefits of breastfeeding exist, it is the best food for babies – but it’s still just food, and formula is close enough behind as to render all the hype over breastfeeding to be hysterical in my mind.

    This was not our experience. I wonder if they have evidence to support this?

    I would expect a scientific body would have evidence. I would also expect that a rabid proponent of SCAMs such as yourself would be unable to recognize your own confirmation bais and the irrelevance of your personal experience to a scientific question.

    And oh look – I’m right.

    http://www.aapd.org/assets/1/25/Adair-17-07.pdf

    (The AAPD website, btw)

    Yeah, sure, the AAPD website from 1995. Is it too much to ask for something produced within the current century?

    1. Nova Squadron says:

      Formula is not “close behind” as you say. Formula is actually the fourth best feeding option. First is mother’s milk from the breast, second is mother’s milk from a bottle, third is a wet nurse or donated milk, and lastly, formula.

      Also…considering that nearly 900 baby’s lives would be save *in the US alone in a single year* by breastfeeding, I find it comical you would say it is “close behind.”

      1. Harriet Hall says:

        Those 900 lives are not a reliable number. They took a study that showed no clear relationship with mortality and re-interpreted it to predict that 900 lives a year could be saved: it was statistical skullduggery. See http://www.sciencebasedmedicine.org/breastfeeding-is-good-but-maybe-not-that-good/

        1. Nova Squadron says:

          Thank you I had not seen this. Unfortunate the number is unreliable. Wonder what the true number is, and also about the authors inherent bias.

          1. WilliamLawrenceUtridge says:

            What makes it “unfortunate” that this number is unreliable? Wouldn’t it be better if the number was lower, so low that the difference between breastfeeding and formula feeding was nil? There is no reason to want breastfeeding to be better; if it is, great! If not, I would say even better as it greatly expands the feeding options available to parents and would hopefully tone down the rhetoric that accompanies it.

      2. WilliamLawrenceUtridge says:

        …except for when you delve into the studies, while the abstracts may not detail the limitations, their bodies do. Randomization of breastfeeding is never done, as it’s seen as unethical – like randomization of vaccination and not vaccinating. These studies can never, ever differentiate between breastfeeding and the decision to breastfeed. And that fact alone means you can never know if the health improvements are due to the breastmilk, or myriad other factors such as parents having the time to breastfeed (and thus the time to do other things), or parents having the wealth to breastfeed (and thus living in a suburb, far from pollutants that can cause breathing disorders). Not to mention the characteristics of the children as well – babies being innately healthier, thus better able to suck at a much less nutrient dense source of energy, would show as “continuously breastfed” meanwhile those with health problems might show failure to thrive and be switched to formula.

        Then there is the fact that these studies all account for maternal factors like IQ, socioeconomic status and age, but rarely if ever account for paternal factors like IQ, socioeconomic status and age. And personally, I think the contributor of 50% of the DNA to the child might have some bearing on the effects of their health.

        On top of that, most of the studies don’t find particularly strong correlations, but as a bit of received wisdom the necessity of breastfeeding becomes an ouroboros of studies. “We didn’t find benefits for asthma, but because it protects against cancer, breastfeed. We didn’t find benefits for cancer, but because it protects against asthma, breastfeed.” Wash, rinse, repeat.

        The evidence base for breastfeeding benefits is surprisingly shaky considering the rhetoric that accompanies it. The best, most consistent and reliable finding is that of GI infection – a 40% reduction in risk! Until you delve into the numbers and find it’s 13% risk of an extra episode for formula fed, and 9% for breastfeed, for one more incidence. If you delve into the numbers needed to treat, you get an interesting figure – 25 babies must be breastfed exclusively to protect against one fewer GI infection. Certainly for long-term impacts, there’s not much – obesity isn’t well-supported, the WHO report on the matter said basically there’s no evidence. Ditto hypertension. The “best” evidence is for IQ, and it’s an extra 3 points, which is conveniently the error bar of the IQ test itself.

        This is from Is Breast Best?, a short and interesting book you should read. Among its other interesting findings are the disproportionate weight of care placed on women because of breastfeeding (it essentially leads inevitably to more and more childcare being the woman’s task, even when the intent is to share duties), and the disproportionate weight carried by low income parents (because the assistance provided for formula feeding have been systematically eroded).

        Please, read the book. It won’t take you long, right? And you don’t mind challenging your beliefs, right? What do you have to lose?

        1. It often strikes me as something that has gone rather out of control. I recently read a facebook group where a mother asked for advice because her GP advised that she *supplement* her child with formula because their weight was on the low side. The responses were rabid:

          “Get a new doctor” and “Do X, Y, Z to increase your milk supply” – were probably the two most popular.

          A few recommended organic formula but I kept wondering. Even if we believe that breast milk is superior to formula. Is it really so significant that a 10%-20% supplement of formula is going to be noticeable on any outcome?

          I’ll be checking out that book when I get a chance.

          1. DugganSC says:

            Some of the vehemence may be due to early formulas using added sugar to encourage babies to drink. So, from the poster’s point of view, it’s like a doctor saying, “Your child needs more fluids. Give him Coca-Cola ™! Hey, have a free sample bottle they provided the hospital!” Formula is still a big marketing thing, but my understanding is that they’ve reduced the amount of unhealthy stuf in it.

          2. WilliamLawrenceUtridge says:

            I wonder what the studies would find if they reviewed current formula constituents versus breastmilk. I doubt they’ll ever get antibodies into formula, but they have matched the fats found in breastmilk in recent years. Science, she marches on.

        2. Nova Squadron says:

          Thank you for the recommendation, but I do stand to lose…my time. Unfortunately your post is not enough to convince me when the AAP, WHO and author of the original article still maintain there are major benefits to human milk.

          1. Clay Jones says:

            There are certainly benefits, and the author of the recommended book doesn’t disagree with that she isn’t as impressed as I am for instance. I am skeptical, as we all should be, about claims that seem to go against expert consensus but, again, what we should consider to be a significant versus moderate or minor improved outcome is a bit hard to peg down. A lot has to do with the context of the individual child. Where they live, what there access to modern medical care is, and many other variables in addition to whether or not they were breastfed play a role in a child’s health.

          2. WilliamLawrenceUtridge says:

            Nova, if you are wrong, if your beliefs about breastfeeding’s benefits are wrong, how much time are you losing by defending it?

            Is Breast Best goes into a very interesting history of the AAP’s support of breastfeeding by the way. The initial recommendations were there, but tentative, and included heavy caveats about the quality of the evidence and the limitations of the studies (most notably, one never overcome, is controlling for the decision to breastfeed). Each iteration of the recommendations became more certain, and gradually those caveats disappeared but the studies never successfully accounted for the decision to breastfeed.

            What if you, and everyone else that spends so much time and effort insisting on the vitality of breastfeeding, are wrong?

            Please don’t accuse me of being in the pay of the formula companies merely because I disagree with you. I have been accused of being a shill for Big Pharma, Big Ag, Big Kimball (ATK FTW!) Big Everything merely because the people I disagree with don’t do the reading I do, and can’t refute my points. If you can’t refute my points, it might indicate that your own are weak, not that I’m being paid to hold these opinions.

            @Dr. Jones

            What we should consider to be a significant versus moderate or minor improved outcome is a bit hard to peg down.

            Wolf makes this very point, and that even the best-demonstrated benefits of breastmilk (GI infection incidence reduced by 40%) don’t approach anything close to the relationship between smoking and lung cancer (2,000% increase) but despite this the public health campaigns are incredibly, borderline deceptively ardent in their promotion of breastfeeding and (unfortunately) the risks of formula. Even the fact that formula feeding is seen as “risky” is itself a framing device that portrays formula as inherently, dangerously, worse.

