The science on breast-feeding (and what we ought to do about it).

There's an interesting article in the New York Times about efforts by the U.S. Department of Health and Human Services to promote breast-feeding. Proponents of breast-feeding point to quite a lot of science that supports advantages -- for child and mother -- of breast-milk over formula. But there's also a real question about what we (i.e., individual families making choices, DHHS, employers, and society as a whole) ought to be doing in light of this information.

From the New York Times article:

"Just like it's risky to smoke during pregnancy, it's risky not to breast-feed after," said Suzanne Haynes, senior scientific adviser to the Office on Women's Health in the Department of Health and Human Services. "The whole notion of talking about risk is new in this field, but it's the only field of public health, except perhaps physical activity, where there is never talk about the risk." ...

Senator Tom Harkin, Democrat of Iowa, has proposed requiring warning labels, on cans of infant formula and in advertisements, similar to the those on cigarettes. They would say that the Department of Health and Human services has determined that "breast-feeding is the ideal method of feeding and nurturing infants" or that "breast milk is more beneficial to infants than infant formula."

Child-rearing experts have long pointed to the benefits of breast-feeding. But critics say the new campaign has taken things too far and will make mothers who cannot breast-feed, or choose not to, feel guilty and inadequate. ...

[U]rging women to breast-feed exclusively is a tall order in a country where more than 60 percent of mothers of very young children work, federal law requires large companies to provide only 12 weeks' unpaid maternity leave and lactation leave is unheard of. Only a third of large companies provide a private, secure area where women can express breast milk during the workday, and only 7 percent offer on-site or near-site child care, according to a 2005 national study of employers by the nonprofit Families and Work Institute. ...

Public health leaders say the weight of the scientific evidence for breast-feeding has grown so overwhelming that it is appropriate to recast their message to make clear that it is risky not to breast-feed.

Ample scientific evidence supports the contention that breast-fed babies are less vulnerable to acute infectious diseases, including respiratory and gastrointestinal infections, experts say. Some studies also suggest that breast-fed babies are at lower risk for sudden infant death syndrome and serious chronic diseases later in life, including asthma, diabetes, leukemia and some forms of lymphoma, according to the American Academy of Pediatrics.

Research on premature babies has even found that those given breast milk scored higher on I.Q. tests than those who were bottle-fed.

The goal of a government health initiative called Healthy People 2010 is to get half of all mothers to continue at least some breast-feeding until a baby is 6 months old. Though about 70 percent of new mothers start breast-feeding right after childbirth, just over a third are breast-feeding at 6 months and fewer than 20 percent are exclusively breast-feeding by that time, according to the 2004 National Immunization Survey. Breast-feeding increases with education, income and age; black women are less likely to breast-feed, while Hispanics have higher breast-feeding rates.

For women, breast-feeding can be an emotionally charged issue, and a very personal one. Even its most ardent supporters acknowledge that they have made sacrifices. ...

Scientists who study breast milk almost all speak of it in superlatives. Even the International Formula Council, a trade association, acknowledges that breast-feeding "offers specific child and maternal health benefits" and is the "preferred" method of infant feeding. The American Academy of Pediatrics states in its breast-feeding policy that human breast milk is "uniquely superior for infant feeding."

Dr. Haynes, of the Health and Human Services Department, said, "Our message is that breast milk is the gold standard, and anything less than that is inferior."

Formula "is not equivalent," she went on, adding, "Formula is not the gold standard. It's so far from it, it's not even close."

Formula manufacturers say infant formula is modeled on breast milk and emphasize that it is the only safe alternative recommended by pediatricians for mothers who cannot, or choose not to, breast-feed.

But while formula tastes the same way at every feeding, advocates of breast-feeding say, the smells and flavors of human breast milk change from day to day, from morning to evening, influenced by the mother's diet. Many nutritionists believe that exposing an infant to this bouquet of flavors early on may make for less fussy eaters who are more flexible about trying new foods and more likely to eat a healthy, varied diet.

