"Whenever I go into a restaurant, I order both a chicken and an egg to see which comes first"

Wednesday, August 1, 2012

The Case Against Breastfeeding

An article in today’s (8.1.12) Atlantic http://www.theatlantic.com/health/archive/2012/07/a-womans-right-to-choose-not-to-breastfeed/260530/ discusses Nanny Michael Bloomberg’s most recent campaign to protect us from ourselves:

New York City's new pro-breast milk policy stigmatizes infant formula and limits access to it, effectively revoking women's freedom to feed their babies as they choose.

Already leading one of the most aggressive "pro-breast milk" campaigns in the country, New York City has announced that it will now track usage of infant formula. In the latest salvo in the push to turn breastfeeding from a healthy option to a public mandate, hospitals will keep formula locked away, treating it more like contraband than basic infant sustenance.

For years I have followed the issue of breastfeeding and was on hand for its introduction into the Western Canon and its transformation from a reasonable nutritional intervention into a political cause led by La Leche League.  I participated in USAID-sponsored programs in the developing world which, like Mayor Bloomberg, demonized bottle-feeding, and in gross contradiction to the feminist appeal to free women from the slavery of a subservient marriage, forbade any mention of the bottle – a helpful tool which could enable them to work outside the home. An even grosser irony was the fact that the very same La Leche League women who evangelized for St. Breast had benefitted from the bottle.  Women who fed their children formula were able to take their first steps out of the home and into the world of work, individual status, and economic independence.  To no discernible disadvantage, I might add.  Everyone in the power corridors of New York or Washington sucked only formula.   Our greatest talents born in the 40s and 50s were bottle-fed. Whole generations were bottle babies.  So what’s the big deal now?

Perhaps the main reason for avoiding the bottle in the developing world is contamination and infection.  If a woman exclusively breastfeeds, she will not have to feed her baby formula made with river water in a dirty bottle with flies breeding on the caked, sugary mess around the nipple.  This is a good thing, and while ‘experts’ in the thrall of La Leche began to suggest the links between breastfeeding and earaches, intelligence, and self-esteem, most of us knew that simply avoiding river water would result in the reduction of disease.  Self-serving breastfeeding advocates used the positive data for their own ends, suggesting that it was breast milk itself rather than the avoidance of contaminated water that was responsible for the decrease; but most of us felt that the breastfeeding was a good thing, and if ever a positive correlation was established between breast milk itself and disease prevention, so much the better.  The women in South Asia and Africa where I was working could indeed use all the help they could get, for their children were daily assaulted by diarrheas, upper and lower respiratory infections, skin diseases, eye diseases, ear infections and much more. 

I was often appalled by the doctrinaire approach of breastfeeding advocates.  The focus was on exclusive breastfeeding, and the campaigns run in the US-funded projects allowed for no breach in the wall.  If you even hinted that an occasional bottle is acceptable, then the wall would come tumbling down, and the breast would be forever covered.  I worked on a breastfeeding project in the Dominican Republic, one that had been designed to promote exclusive breastfeeding.  “What about the women working in the Zona Libre”, I asked.  The Industrial Duty Free Zone was a geographical area where where local and foreign companies could be established and their products or services shipped to the international market with incentives that would boost their development such as customs special controls and tax incentives. Women working there could earn far more than they could anywhere else on the island, and the economic rewards would enable them to provide better education and health care for their families.  It was a way out of poverty.  In order for women to work in these factories, they would have to leave their babies with a caretaker who would feed them the bottle.

“Absolutely not!”, shouted the breastfeeding czar of the project.  “We are promoting exclusive breastfeeding only.”  I argued that a more reasonable campaign addressing the needs of these women would be built around mixed feeding and focused on the importance of sanitary bottles and water, would resonate more, more women would continue breastfeeding, and certainly with the additional income earned, they would be better off.  Needless to say, my appeals were rejected out of hand.

Breastfeeding had become a religion, so I was not surprised when I returned to the United States and witnessed the same La Leche League onslaught.  The problem was that most babies were not exposed to the same pathogens as Third World infants.  Their world, protected by vaccines, good nutrition and health care, immaculate counters and floors was far different from the fly-infested, feces-polluted, infection-ridden village of Bangladesh or India.  Why should an American woman delay her return to productive economic life and be beset with the miseries of breast-pumping when the advantages of breastfeeding were so relatively minor and the evidence for them tenuous at best?