      3. “Formula is actually the fourth best feeding option.”

        …and ordinals are the 2nd worst kind of data. :D

  8. X says:

    It does seem like the backpedalling on breastfeeding contradicts the intended message. If breastfed babies have superior outcomes, those outcomes are superior to whose? If not to superior to formula-fed babies then who? It doesn’t make a lot of sense.

    Also, why is there never any mention of bottle-feeding breastmilk to babies? For mothers who are having trouble with the mechanics or time constraints of standard breastfeeding, this is an obvious alternative. Is it the milk that is beneficial or the actual mechanics of the feeding? If the former, why are we obsessed with the latter?

    1. Clay Jones says:

      It depends on what you mean by superior. It is clear when looking at populations that breast milk leads to improved outcomes in a variety of areas. And yes, exclusive breastfeeding is compared to partial and exclusive formula feeding. There appears to be a dose response in many outcomes with exclusive breastfeeding having the greatest benefit. But in an individual case, much of this breaks down and it really depends on a lot of factors. Take the benefit of less risk of gastrointestinal illness for instance. If it takes feeding ten kids breast milk to prevent one case of gastroenteritis (I made this number up), then for 9 babies there isn’t a benefit, right? But for that tenth kid it may be a minor benefit if living in Boston for instance or a life saving intervention if living in Botswana. Overall there is clearly a net positive impact with breastfeeding but the impact may not be significant in any one formula fed baby.

      Feeding human milk via a bottle has the same benefits as via the breast with perhaps the exception of some of psychosocial ones. But pumping is a difficult practice to maintain and many women find that they are unable to produce enough milk as the child ages. The biggest benefit, in my opinion, which involves outcomes in premature infants is gained from expressed breast milk. A 27 week gestational age infant is unable to breastfeed, or bottle feed for that matter, and receives milk via a feeding tube generally for several weeks.

      1. WhatPaleBlueDot says:

        Feeding human milk via a bottle has the same benefits as via the breast with perhaps the exception of some of psychosocial ones.

        Except that we know that many so-called psychological benefits profoundly affect physical outcomes. Differentiating this is important, but quite possibly impossible. The tendency of breastfeeding to reduce abuse and neglect in and of itself could be the mechanism for the health benefits (premature infants excluded).

    2. CM25 says:

      “Also, why is there never any mention of bottle-feeding breastmilk to babies? For mothers who are having trouble with the mechanics or time constraints of standard breastfeeding, this is an obvious alternative. Is it the milk that is beneficial or the actual mechanics of the feeding? If the former, why are we obsessed with the latter?”

      LLL and other breastfeeding advocates would claim breastfeeding promotes “bonding.” It has never been clear to me how you would bond any less with your child by holding them in your arms and bottle-feeding them. Also, by stating it promotes bonding there is an implication that the husband/non-bfing partner does not “bond” with the child. This has always bothered me.

      1. Kate McAfee says:

        What time savings? The time to set up the pump, pump the milk, and clean everything up is far greater than the time it takes to sit down and latch the baby on. I can see a benefit to exclusive pumping if you are having difficulties with latching, etc, but not for time savings.

        1. X says:

          The time needed to drive home from work, pick up the baby, breastfeed and drive back to work… every time the baby needs to be fed. So: many hours.

    3. Nova Squadron says:

      Oxytocin. The answer to how feeding from the breast promotes bonding vs. feeing human milk from a bottle.

      1. CM25 says:

        It’s my understanding that oxytocin can also be released by skin-to-skin contact, and for husbands/partners/adoptive parents they encourage this. So why wouldn’t bottle-feeding with your shirt off be just as effective?

        To me I read the whole bonding claim as just another way of trying to guilt women into BFing.

        1. Nova Squadron says:

          Okay then. We all better start advocating bottle feeding in public with our shirts off! Lol

          1. CM25 says:

            I love it!

        2. CM25 “It’s my understanding that oxytocin can also be released by skin-to-skin contact, and for husbands/partners/adoptive parents they encourage this. So why wouldn’t bottle-feeding with your shirt off be just as effective?”

          Really, I’m pretty sure that a lack of shirtless bottle feeding is not the cause of poor attachment or bonding in adoption.

          Really, I don’t even need to look this up. It’s just not a thing. :)

      2. WilliamLawrenceUtridge says:

        I’d like to think that a lot of parents can bond with their children without the benefit of hormones – particularly over the long term. I don’t think the only mothers who love their children, and the only children who love their mothers, are the ones who breastfeed/are breastfed. I would think, and as a man I would hope, that I can come to love any child I might have through ways other than strapping it to my naked body. I think rather wistfully of things like helping with homework, asking about school days, playing dolls or catch, teaching him/her to cook, read and speak, taking delight in their accomplishments, and so forth.

        I would like to think, as a man, that I am not somehow crippled in my ability to love due to my lack of lactation.

        1. WLU – I’m pretty certain that a parent can’t bond without the benefit of hormone…because without hormone, they’d be dead. ;)

          Regardless, you have it all wrong. The love for a child has nothing to do with genetic connection or hormones. First the infant or child cries a lot, causing stress and exhaustion in the parents. Then the child coos and is happy…a sort of Stockholm syndrome sets in, where you will do anything to befriend or please your captor…I mean child.Then one day, as you are cuddling the child, who is babbling happily (finally, after an hour long wailing episode over not being allowed to eat lady bugs) the child sinks their newly erupted fang…No teeth, teeth into your bare neck or shoulder* infecting you with a chronic bacteria that turns you into a kind of zombie/caretaker/parent who thinks only of
          how they may serve and protect. Your immune system may occasionally fight back and you will momentarily regain your senses and arrange a date night, during which you will mostly talk about ways to insure your child’s happiness and health. After a few years, you have grown used to your disease all hope for a cure is forgotten, all is lost…and you are kinda happier than you have ever been. Until they become teen-agers. which is, I hear, too dreadful to speak of.

          As an aside, I wrote this before, my comment vanished. But…

          I am certain the lack of shirtless bottle feeding by adoptive parents (or dad’s) has never been the cause of insecure attachment or bonding. Really, I don’t even have to look it up. It’s just not a thing.

          *Maybe your chest is bare because you have been encouraging bonding but more likely it is because your shirt has been drooled or thrown up on.

          1. Oh shoot, sorry for the partial double post, my comment viewing is wacky.

        2. Kathy says:

          Mouse, dear Mouse, I do love your daft comments. You remind me of my mother, who is the best mother in the world. I’ve not a clue whether she breastfed me or not, but we are very bonded. What’s more it has lasted, even though she is now 80 and I am in my 50′s. It last a lifetime, I must tell you, though whether you will regard this as a promise or a threat I dunno.

          1. mousethatroared says:

            HeHe! Thanks Kathy – I consider the story of your lifelong bond more of a promise than a threat. Although I’m a little concerned about being 80. My grandmother once told me “Don’t get old!” Advice that I thought was silly at the time, but seems increasingly wise. Unfortunately I haven’t quite worked out a way to follow the advice.

  9. CM25 says:

    Just wanted to say that I am surprised by your parroting of the supposed benefits of breastfeeding. When the studies showing the benefits of breastfeeding are closely examined, it quickly becomes clear that any “benefit” is just an artifact of the socioeconomic status of breastfeeding v. formula feeding mothers. There is simply no evidence that breastfeeding is better than formula feeding.

    1. Clay Jones says:

      Why the surprise? Clearly I am on the payroll of Big Lactation. As are the members of the expert panel which penned the AAP policy statement, the overwhelming majority of pediatricians and family practitioners, thousands of scientists, the United States government of course, and, heck, let’s just throw in NASA too.