"I think of human milk not just as food, but as a sophisticated and intricate infant support system that has evolved over millions of years to provide the infant with nutrition, protection and components of information," said Dr. E. Stephen Buescher, a professor of pediatrics at Eastern Virginia Medical School in Norfolk, who heads the inflammation section in the school's Center for Pediatric Research.

"It isn't just calories," Dr. Buescher said.

The protection that breast-feeding provides against acute infectious diseases -- including meningitis, upper and lower respiratory infections, pneumonia, bowel infections, diarrhea and ear infections -- has been among the most extensively studied of its benefits and is well documented, said Dr. Lawrence M. Gartner, chairman of the American Academy of Pediatrics' breast-feeding section.

Breast-fed babies have 50 percent to 95 percent fewer infections than other babies, Dr. Gartner said, adding, "It's pretty dramatic."

One reason for the reduction in the incidence and the severity of infections is the antibodies contained in the mother's milk. "A lot of this has to do with the mother and baby interacting," he explained. "Whatever the baby is exposed to, the mother is exposed to, and the mother will make antibodies within three to four days." The baby absorbs them through breast milk.

Breast milk also protects the baby through other mechanisms. For example, it contains agents that prevent bacteria and viruses from attaching to cells in the baby's body, so the foreign agents are expelled in the stool, Dr. Gartner said.

The protection is not ironclad, so breast-fed babies will often get a mild infection that does not make the baby sick but acts almost like a vaccine. "What we think is that human milk creates an environment where you get your immunity without the cost of an infection, the vomiting and the diarrhea," Dr. Buescher said. "That's a bargain."

Neonatologists are urging the mothers of their tiniest patients to express breast milk because premature and low-birth-weight babies are particularly vulnerable to infections. Studies have found that premature babies who get breast milk are discharged earlier from the hospital and are less likely to develop necrotizing enterocolitis, a potentially deadly disease.

Breast milk has also been shown to lift the cognitive development of premature babies, presumably because it contains certain fatty acids that aid brain development.

Experts say it is possible that human breast milk produces permanent changes in the immune system, in a sense "educating" the baby's immune system, Dr. Gartner suggested. That may explain why children who were breast-fed appear to be at lower risk for autoimmune diseases like Crohn's, asthma and juvenile diabetes. Several studies also indicate that breast-fed children are at reduced risk for the cancers lymphoma and leukemia.

Officials with the International Formula Council say there is not enough evidence to prove a relationship between early feeding and serious chronic diseases.

Dr. Myron Peterson, director of medical affairs for Cato Research, a private independent research organization which reviewed the literature on breast-feeding for the council, said that studies have found a link between nursing and health benefits but that they do not prove a causal relationship. "It's like the old statement about the rooster crowing making the sun come up," he said. "If you did an observational study on that, what would you say?"

An unpublished report the council commissioned from Cato says "it is not scientifically correct to conclude the lack of exclusive breast-feeding plays a causative role in the development of these diseases."

But scientists are so intrigued about the potential to protect children from juvenile diabetes that a large 10-year multinational study called Trigr (for Trial to Reduce Insulin-dependent diabetes mellitus in the Genetically at Risk) is under way to find out whether breast-feeding protects at-risk children from developing the disease.

And public health officials, excited about mounting evidence suggesting that children who were breast-fed are at lower risk of being obese, have been promoting breast-feeding as a strategy to combat alarming rates of childhood obesity.

The health benefits of breast-feeding may extend to mothers as well. According to the American College of Obstetricians and Gynecologists, extended breast-feeding reduces the risk of ovarian cancer and breast cancer. New studies have also found that women who breast-feed face a lower risk of adult-onset or Type 2 diabetes, and they seem to be at lower risk for osteoporosis later in life.

Immediately after childbirth, nursing accelerates healing by reducing the amount of bleeding and causing the uterus to contract more rapidly back to its normal size. Making milk burns up to 500 extra calories a day, so nursing mothers get help shedding extra pounds from pregnancy, experts say, especially if they nurse for an extended period.