A previous article in the Atlantic, entitled The Case Against Breastfeeding http://www.theatlantic.com/magazine/archive/2009/04/the-case-against-breast-feeding/7311/3/  raises these and other issues in detail.  Basically the author states that the evidence for breastfeeding benefits is inconclusive, and yet the breastfeeding lobby and interest groups have kept up their drumbeat to such a degree that millions of women continue to breastfeed.  Not only that, breastfeeding has become the only acceptable membership card to the new, upwardly-mobile, politically-aware and environmentally-concerned Motherhood.  Not to breastfeed is grounds for dismissal from the group and the playground.  The author complains:

Still, despite my stint as the postpartum playground crank, I could not bring myself to stop breast-feeding—too many years of Sears’s conditioning, too many playground spies. So I was left feeling trapped, like many women before me, in the middle-class mother’s prison of vague discontent: surly but too privileged for pity, breast-feeding with one hand while answering the cell phone with the other, and barking at my older kids to get their own organic, 100 percent juice—the modern, multitasking mother’s version of Friedan’s “problem that has no name.”

A chance glance at a 2001 issue of the Journal of the American Medical Association open to an article about breast-feeding gave her pause and reason to explore further:

“Conclusions: There are inconsistent associations among breastfeeding, its duration, and the risk of being overweight in young children.” Inconsistent? There I was, sitting half-naked in public for the tenth time that day, the hundredth time that month, the millionth time in my life—and the associations were inconsistent? The seed was planted.

After a couple of hours [of investigation], the basic pattern became obvious: the medical literature looks nothing like the popular literature. It shows that breast-feeding is probably, maybe, a little better; but it is far from the stampede of evidence that Sears describes. A couple of studies will show fewer allergies, and then the next one will turn up no difference. Same with mother-infant bonding, IQ, leukemia, cholesterol, diabetes. Even where consensus is mounting, the meta studies—reviews of existing studies—consistently complain about biases, missing evidence, and other major flaws in study design.

“The studies do not demonstrate a universal phenomenon, in which one method is superior to another in all instances,” concluded one of the first, and still one of the broadest, meta studies, in a 1984 issue of Pediatrics, “and they do not support making a mother feel that she is doing psychological harm to her child if she is unable or unwilling to breastfeed.” Twenty-five years later, the picture hasn’t changed all that much. So how is it that every mother I know has become a breast-feeding fascist?

Of all the controversies surrounding breastfeeding, perhaps the most overlooked is the guilt factor – a mother is not being a good mother or good parent if she deprives her baby of this magical benefit.  The loss of income, the interminable two-hour on-demand breastfeeding, and the Torquemada torture of the modern rack – the breast pump – is nothing compared to the Guilt of the Modern Mother.  Most women, if given the facts and allowed to assess their own, personal cost-benefit of breastfeeding, it is doubtful that they would continue or even begin; or perhaps would feed for the first few months before a return to work (which is what most women do now anyway)

The debate about breast-feeding takes place without any reference to its actual context in women’s lives. Breast-feeding exclusively is not like taking a prenatal vitamin. It is a serious time commitment that pretty much guarantees that you will not work in any meaningful way. Let’s say a baby feeds seven times a day and then a couple more times at night. That’s nine times for about a half hour each, which adds up to more than half of a working day, every day, for at least six months. This is why, when people say that breast-feeding is “free,” I want to hit them with a two-by-four. It’s only free if a woman’s time is worth nothing.

The problem is a rush to judgment conditioned by associative belief.  "Breast milk must be better”, advocates intone.  “It is natural”.  Their belief in the protective and developmental powers of breast milk are conditioned by a wider belief in things natural and organic, not by science.