      Or could it be that there are valid reasons to respect the expert consensus and, after careful review of the literature myself, to agree with most of it. There is nuance and room for disagreement about many aspects of this issue, particularly about how significant the benefits are in individuals or specific populations. But blanket statements that there are absolutely no benefit are not evidence based or in any way reasonable.

      1. CM25 says:

        I’ll relent and say there might be very minor benefits to breastfeeding (though I still have my doubts and I doubt we can ever know what they are), but any of those benefits are outweighed by the numerous other confounding factors that lead you to become the person you are.

        If you can point me to a study that has been done which shows benefits of breastfeeding over formula and is able to control for any of the confounding factors I would love to read it, but I have never seen one.

        At the risk of sounding trite, all the literature on breastfeeding benefits can be read in this way: poor people don’t breastfeed, poor people have worse overall outcomes. Wealthier people do breastfeed, wealthier people have better overall outcomes.

        1. Harriet Hall says:

          I wonder…surely that’s not true everywhere. Really poor people have no option, they can’t afford formula and bottles. From what I’ve read, education level may be more important than economic factors in the US.

        2. Chris says:

          I found one very important benefit when breastfeeding my second baby. I could hold him with one arm as he nursed while I used my free hand to operate the mouse in a CAD program for a design I was working on. ;-)

        3. WilliamLawrenceUtridge says:

          Heh, this was the most timely post ever, ’cause I get to recommend for the third time in one day, for one post, Is Breast Best?

          I would actually love a review of the book by an expert, it was a very fascinating read, but I don’t have the expertise to know how much of it is counter-argument and iconoclasm to the mainstream discourse simply for its own sake.

      2. WilliamLawrenceUtridge says:

        One comment found in Wolf’s book was regarding the makeup of the panel. All were breastfeeding researchers who specialized in various hypothesized diseases (i.e. the effects of breastfeeding on asthma, the effects of breastfeeding on obesity, the effects of breastfeeding on IQ). Wolf comments that the panel’s make-up might have reached a different conclusion, might have acknowledged the weaknesses in the evidence base, might have been clearer about things like the NNT and effect sizes of the alleged benefits, if it had included researchers on asthma, obesity and IQ independent of breastfeeding. The point being, of course, that bias comes in more forms than merely financial conflicts of interest. Defending a ideologically-held conclusion, particularly when you fervently believe that you are saving lives, may also lead to bias – and in particular may lead you to the belief that you are justified in exaggerating risks or phrasing the conclusions more firmly than they warrant.

        Now I found this to be an interesting and valid point to make, particularly given the pages spent detailing the weaknesses of the evidence base. But it made me wonder about a comment made in another thread regarding potential bias on the part of the vaccination recommendation committee.

        But then again, the evidence base, prior probability, effect sizes, NNT and convergent evidence for vaccination is a fair bit better.

  10. Mark G says:

    Clay,

    Thanks for the insightful article; I look forward to your future ones. As a father of a 5 month old, the wife and I can certainly relate to a lot of the issues you addressed. I do have a follow up question regarding “spit cleaning” a pacifier:

    I’ve seen several articles this year on the benefits of transferring parental bacteria to a newborn/infant and one or more articles mentioned that “spit cleaning” was beneficial for a reduction in allergies, etc. Do you agree with this research? Is this a harmful practice even before the first tooth?

    Thank you.

  11. Also, my children never did pacifiers. I think they are not essential in orphanages. My daughter was a big thumbsucker. I always wondered what the point of banning a pacifier was when children clearly have a built-in alternative. The benefit of the thumb is that it’s always attached. Of course, the drawback of the thumb is that it’s always attached.

    Our orthodontist was very helpful in thumb sucking cessation. She had our daughter mark a calendar for each day she didn’t suck her thumb. When she reached a month of consecutive non-thumb days, she got lots of praise and a reward from the orthodontist. My daughter has always been very inspired by non-parental praise (we are chopped liver).

    Braces are not the end of the world and our daughter’s mouth is way too small for all her teeth, I doubt that the thumb sucking could have been to blame for that.

    1. Kate McAfee says:

      When we “gave the pacifiers to the pacifier fairy” my daughter did not resort to thumb sucking. She cried about it for a few nights, then moved on. I don’t think the thought of sucking her fingers even occurred to her. The action of sucking may be the same, but pacifiers and thumbs don’t feel the same, especially as you get older and it’s not a reflex anymore but an addiction. On the other hand, my parents tried everything short of thumb amputation (and even then I probably would have just switched to a different finger) to get me to stop but I didn’t for a very long time.

      1. Harriet Hall says:

        My daughter stopped using a pacifier at age 4, if I remember correctly. She hadn’t been using it very much, and we decided it was time, and we put a few drops of a safe bad-tasting over-the-counter product on her pacifier. She put it in her mouth, spit it out, said “Tastes yucky” and never wanted a pacifier again. Didn’t suck her thumb either. Maybe we were just lucky.

      2. That’s interesting. The idea being, if they habituate to the pacifier, then you can take it away and they are unlikely to start sucking their thumb, because, to them, it’s not satisfying.

        This wouldn’t have helped us, because my daughter sucked her thumb before we adopted her and she wasn’t interested in pacifiers that were offered. But if I had an infant (good lord no) I would definitely consider that.

  12. Clay Jones says:

    Damn, ate my longer reply again! Briefly, mouth is different than gut. We give stool transplants not saliva. Transfer of oral bugs from adult to baby allows early colonization with acid forming bacteria and subsequent increase risk of caries. I’m not aware of any legitimate benefit of spit cleaning.

    1. WilliamLawrenceUtridge says:

      Is stool a transplant a viable choice for babies? Are we likely to reach the point where their first meal is likely to include a few drops of colonized bacteria from one parent or the other? Oversold as it seems to be in so many websites, the microbiome is a very interesting hypothetical area of research.

      1. Clay Jones says:

        Infants don’t tend to get sick with C diff and are in fact very frequently colonized asymptomatically despite having toxin in their poop. This is why it is recommended to avoid testing them for presence of the toxin to avoid uneccessary treatment. When an older child develops illness due to C diff, stool transplant is a very safe and effective option but is not first line…yet.

        1. WilliamLawrenceUtridge says:

          What about as a general approach, to ensure the gut is colonized by healthy bacteria rather than pathogenic?

          But to answer my own question, I doubt the science is far enough along to indicate a “best” kind of bacteria, particularly given the complexities of possible interactions between the microbiome and the human genome.

  13. Mark G says:

    Thanks for the reply Clay. Here’s an article from earlier this year that discusses the recent research regarding “spit cleaning”. Do you see anything in this that would change your mind?

    http://well.blogs.nytimes.com/2013/05/06/why-dirty-pacifiers-may-be-your-childs-friend/?_r=0

    Thank you.

    1. Clay Jones says:

      Well, the issue is right there in the article. Are people who do a lot of spit cleaning pacifiers also more likely to let their kids roll around in the dirt and put bugs in their mouths? We already have a decent amount of evidence in support of the so-called hygiene hypothesis, and this possibly fits in with that data. But, there are clear potential negative aspects of spit cleaning, particularly if the mother or father doing it has problems with dental caries. So, essentially, even if true it is probably better to avoid sharing saliva and just get a dog.

  14. Nova Squadron says:

    I generally agree with everything here, except that I think part of the LLLI quote was misinterpreted.
    One thing that was not mentioned was the way in which I know pacifiers actually helped me continue breastfeeding. In the case of oversupply and OALD, pacifiers can actually keep the problem from worsening.