Experts say lactation also seems to have a calming effect on the mother, which may be an adaptive mechanism to ease the transition to life with a new baby. Every time a mother nurses, she gets a spike in oxytocin, which may have an antianxiety effect and help promote bonding with the new baby, said Kathryn G. Dewey, a professor of nutrition at the University of California, Davis, and an expert on breast-feeding.

Nursing may even produce a euphoric feeling, she said.

Dr. Michael Kramer, a professor of pediatrics and of epidemiology and biostatistics at McGill University's medical school in Montreal who has been studying the health effects of breast-feeding among infants in Belarus, found a strong protective effect against gastrointestinal illnesses and a lesser protective effect against respiratory infections. Dr. Kramer is still analyzing data on obesity, I.Q., behavior and blood pressure.

"It can't do all of the things that are being claimed for it," Dr. Kramer said, injecting a note of caution into the debate. "But it probably does some of them."

Did you notice that the scientists from the International Formula Council and Cato research question what appears to be a good bit of scientific agreement (not to say consensus) on all the benefits breast-milk brings about that formula doesn't? Where have I seen this tableau before?

Let's say, even if some of the purported benefits of breast-feeding don't hold up under rigorous scientific scrutiny, that breast-feeding does confer real benefits upon infants relative to what formula would give them. Does this knowledge impose obligations?

Probably, it obligates the companies selling formula not to claim that formula is equivalent to breast-milk. As well, DHHS probably has an obligation to make sure information about the advantages of breast-feeding is widely disseminated (to health care professionals and parents, for example).

But does a new mother have an obligation to breast-feed her baby? Does DHHS (or society at large) have an obligation to pressure her to breast-feed -- shaming her if she purchases a container of formula at the drug store, for example?

What kind of weight must potential benefits to the infant carry in this decision? In other words, if breast-feeding can confer certain benefits upon the infant, must the infant be breast-fed no matter what the costs breast-feeding imposes? Must the mother stay out of the workforce until the child has been breast-fed for the required duration? Some families can't afford that, and breast-milk can be pumped and fed to the infant in bottles -- but some workplaces don't provide the time or the privacy for a lactating mother to pump. Must employers provide such accomodations? (And what kind of obligations fall on those retailers who sic the mall-cops on mothers nursing their babies -- gasp! -- in public?)

What about the mothers whose milk production is insufficient? Are they allowed to supplement with far-from-gold-standard formula? Is society obligated to, say, establish breast-milk banks to make up for individual mothers' production shortfalls? What about mothers who can't breast-feed their infants without potentially exposing their infants to HIV infection? Must DHHS find them healthy wet-nurses?

Does this way of looking at the situation seem a little misguided? It does to me.

Breast-feeding has a lot going for it. Breast-milk is essentially free, and even the cost of bottles and a good breast-pump ends up being a lot less than the cost of formula during the first year of a child's life. But there are other costs to consider here -- not just the economic impact of the mother being part of or staying out of the workforce, but also the emotional impact for mother, as well as child. Being with the source of the breast-milk 24/7 might be suboptimal if she's isolated and unhappy.

Sharing scientific information is a good thing. It lets people make better informed choices. But using knowledge to get paternalistic and shame people -- especially when it's selective shaming (e.g., of mothers who might use formula but not of employers who could be providing more reasonable conditions for lactating employees) -- strikes me as a bad thing.

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I would say that what constitutes an appropriate stance must be at least partly dependent on the cultural context - and to me one critical thing here is how well-established 'intrusive' health advice is.

We have health warnings on cigarettes. We have constant health advice on the dangers of drinking, eating a poor diet, etc. etc. - and this is established and generally accepted. Yet smoking, drinking etc are the choices of adults: in this instance, it's about choices adults make that solely and purely affect the health of babies who, by definition, are dependent on those adults' choices. If we're going to deem strong health advice on an issue such as that to be too dictatorial we should do away with warnings on fag packs as well (OK, that'sa bit strong - but I hope you get my point).