Since 1961 labs have hunted for other marvels. Could the oligosaccharides in milk prevent diarrhea? Do the fatty acids boost brain development? The past few decades have turned up many promising leads, hypotheses, and theories, all suggestive and nifty but never confirmed in the lab. Instead, most of the claims about breast-feeding’s benefits lean on research conducted outside the lab: comparing one group of infants being breast-fed against another being breast-fed less, or not at all. Thousands of such studies have been published, linking breast-feeding with healthier, happier, smarter children. But they all share one glaring flaw.

They are methodologically flawed.

An ideal study would randomly divide a group of mothers, tell one half to breast-feed and the other not to, and then measure the outcomes. But researchers cannot ethically tell mothers what to feed their babies. Instead they have to settle for “observational” studies. These simply look for differences in two populations, one breast-fed and one not. The problem is, breast-fed infants are typically brought up in very different families from those raised on the bottle.

Researchers try to factor out all these “confounding variables” that might affect the babies’ health and development. But they still can’t know if they’ve missed some critical factor. “Studies about the benefits of breast-feeding are extremely difficult and complex because of who breast-feeds and who doesn’t,” says Michael Kramer, a highly respected researcher at McGill University. “There have been claims that it prevents everything—cancer, diabetes. A reasonable person would be cautious about every new amazing discovery.”

Even the core principle of immunological protection has caveats attached:

A human baby is born with antibodies already in place, having absorbed them from the placenta. Breast milk dumps another layer of antibodies, primarily secretory IgA, directly into the baby’s gastrointestinal tract. As the baby is nursing, these extra antibodies provide some added protection against infection, but they never get into the blood.

The claim to improvement in I.Q. is similarly doubtful:

Both the Kramer study and the sibling study did turn up one interesting finding: a bump in “cognitive ability” among breast-fed children. But intelligence is tricky to measure, because it’s subjective and affected by so many factors. Other recent studies, particularly those that have factored out the mother’s IQ, have found no difference at all between breast-fed and formula-fed babies. In Kramer’s study, the mean scores varied widely and mysteriously from clinic to clinic. What’s more, the connection he found “could be banal,” he told me—simply the result of “breast-feeding mothers’ interacting more with their babies, rather than of anything in the milk.”

And yet, despite the lack of evidence linking breastfeeding to any of the positive results claimed, the breastfeeding mafia continues its assault:

In 2004, the Department of Health and Human Services launched the National Breastfeeding Awareness Campaign.  One television ad shows two hugely pregnant women in a logrolling contest, with an audience egging them on. “You wouldn’t take risks before your baby is born,” reads the caption. “Why start after?” The screen then flashes: “Breastfeed exclusively for 6 months.” A second spot shows a pregnant woman—this time African American—riding a mechanical bull in a bar while trying to hold on to her huge belly. She falls off the bull and the crowd moans.

To convey the idea that failing to breast-feed is harmful to a baby’s health, the print ads show ordinary objects arranged to look like breasts: two dandelions (respiratory illness), two scoops of ice cream with cherries on top (obesity), two otoscopes (ear infections). Plans were made to do another ad showing rubber nipples on top of insulin syringes (suggesting that bottle-feeding causes diabetes), but then someone thought better of it.

The whole campaign was [superciliously] knowing and dripping with sexual innuendo and condescension.

The most damning conclusion of serious researchers is that, in the absence of any real proven correlations or finding the smoking gun intervening variable in the equation, it may not be the breast milk at all.  It is the licking:

In his study on breast-feeding and cognitive development, Michael Kramer mentions research on the long-term effects of mother rats’ licking and grooming their pups. Maybe, he writes, it’s “the physical and/or emotional act of breastfeeding” that might lead to benefits. This is the theory he prefers, he told me, because “it would suggest something the formula companies can’t reproduce.”

If the researchers just want us to lick and groom our pups, why don’t they say so? We can find our own way to do that. In fact, by insisting that milk is some kind of vaccine, they make it less likely that we’ll experience nursing primarily as a loving maternal act—“pleasant and relaxing,” in the words of Our Bodies, Ourselves and more likely that we’ll view it as, well, dispensing medicine.

As the husband of a breastfeeding mother, I benefitted.  Ahhhh, at last something I could not share; and despite my wife’s glares as I headed off to the comfortable attic bed to get a good night’s sleep, I slept like a baby.

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