  15. Oh my–anything that even touches on breastfeeding seems to generate such heated opinions. I’m so glad I did at least one of each. It gives me some balance, even though I am a little sad about the one that got the bottle, but only a little. No thumb suckers either. I wonder if there isn’t some innate neurological status that predisposes a child to thumb or no thumb, loving the binkie or spitting it out (as three of mine did even when I tried them in desperation)?

    I don’t think anyone but the most ardent LLLer (that is, a loon) would ever accuse an adoptive parent of not trying hard enough to breastfeed, so I’m never sure why adoptive parents usually react to these discussions as if they are the targets of anti-bottlefeeding zealots (I hope they have NOT!). On the other hand, I find LWU a bit strident as well. I have seen enough half-hearted, and downright wimpy attempts at breastfeeding to wish there would have been someone to push those people just a little more–perhaps “support” would be a better word. That’s not the same as being creepy about people’s choices.

    Lastly, there is one thing in this world that women can do that men cannot and that is give birth and nourish a child. There are many things Dad can do to support, bond, and be a good father, but only mothers b-feed, not “parents”. But then I never thought “we” were pregnant either. Perhaps it’s a generational thing (or perhaps I just have a goddess complex), but I always gloried in the special biological things that only women can do. :-)

    Oh! Thanks for the note on swaddling–I always found wrapping them up like a burrito (with arms mostly free) to be helpful for “colic” (fussing for no apparent reason).

    1. goodnightirene “I don’t think anyone but the most ardent LLLer (that is, a loon) would ever accuse an adoptive parent of not trying hard enough to breastfeed, so I’m never sure why adoptive parents usually react to these discussions as if they are the targets of anti-bottlefeeding zealots (I hope they have NOT!).”

      Nah, that’s not it. My first reaction to Tuck was because I thought he was just way misrepresenting Clay Jones well balanced article without any concrete evidence that pediatricians currently discourage breast feeding.

      I have never had problem with folks who encourage breast feeding. I think supporting any healthy behavior is great.

      Sometimes listening to the health benefits of breast feeding makes me sad because I think of all the healthy things that my kids and other kids in the orphanages missed out on in their first year or two of life. And then I get aggravated because, in some cases with low risk children, the benefits that are being discussed with BF are so small compared to other kids getting appropriate vaccination, formula that is safe, full strength and not propped at bedtime, proper skin care, sleep position, appropriate surgeries, adequate holding and exercise, etc. I feel like there may be a loss of perspective, in some cases. (Although not in CJ article).

      Also, I get annoyed by the folks (not the ones in this discussion, just history) that are so immersed into attachment parenting or perfect parenting that they unconsciously view a child who is not breast feed, worn or lived their infant years in a less than optimal attachment environment as inevitably “broken or damaged.” with all the sensationalist news footage of violent adoptive children as a reference point.

      I mean, it parenting, it’s not easy, but it’s not typically like defusing a bomb. They generally don’t explode because you did one small thing or even several small things wrong.

      But that stuff is all tertiary to breast feeding or pacifiers. But I didn’t feel I was targeted in anyway, just sharing my (out-spoken) perspective.

      Also, I’m just in a ranting mood. Some days you just gotta go on about something.

      1. Chris says:

        “I mean, it parenting, it’s not easy, but it’s not typically like defusing a bomb. They generally don’t explode because you did one small thing or even several small things wrong.”

        Exactly. I view it from someone whose first born was a frequent flyer to the Children’s emergency room as a newborn (and in adult emergency rooms a couple of years ago before his surgery). While in waiting rooms and special ed. programs we got to have lots of conversations of issues that were far and above more important than infant feeding.

        Needless to say, I was much more relaxed with his two younger siblings. Both of whom spent lots of time with me in therapy waiting rooms. So rant away, I’m right behind you. Especially I did not have a good experience with LLLI.

        1. Nova Squadron says:

          Right! It’s only food! Which is why my older children eat a straight diet of Twinkies and frozen pizza. It’s the way I parent.

          ???

          Incidentally, you’re not the only one here with a kid in special ed. My younger two spend plenty of time in therapy waiting rooms too. I generally don’t read this blog for the infant feeding posts, but when I see people making illogical comparisons I felt the need to comment.

          Formula and breastmilk are not equivalent. The typical wording of the argument is even off. There is no such thing as a “benefit” to breastmilk. Breastmilk is the norm. The way mammals have fed their young since the dawn of …mammals. It is formula that has something to prove, in regards to safety and outcomes. I don’t know when exactly formula was invented, but I personally require more proof than has been presented here or elsewhere if I were ever to choose formula over something which evolution has been perfecting for millennia.

          1. WilliamLawrenceUtridge says:

            Formula is not the equivalent of pop, it’s a high nutrient density foods scientifically designed to meet the nutritional needs of babies (in some ways better than breastmilk, such as through higher levels of iron and vitamin K). It is matched in many ways to the specific constituents of breastmilk (for instance adjusting the branching and chaining of fats). Comparing formula to twinkies is ridiculous, and adds further to the rather unnecessary guilt that some parents may feel about being unable to breastfeed their children. I accept that breastfeeding has benefits over formula (as well as limitations), I accept without reservation that many women love it and love having that unique relationship with their child, and I encourage it for everyone who wants to and is able to. I hate, utterly hate, the anguish felt by mothers who can’t breastfeed, and I hate the guilt, shame and judgement heaped upon woman who choose not to.

            Breastfeeding also has the possibility to be pathogenic and pass along diseases. Some infants are allergic to their parents milk. It’s far more time consuming than formula, and only cheaper if you don’t consider a woman’s time valuable. It’s not harm-free for the woman, there is mastitis, blocked ducts, cracked and bleeding nipples, pain, exhaustion and insufficient milk. It’s not a panacea, breastfed kids still get sick. Claiming that it is the best way to feed a baby because “it is how we have always done it” is both questionable (do we have a continuous history of how humans fed their babies since their divergence from their common ancestors with chimpanzees?) and a fallacy (specifically, the naturalistic fallacy as one way of “naturally” protecting the human species from disease has included killing off everyone vulnerable to it, a practice interrupted through the incredibly unnatural practice of vaccination – that I’m quite in favour of).

            Evolution “perfects” nothing. It is a “good enough” process. Evolution, for instance, would selectively kill off those children whose mothers were unable to produce adequate amounts of breastmilk. Formula interrupts this process, and I’m quite in favour of it. Humans are riddled, absolutely riddled with the scars of evolution (Elaine Morgan died this week, I hope nobody pics up her torch) such as the appendix (mostly useless, highly deadly), the recurrent laryngeal nerve (which wanders down and around the torso before getting to its destination); or the human back (extraordinarily painful in many people since it evolved from a hanging start, not a supporting start). Evolution only cares if you survive long enough to breed – and doesn’t really care about that, it is indifferent to the survival of any single individual or even species. Evolution makes compromises no human engineer would make (sickle cell anemia springs to mind). Further, formula has evolved far, far more quickly than breastmilk has, and as more benefits are identified and their underlying biological mechanisms untangled, formula will improve further in vast leaps completely unattainable for any form of evolution, which again requires death in order to improve.

            Evolution is dumb, we can do much better.

          2. mousedthatroared says:

            NS “Right! It’s only food! Which is why my older children eat a straight diet of Twinkies and frozen pizza. It’s the way I parent.

            ???”
            also
            “when I see people making illogical comparisons I felt the need to comment”

            You are comparing formula with Twinkies and frozen pizza? Then complaining about illogical comparisons…

            Come on, really? :)

        2. mousedthatroared says:

          Thanks Chris – I hope they catch the folks behind those robberies. It sounds like a bad situation.

    2. WilliamLawrenceUtridge says:

      I’ll be the first to admit that my responses are not based on a neutral reading of the information, I’m a bit outraged at the disparity between the rhetoric and the science, and sacred cows should be slaughtered for hamburger. But thank you for the prompt, I’ll try to dial it down a bit.