Of course, as with all policies there needs to be a consistent approach which makes sense. There needs to be greatly improved public education on breastfeeding, including on the difficultries some women have sustaining milk production (and on strategies for helping this, such as breast pumping). There needs to be legislation and provision for nursing mothers (you're shittin' me when you say there's no paid maternity leave in the US, right?). And there needs to be more encouragement of bottle-delivery of breast milk and education about this (husbands, carers etc can help out with the delivery of breast milk - it doesn't have to be delivered there-and-then).

Of course we need to make sure mothers who can't breastfeed are not made to suffer from this, but surely the health of the babies comes before the convenience of formula?

(And what kind of obligations fall on those retailers who sic the mall-cops on mothers nursing their babies -- gasp! -- in public?)

People who whine about public breastfeeding are putting their own prejudices ahead of a baby's need for food and affection. It's callous and it's selfish.

Oh my goodness, yes, Ms. Janet. The same dietary and socio-ideological arguments going on here under the guise of science to make same species breast-feeding the law of the jungle could also be applied to promote cannabilism. Not only are individuals among the same species logically the best balanced nutritional source for each other, it is the "natural" way and can be confirmed by simple observation in the wild on both land and sea. And oh, my! From my observations of the way mother's behave nowadays regarding diet and lifestyle, passing this on to infants through breast-feeding could be much more destructive than well-designed and balanced formulas.
But----
[Despite everything, I believe that people are really good at heart--Anne Frank]

By Polly Anna (not verified) on 14 Jun 2006 #permalink

I think the analogy outeast draws to smoking is not inappropriate. In addition to the warning labels on cigarette cartons and the ad campaigns, we've outlawed smoking in many public buildings. For breast-feeding, perhaps in addition to warnings on formula cans, we need to explicitly legalize breast-feeding in public places and lactation breaks for working moms. And it would be ideal to somehow accomplish this without overly shaming moms who can't exclusively breast-feed. (More thoughts on my blog.)

At least on the formula cans in my house, there is a label saying breastfeeding is best for the baby.

So, yes. . . There are formula cans in my kitchen. I give my 9-month-old son both formula and breastmilk. Did I feel guilty about the formula at first? Of course. Have I been pleasantly surprised not to be accosted by the breastfeeding brigade in my university-hippie town every time I bring out a bottle? Yes. (Of course, it helps that my son has a distinctive way of chugging the formula one-handed--that might distract any naysayers.)

I started formula feeding when I had thrush. I was in labor for more than 40 hours, much of it very, VERY painful, but thrush was a whole new level of pain. Every time the boy latched on, I broke out in a sweat and my whole body was shot through by the most unbelievable pain. Breastfeeding was painful for three long months, followed by a couple months of respite before the boy's little serrated teeth came in.

On top of that, breastfeeding was the hardest thing I've ever had to learn how to do.

I share these points because don't think there's enough acknowledgement made of how physically difficult breastfeeding can be, even for those of us who have enough milk for our babies.

In addition to greater acceptance of breastfeeding in public, more lactation rooms, etc., I'd like to see governments on some level make 24-hour, on-call, free- or low-cost lactation consultants available to ALL new moms.

I'd also like to see the government get more serious about environmental contamination because all that stuff ends up in breastmilk. Anyone read Our Stolen Future? It's positively frightening.

Thanks for another great post, Dr. Free-Ride!

I also question DHS's decision to target potentially breastfeeding mothers in their ad campaign.

I get that they have a tight budget, and that an ad campaign may deliver more health benefit-per-very-stretched-buck than providing direct support (funding lactation consultants, etc.).

However, there are other ad campaigns they could run. Namely, they could direct the public shaming at those people who make it difficult to breastfeed - the aforementioned mall store clerks, employers who don't have a quiet room set aside for pumping, random strangers who discourage breast feeding in various ways, etc.

The guilt-trip-the-mothers route is easy to conceive, simple to carry out, and just downright cruel. It's as though DHS somehow thinks that women aren't already hearing the message "do breastfeed", and as though the messages from others saying "don't breastfeed" aren't worth combatting. Heck, I heard the "do breastfeed" message enough while my wife was pregnant that I got sick of it.