      I don’t think people should be pushed into breastfeeding, I think children should never go hungry. While I agree that breast is best, and I would react vehemently to any attempt to discourage breastfeeding or scale back efforts to support things like public or workplace breastfeeding, I am equally (probably more) vehement regarding efforts to discourage bottle feeding. It just doesn’t seem to be that much better than bottle feeding, the permanent benefits are extraordinarily tentative, yet even in what should be science-based public health campaigns bottle feeding is treated as if it were a frank and important risk.

      I wish parents were supported in feeding, whatever their choice, and were otherwise left to their own devices. A single question, “how are you feeding?” should be enough, and whatever the answer the next step is how to ensure the baby gets enough food. I wish breastfeeding debates resulted in a resounding “meh”.

      1. Maxesma says:

        WLU
        Infant formulas need to contain more iron than what is in breast milk because of the lower bioavailability of added iron in both cows milk and soy based forms. Iron absorption is about 7 – 12% for formula verses 50% for breast milk. http://pediatrics.aappublications.org/content/104/1/119.full

        1. Angora Rabbit says:

          The situation is more complex than this. While lactoferrin has good bioavailability, breast milk iron content is not adequate for the infant and, above about six months, additional iron sources are needed. For the first six months, the term infant’s iron needs are met by the iron endowment that was transferred placentally in the late term period. For premies, the situation is challenging because we need to meet their iron needs while avoiding toxicity from iron overload. As someone else pointing out, like a lot of things in biology, breast may be best but it is by no means perfect.

  16. Clay Jones says:

    Which part was misinterpreted?

    1. Nova Squadron says:

      Basically just the very first sentence. When I read it I am looking more from the mother’s perspective than the baby’s. The baby will not get confused about the different nipples, but the mother’s body will get confused if there is not milk being expressed in the amount that matches the baby’s needs.
      Also, FYI all the LLLI articles are written by LLL leaders – and there are probably thousands of them. There is little required to become a leader beyond having personal experience breastfeeding, so one can’t give any the articles much authority. The question remains then, where should women go for breastfeeding advice? The generation before was told to formula feed. The CDC no longer has their lactation hotline. Most doctors offices don’t have lactation consultants on staff. Little wonder they turn to message boards and blogs.

      1. Chris says:

        “The question remains then, where should women go for breastfeeding advice?”

        Most hospitals with birthing centers and outside of hospital birthing centers, plus midwives, have lactation consultants. It took ten seconds on Google to find one in my local area.

        I had my first kid twenty five years ago. This was when breastfeeding was really, and I mean really getting a big push. Not long after my newborn was taken away in an ambulance, a nurse came in with a breast pump. The Children’s Hospital had special breast pump rooms and places for us to leave the milk! The women who had kids the same time I did while we were getting into breastfeeding (and often proudly in public) are now having children.

        This was at a time when the real formula fiend would be Nestle for pushing formula in developing countries where there was little money, and no safe water. Which is apparently still a problem. That is where formula is the problem.

        Trust me, in the North America and Europe there are more pressing things to worry about than whether or not your neighbor is giving their baby formula. Like multiple armed robberies less than a block from where my younger son lives! (sorry, that is kind of on my mind now, since my youngest just left with her friends to walk to some stores, we live less than a mile from her brother)

  17. Nashira says:

    Right, are we talking from a screened donated milk bank here, or (as your citing wet nurses suggests) do you mean milk from some kind soul you know personally? Given that breast milk can be a disease vector, I am so not okay with the idea of feeding my kid another woman’s milk unless it is screened, sterilized, and distributed by a milk bank.

    And even then, I would only request that donated milk for a premature infant – otherwise I would feel like I was stealing life-saving medicine from someone else. Formula is perfectly good food for full term infants. One doesn’t have to let perfect be the enemy of good enough, in all things.

    1. Nova Squadron says:

      Ha! Glad I could sufficiently gross you out. I mentioned wet nurses just as a nod to the fact that it was done historically, not in a “let’s all be Salma Hayek” kind of way.

      As someone who has been on the donating end of the equation I will say that I have thought long and hard if I would accept milk from another person and the answer is no I would only accept screened and pasteurized from a milk bank. That said, I have donated both to a milk bank as well as privately (to friends as well as strangers – hey, I needed room in the freezer).

      1. WilliamLawrenceUtridge says:

        Nova, I’ve obviously been somewhat intemperate in my rhetoric (might even be a button issue for me…) but a healthy nod of respect, a firm internet handshake, a genuine bit of encouragement and an honest recognition for you taking the time and effort to donate breastmilk. For what it’s worth, though I may disagree regarding the risks of formula feeding, I agree that breastmilk banks are a good thing and requires generous volunteers (like yourself) to take the time.

        So for all the strangers you might help, a big thanks.

      2. Nashira says:

        @Nova: It is bad ass that you donated! Thank you for doing so. Even if you had enough extra milk to open a creamery, it’s significant and awesome that you took the time and effort to share it with a bank.

        1. Chris says:

          Agreed. She does indeed walk the talk.

  18. Nashira says:

    Dang it, forgot about the bad threading. My comment #17 was in response to NovaSquadron’s listing formula as the ‘fourth best’ food for infants.

  19. “Spit cleaning.” Yuck.

    I did tons of baby-sitting as a teen, and I grew to HATE pacifiers with a passion bordering on mania. I’d be sitting doing my homework, bowl of ice cream close at hand, baby sleeping peacefully. And then not, wailing desperately, because the pacifier fell on the floor. Or at the park, where the baby dropped the pacifier and neither of us noticed until we’d walked much farther, and then it was lost and the baby was furious all the way home, or at the mall, dropped on the filthy floor, and there was no place to wash it. Or the ugly rash a cute baby would develop around the mouth from the pacifier, and having to put the antifungal cream on a squirmy child.

    I raised my daughters without pacifiers. But I didn’t know about the slight SIDS benefit, and if I were to work as a retail pharmacist again, I think I’d be wrong not to mention it. Formerly, I always recommended against pacifiers, mainly for the reasons detailed above. Mainly, the risk of facial Candida makes pacifiers a tough sell.

  20. leah says:

    “stating that ”Dental effects are generally reversible and unlikely to cause any long-term problems if the habit is discontinued by the age of 5.””

    I think this reveals a problem that is serious but often overlooked. The medical profession seems to be overwhelmingly blasé about iatrogenic problems as long as they think that they can be mitigated or don’t cause *measurable long term effects. This is especially prevalent in obstetrics. Considering that – despite efforts, and the well known and publicized health benefits – breastfeeding rates are still poor, maybe it is time that studies look into some of the possible reasons that involve our obstetric practices in general that might be influencing breastfeeding rates.

    And, in reference to another post and retort, individual anecdotes are not of much value- but they are not entirely worthless either – the health benefits of breastfeeding are well known. If someone points out health issues they have in reference to their having been fed formula, that is as much a valid point as pointing out that you were breastfed and still have problems. The data, however, point to the reasonable possibility that someone who experiences certain health problems may not have experienced them if they were breastfed. Although anecdotes are not worth much, the consensus certainly favors one over another.

    Tying back into my original point, long term health effects may not reveal themselves in easy to identify trends such as life expectancy or heart disease, but we know there are appreciable differences in for example -quality of life related to obesity, or overall health related to dental health. The long term effects of feeding formula may not be appreciable in a table, but they are experienced by individuals, not graphs. Consider the child who is afraid to smile because they are experiencing dental/orthodontic problems or the missed job opportunities to someone sick at home with digestive issues, or the impact of medical interventions related to health problems – these may not show up as measurable long term effects and may even be something that is controlled for, but they are quite influential. What about the costs of orthodontic procedures? What about the use of antidepressants related to poor self image? What about the effect of the relationship between mother and child? Measurable long term medical effects rarely account for the realities of peoples lives that include a host of incidental, but hard to measure, consequences.

    1. WilliamLawrenceUtridge says:

      As a parent, I would also be blase about practices that don’t have long-term effects. If breastfeeding genuinely improves lifelong IQ, I’m interested. If it only prevents GI infections (thanks for your reply Dr. Jones, very interesting!) I’m much, much less interested and am irked by the rhetoric and effort put into promoting it. I’m especially irked that they are actively depriving parents of options in terms of formula samples and coupons. Some parents need those samples to have enough money to pay their rent.

      The fact that breastfeeding rates are poor is questionable (in the US it’s around 2/3 of all children) particularly given the lack of evidence of clear, unambiguous and clinically significant benefit to breastfeeding over formula.

      Anecdotes are hypothesis-generating, they cannot confirm a hypothesis.

      If the long-term benefits to breastfeeding are significant, they should show up in the studies. If they are so rare that it is difficult to demonstrate them, that suggests that their clinical significance is limited and no parent should have to agonize over whether they could have prevented their child’s cancer by breastfeeding. Much of the rest of your comment appears to be a meditation on unmeasured possible sequelae of not breastfeeding – all of which are largely irrelevant in the absence of evidence linking these issues to breastfeeding. What about a mother who gets depressed because she can’t breastfeed and feels like a failure? What about the child whose first months of growth and neurological development are stunted because their mother insists formula is poison? What about the infant infected with HIV through breastfeeding (which is an actual, confirmed risk by the way, not a hypothetical)?

      What ifs can be agonizing, they will always haunt parents. A what if based on a hypothetical is needless agonizing.

      1. Calli Arcale says:

        Breastfeeding *initiation* is high, but keeping it going is not. Most mothers are breastfeeding when they leave the hospital. At six weeks, a lot of them have stopped. At two months, very few are. I see this more as a symptom than a problem in itself, though. It’s a symptom of the lousy support breastfeeding mothers get; it is no coincidence that most women stop breastfeeding at six weeks. Six weeks isn’t a magic age in infant development, but it *is* a magic age in most companies’ maternity policies.

  21. WilliamLawrenceUtridge says:

    A question about the antibodies in breastmilk. They line the GI tract and prevent diarrhea and whatnot. Any evidence they cross through the mucosa into the bloodstream?

  22. Clay Jones says:

    Humans differ from other animals in that although the human fetus receives IgG antibodies, sometimes ones that cause harm, from mom via the placenta, IgG ingested after birth does not enter circulation. The primary protective component of human breast milk is IgA, which protects against infection at mucosal surfaces. Newborns do not produce secretory IgA and receive a large dose of them in colostrum. There are other likely immunemodulating components of breast milk however such as macrophages and leukocytes that, along with IgA, would not be found in formula and likely play some role in protecting newborns and young infants.

  23. cphickie says:

    As a pediatrician*, babies who won’t take binkies often binkify their thumbs. I don’t think either is a big deal other than binkies get lost and until your wee one is 4-6 months old, they typically can’t put them back in their mouth, so they often cry (in the middle of the night) for you to do so. My kids all breastfed–two would only take breast and cared not for bottle or binky. I wished they would have taken a bottle so I could have bonded with them by bottle feeding, but as far as I can tell they’ve still wound up normal children who still love their dad and were not in any way emotionally traumatized by my absence at feeding time

    My basic “rules” in this area are along these lines: (1) binky? ok. (2)No binky? also ok. (2)Thumb? Well, how are you going to stop that in an infant anyhow short of tying up their hands? (4) breast milk? great. (5) formula? fine. (6) both breast milk and formula? just dandy. (6) anything other than breast milk or formula during infancy= concern for child abuse/neglect.

    *I am not a shill from big lactation, big formula, big binkies or big thumbs. I also think the Sears family is a bunch of morons.

  24. nancy brownlee says:

    @cphickie
    “(6) anything other than breast milk or formula during infancy= concern for child abuse/neglect. ”

    Just curious- how are you defining ‘infancy’? My assumption, when my own children were babies, was that once they were big enough to make a grab for my tuna sandwich, they were big enough to have a very tiny shred of it- just a taste. I do the same with the grandchildren. All the kids have eaten from the table (well mashed veges, unsalted, tiny minced bites of meat) as soon as they could manage it- mostly some time between 6-8 months. All self-weaned (breast fed, some formula) by 15-18 months. No problems, no food allergies.

    1. chris hickie says:

      I should have been more clear–I was not referring to introducing solids and I was talking about using anything else in place of breast milk or formula, most especially so in the first 6 months and preferably out to 12 mos. This includes cow and goat milk, as well as “soy” milk and all those other “milks” out there. Your baby only needs breast milk or formula in the first 4 months of life. I have seen some pretty sick babies who were getting other things.

  25. Calli Arcale says:

    The claim about pacifiers increasing pain in a breastfeeding mother makes me laugh uproariously, because in my case, it was entirely the opposite!

    With my first child, the lactation consultants were keen to tell us not to use a pacifier if we could at all avoid it, because of the danger the child would then have to be bottle fed. I consider myself a skeptical person, but I had no parenting experience, and besides, when you have a newborn you are not operating on a lot of sleep. Anyway, I was dutifully offering the breast anytime the baby cried and could not be soothed with a little rocking or bouncing. The result was that within a week and a half, she was nursing every hour, even at night, I had almost no sleep, and my nipples were getting severely chapped. I would cry when she’d latch on, because it was so excruciating by then. The doctor actually had me use the oxycontin given to me for postpartum recovery (I’d had a c-section) to take the edge off, and also *ordered* me to use a pacifier and not allow the baby to nurse any less than 2 hours apart.

    Turns out, using the breast for your only soothing mechanism creates exactly the sorts of problems the lactation consultants wanted to prevent — bad nursing habits and insufficient milk supply. WIth only an hour between nursings, there wasn’t time to make enough milk to satisfy her hunger, so a nasty feedback loop had been started. Once we started using the pacifier, everything changed. I nursed her for a year an a half before completely weaning. With my second child, we had a pacifier available for her right in the hospital, and had nowhere near the problems. She also nursed a year and a half. Both children were also drinking from a bottle during daycare, yet were quite happy to go back to the breast when I was around. I observed precisely zero confusion from them. Honestly, food is so intensely rewarding that of all the things infants can get confused about, I’d have to say this is about the last.

    1. Maxesma says:

      “turns out, using the breast for your only soothing mechanism creates exactly the sorts of problems the lactation consultants want to prevent – bad nursing habits and insufficient milk supply.”

      Citation needed

      I don’t doubt that this method worked for you and I’m really happy that you were able to breastfeed as long as you wanted to, but there are too many individual factors surrounding breastfeeding, such as breast volume and age of infant, to make such broad statements about breasts needing time to fill, for everyone without some backing.

      Many of the people that I know who work with new families are less concerned about soothers and so called “nipple confusion” than with those families who have milk supply issues and have been using a soother to space feedings to some “non science based” ideal or average length of time between the feeds.

      Sorry about the run-on sentences, I’m new to this

      1. Calli Arcale says:

        Citation: my doctor. ;-) But c’mon, I mean why would you need a citation that breasts don’t instantly fill with milk, or that it’s unhealthy to let the baby nurse 24+ times a day? Spontaneous generation isn’t a thing in this universe, and mothers need SLEEP dammit.