Another consideration to add to why breastfeeding may not be an option in some cases: some women suffering from PP psychosis or other serious disorders may well be prescribed psychiatric medications that make breast feeding a very bad idea. Do you really want to create an ad campaign that will guilt-trip these women?

"Did you notice that the scientists from the International Formula Council and Cato research question what appears to be a good bit of scientific agreement (not to say consensus) on all the benefits breast-milk brings about that formula doesn't? Where have I seen this tableau before?"

The last place I saw this tableau was with regard to HRT. Scientific consensus said HRT was the best thing a woman could do for herself. Then at least came the large scale, generalized, double-blind study, and aha, it's not so clear cut, now is it?

Women who breast-feed are largely a self-selected group. When you look at factors like decreased incidence of childhood obesity and higher IQ's, have they corrected for health of the parents, educational levels, income levels, etc? How much of these calming and euphoric feelings of the mother are due to the act of sitting with your baby in your lap? How many of the benefits to the child are due the acting of sitting with its mother? Or father, for that matter, if bottle feeding. The data on preemies in the ICU are intriguing, given that they all have to be held while feeding.

When we look at the purported benefits of breastfeeding, it's not as though we are comparing growth-stunted, mentally-retarded, formula-fed children to tall, strong, genius-level, breast-fed children. Statements like "it's risky not to breast-feed" are overblown. Without at minimum correcting for the self-selected nature of the test subjects, I do not think that the data are strong enough to pressure women who do not want to breastfeed into doing so. If a woman would like to work a full day and does not like pumping, we should respect her right to control her body and not insist that she become a wet bar.

By Frumious B (not verified) on 19 Jun 2006 #permalink

I have breastfed all kinds of places: in restaurants, movie theaters, walking down the aisle in the supermarket. With practice and a sweater or baby blanket you can feed a young baby almost anywhere. It's lots less disruptive that a baby squalling pitifully while the parents struggle with a diaper bag and bottle.

Older babies (old enough to undo buttons and try to help themselves) are old enough to learn about waiting for a private time and place.

And here's the key: Newborn babies need almost constant access to the breast for the first 8 weeks. Nursing mothers need rest and care for that time in order to recover from childbirth and settle in to milk production. By 12 weeks most babies have settled down to some sort of schedule and Mom's milk production has stabilized so that baby can stop eating constantly and start smiling, watching the world, rolling over, and all the other milestones of development. Many women give up on breastfeeding because they don't realize that the 24/7 part of the job only lasts for a little while. They've not been told that there will be a pay-off in a few months as baby eats less frequently, is healthier, has no formula bills, and no midnight bottle fixing, no hurrying home because you've run out of bottles.

I am a casino dealer. I work on my feet for 8 to 10 hour shifts. Our company policy provides for a 6 week paid maternity leave. Medicine's standard is for a checkup eight weeks post-partum, to make sure the uterus is back to normal size and the risk of prolapse is past. Do we have women coming back to work before their doctor clears it? Sure. they need the money.

Rather than lay more guilt on women, I would put pressure on employers to provide for adequate maternity leave. I would challenge them make pumping and storing milk easier. It is in their best interests to have their worker's kids be more healthy, since moms are more likely to use sick time for their kids' illnesses than their own. I would convince fathers that breastfeeding is in their own best interest. Healthier babies and no midnight bottle fixing is all they really need to hear. Fathers have a role to play in the first weeks of the baby's life just running interference to make sure Mom doesn't get too tired. (Meet well wishers at the door, take the casserole or gift, show them the baby --from a distance-- and then politely but firmly send them on their way again.)

Finally, to Frumious B: read the literature. Breast milk is better. Formula cannot provide live T-cells, live white blood cells, or antibodies to the infection du jour. It is an expensive and poor quality alternative.

Namely, they could direct the public shaming at those people who make it difficult to breastfeed - the aforementioned mall store clerks, employers who don't have a quiet room set aside for pumping[...]