        Seriously, I’m not trying to imply there is some magic ideal time between feedings. Just that letting the baby latch on every time the baby screams, given that a normal baby will scream for far more reasons than just being hungry, is not going to work out. If any lactation consultant told me I should let my baby continue nursing every time she wanted to suck, when she was asking 30-45 minutes after the last time, 24 hours a day, I would ask them to kindly take my breastpump and shove up their backsides. There is no planet where that is going to result in a healthy out come for anybody.

        Look, I’m saying it’s not healthy to have the baby latched on more often than not, and you bring up how making the baby wait too long wasn’t helpful in people with milk supply issues — these are actually different problems, and I hope you can see that.

        1. Maxesma says:

          In no way was I trying to say it is a good thing for babies to be on the breast 24/7. That isn’t good for anyone. I was being a bit facetious because breastfeeding and baby care advice is one area where professionals and non professionals continue to make stuff up and present it to parents as gospel, science based and the one-true-way. There is a lot of emotions involved by both those giving the advice and the ones receiving it. Often it is given based on what worked for them with no evidence for what they are saying.

          Information on breastfeeding has increased in the past 25 years and much of what was thought to be true has turned out not to be so. One thing is the idea that the breasts are empty after a feed and need time to fill. You said that “with having only an hour between nursing, there wasn’t time to make enough milk to satisfy her hunger”.

          Babies cry for many more reasons than hunger and many parents confuse this crying for hunger and start to feel that they don’t have enough milk when baby just need to suck – on anything. Thinking that they have low milk supply because they are crying is one reason parents start to supplement or just give up on breastfeeding.

          I have no problem with soothers, just with statements that frequent feeds can cause bad habits and low milk supply.

          Confession: both my babies had soothers until they were 4 years of age when I had to buy them off them

          1. Chris says:

            Thank you.

            Written word on an internet forum does not always convey intended meaning.

            Pacifiers (or has my Canadian mother-in-law called them, “soothers”), were essential to my sanity. Especially with the third child who somehow managed to infect my breasts with some bacterial infection (ow!), and then still insist on trying to feed at the swimming pool as we changed with she was almost three years old! (Despite being on the university’s Dean’s List, she still drives me crazy… I sense a pattern…)

            By the way, I made bibs from tiny towels (“finger tip guest towels”, which are much smaller than the ones in the link, I would buy them on sale). But I would include a grosgrain ribbon loop to hold the pacifier on another ribbon. They were similar to to this, only it was snaps looped through a grosgrain ribbon loop on the bib. That was color coordinated.

            I was so anal. They were quite lovely though. I used the bibs as a way to practice applique and free-hand machine embroidery. I gave one with a sled dog on it to a teacher from Alaska who taught my daughter about the Iditarod Sled Race, a gold fish for a friend who had several large aquariums, some stars (including a “Red Dwarf”) for a friend who was an astronomer, and the radiation danger sign for a former Navy nuclear engineer who now works for the state’s Health Dept. on radiation issues.

  26. LongtimeLurker says:

    Great post. Though I recognize my personal experience doesn’t constitute “proof” of anything, let’s just say it’s perfectly consistent with what’s said here. My baby sucked on my nose, repeatedly, until her eyesight improved enough to realize that’s not where the food was. She was ravenous from the get-go (before the milk came in) and the hospital staff, though very very very encouraging of breastfeeding, suggested that perhaps a supplement here and there wouldn’t be a problem. Bless them for having exactly the right attitude. Anyone who thinks that hospitals and doctors don’t push breastfeeding hasn’t lived in this country in at least the last two decades.

  27. Rob Cordes, DO says:

    Clay,

    I’m a bit late on commenting but thanks for the post.
    While the world may need more Mark Crislip SBM needs more pediatrics.
    I remember a pacifier presentation at a Medical Associates to LLLI meeting in the late 90′s and the presenters only evidence of potential harm was that pacifier sucking could delay feeding cues.

  28. Shy mummy says:

    I read the article and the comments with interest. I attend La Leche League meetings. I’m a working mother who supplements with formula as I’ve breastfed after breast reduction surgery.

    I’ve enjoyed the support and kindness at the meetings, where some mothers attend with babies who are sucking on dummies and where mothers who have very strong let downs are sometimes given suggestions such as leaning back when feeding or using a dummy as their child wants to suck but is overwhelmed with a gush of milk each time.

    For those of you who haven’t attended a meeting, how it works is that there is a leader who facilitates the discussion, but those attending share tips in answer to questions – it is a support group. Breastfeeding does attract many of the crunchier types of mothers, and they do say some pretty outlandish things at meetings, but there is usually a counter voice of common sense from another mother, and if there isn’t the facilitator will usually correct the information – if she has heard it and it wasn’t a furtively whispered comment at tea time, or put an end to a discussion that is veering off topic from breastfeeding. I attend other parenting groups that aren’t about breastfeeding too, such as mother and toddler classes, and find the same crunchy mother element there too, and have heard the same outlandish things said there by both breastfeeding and bottle feeding mothers and once even by the woman running the toddler activity class. I don’t think it mattes much where you are, there is always a mother suggesting chiropractic for colic (shudder), homeopathic remedies and asking for recommendations for naturopaths. I hear it among mothers at my older child’s school (no idea whether most of them breast or bottle fed or used dummies or not).

    Never have I been made to feel uncomfortable for giving my baby formula, for expressing milk at work or for leaving my children in the care of a nanny while I work or using disposable diapers (aren’t these the usual things crunchy mothers lambaste other mothers for?). I’ve even found their book (The Womanly Art of Breastfeeding) and the meetings helpful for learning how to introduce a bottle so that our nanny could do so while I was at work (I supplemented with an SNS – a device for giving supplemental feeds at the breast). Like all books, I take what I read in the Womanly Art of Breastfeeding with a pinch of salt, though overall, I have found it one of the better parenting books. Others might prefer other books of course, we all have different parenting styles. It is definitely the most helpful book on breastfeeding that I’ve read, but perhaps others have found other books more helpful.

    When it comes to babies who are gaining weight slowly, I’ve heard a leader tell a mother how to increase her milk supply by feeding more frequently so that the baby takes in more milk (so not on the four hour schedule she was feeding on because she read it in a book) and expressing and using that milk to supplement and then to use formula if baby is still hungry. There are mothers who don’t want to give their baby formula and when a doctor tells her that she must do so without giving her information on all she can do before giving the formula the mother then approaches La Leche League for information, she isn’t being pushed into doing these things, the choice is still hers whether she wishes to put in a lot of effort to get her baby’s weight up and then continue exclusively breastfeeding, or if she wishes to give a small amount of formula after feeds as her doctor has suggested – or do both. Nobody has contradicted her doctor, just suggested additional things the mother can do too.

    I do sometimes chuckle when I hear people speak about La Leche League as being complete breastfeeding zealots, as I think more often it is isolated group members, not representatives of the organisation who attach themselves and then give the bad name. I’ve found kindness, cooked meals dropped off at my home on my first day back at work, practical tips and information to help me fit breastfeeding into my life. I’m sure there are others who have not had such positive experiences, that is life.

    Some in my situation would have chosen not to breastfeed, and that is their choice. I don’t really care how formula has improved, I wanted to breastfeed because I enjoy the closeness and I think it is the normal way to feed a baby – all mammals feed their children their milk. I have used formula to fill the gap. I know that I could have used human donor milk, but I preferred to use formula. I was quite comfortable that it was a well researched product and not harmful to be fed to my baby. I’ve met people who think it is an evil product responsible for every illness known to man, but that is completely illogical, so I pay about as much attention to that as to anything to do with religion (nothing at all).

    Sorry, I know this has been one long story about my personal experiences with La Leche League (who by the way was started by 7 Catholic women, but which is not a religious organisation). At meetings, if a mother does bring up a subject (such as religion or politics.) that is not breastfeeding related, the discussion is brought back onto breastfeeding,.

    Just so you know, the bottles my babies have had have been given fairly horizontally so that the milk didn’t gush out but that they had to suck a little bit before getting at the milk, just as they would at the breast to get a let down. Did this help my babies not to prefer the faster flow of the bottle? I don’t know. Was it that my babies were older when I went to work (7 months) and already happily breastfeeding for comfort and warmth and not just milk? I don’t know. Anyway, like many mothers who bottle feed expressed milk and formula while at work, it worked out just fine. Have I seen mothers attend groups in tears because their baby only wants a bottle and is rejecting the breast after being bottle fed while she is at work? Yes. Does anyone know exactly why this happened? No. Some of those mothers change to bottles and stop breastfeeding and some change to cup feeding while at work and then hope baby goes back to the breast – some have and some haven’t. I doubt anyone has researched these things, they’re just suggestions mothers give each other – like we all do with how to get burps up, whether to rock baby standing and singing or on a gym ball or a rocking chair or by doing the special dance our mother in law swears by.

    I’ve even heard a leader say to a mother who was going a bit overboard about bonding “mothers who bottle feed bond with their babies too” and then proceeded to say that there are many ways to bond with babies – bathing them, holding them, smelling their delicious baby smell, reading to them, singing to them.

    Mostly what I hear at the meetings are general tips – some mothers prefer it if baby comfort sucks at the breast, some prefer it if baby uses a dummy and some don ‘t mind thumb sucking. Some mothers use a pram and some mothers use a sling. The leaders at the group that I mostly attend (I’ve been to a few around the city) frequently state that there are many different ways to meet a babies needs and each method is just one tool and that different mothers and different babies will have different preferences.

    The purpose of the organisation is to support breastfeeding mothers in their breastfeeding, and that is what they do. They don’t exist to help mothers to formula feed. When I’ve needed information on formula, I’ve got it from the nursing sister at the clinic I weighed my babies at and our paediatrician and the back of the tin. I gave birth at a baby friendly hospital and when I asked for a cup of formula, it was given to me without questions and a note on my chart saying that I had requested it. Was it locked up? I’ve got no idea, it was brought to me at my bed already prepared and in a bottle which I decanted into the cup provided. This was on day two and my baby was particularly fussy and hadn’t urinated yet, so I was worried about low supply from the breast reduction at that point already. She took 5ml of formula after I had breastfed her from both breasts twice and was still fussing, and she urinated a little later. At that age, about 10ml is apparently almost a full feed as colostrum is quite small in volume and more concentrated than mature breast milk. I wouldn’t know though, I’m no expert, just a breastfeeding mother.

    Apologies for my long personal story, I just thought that it might be relevant to the discussion.

    1. WilliamLawrenceUtridge says:

      There are mothers who don’t want to give their baby formula and when a doctor tells her that she must do so without giving her information on all she can do before giving the formula the mother then approaches La Leche League for information, she isn’t being pushed into doing these things, the choice is still hers whether she wishes to put in a lot of effort to get her baby’s weight up and then continue exclusively breastfeeding, or if she wishes to give a small amount of formula after feeds as her doctor has suggested – or do both.

      This is kinda the nub of it though – the idea that someone must do all she (or he) can before giving formula. The idea that breastmilk is a cure-all, is perfect, or that formula is a risk is the issue, one that now pervades parenting including amongst pediatricians, the idea that all the benefits of breastfeeding are solidly demonstrated through high-quality research (when really it’s far, far more equivocal).

      Parents shouldn’t have to be apologetic for using formula. The question should be “what can we do to ensure your baby thrives”, not “how can we make more people breastfeed”.

      1. DugganSC says:

        :) True. Although, you are talking about how a group devoted to breastfeeding emphasizes breastfeeding, not formula. Complaining about that is like complaining that meetings at your local cycling group talk all about the health benefits of cycling and never stop to discuss the health benefits of operating a motorcar or complaining that the local meeting of Young Democrats don’t do enough discussions about the good points of George W. Bush.

        1. WilliamLawrenceUtridge says:

          Eh, I’m trying to aim my comment (and comments, for this thread in general) at a broader topic. I’m happy the LLL exists, since women should be supported in breastfeeding. I’m unhappy that such disproportionate emphasis is placed on it. I’m irritated that sanctimommies feel empowered to judge parents who use formula. I’m kinda pissed that they pretend it’s all based on rock-solid evidence rather than the naturalistic fallacy and modern middle-class unconscious preconceptions about “total parenting”.

          I should have chosen my quote a little more specifically :)

    2. Chris says:

      “Breastfeeding does attract many of the crunchier types of mothers, and they do say some pretty outlandish things at meetings, but there is usually a counter voice of common sense from another mother, and if there isn’t the facilitator will usually correct the information – if she has heard it and it wasn’t a furtively whispered comment at tea time, or put an end to a discussion that is veering off topic from breastfeeding.”

      Not in my experience. After I left the one and only LLL meeting I went to, I was literally in tears. Sometimes it depends on the people who are part of it, and I hated being belittled because my kid needed community immunity for a disease that was circulating in the county, and that he was not developing normally on time. It was a classic “blame the mother” thing.

      I hope you can understand why that horrible experience colors my opinion of the organization. So I will accept that it is not like what happened to me in all LLL groups.

      1. Shy mummy says:

        That must have been very upsetting. What a pity you ended up in a group where there were a few of the unpleasant mother types. I have been going to LLL meetings for years and have only seen a mother here and there behave like that, and they’ve all been shot down by someone else fairly quickly. I attend one group mainly, but have attended a few others a few times too. I’ve seen that same type of anti vaxx, everyone should live on kale mother at baby swimming classes, toddler music classes. I think it is a problem at all mother gathering places.
        I won’t comment further on the other responses, I don’t have enough knowledge to. Just wanted to say that in my experience they stick within their purpose which is to support breastfeeding. I’ve not been made to feel there is anything wrong with giving formula as a supplement because of my low milk supply fron the breast reduction.

  29. Rynna says:

    As a Lactaction Counselor and mother myself, I applaud this post. Current training programs for lactation professionals are beginning to teach that pacifier use has minimal, if any, impact on breastfeeding outcomes, and is in fact extremely helpful in the outcomes of preterm infants. Speaking from personal and professional experience, as well as research presented to me during trainings, the only “nipple confusion” to be worried about is prolonged bottle use in breastfed newborns; it is very difficult to get a week-old baby to breastfeed for the first time when s/he has been given a bottle every three hours. Newborns are naturally lazy and prefer to conserve their energy, so of course they are going to prefer a free-flowing bottle to a breast that requires work.

    I do wish that pediatricians were more educated about breastfeeding. Most that I’ve encountered are generally quite supportive of it, but can offer no help, and often even use outdated growth charts (breastfed infants tend to follow a different growth curve than formula fed infants). Granted, I live in the Bay Area which is a little more progressive than the rest of the country; there are still many places in Tennessee and Georgia where pediatricians will actually push formula and discourage breastfeeding.

    I also wish that the stance on breastfeeding these days wasn’t so militant. As a lactation counselor, I am passionate about breastfeeding and I obviously want to encourage it as much as possible. But this is 2013, and breastfeeding isn’t for everyone. And that’s ok.

    Thanks for another great read, SBM.

  30. AH says:

    It may be that breastfeeding does not have economic benefits.

    http://asr.sagepub.com/content/77/2/244

  31. Carol says:

    It is sad that these organization have given pacifiers a bad rap without researching the pro and cons more. I agree with you that the pacifiers doesn’t hinder a baby from breastfeeding. I also, agree that the pacifier helps with calming a baby and giving it security. They have blown this way out of proportion.

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