On breastfeeding: don’t listen to what pediatricians say, watch what they do

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It’s an oft stated and remarkably valuable aphorism: “Don’t listen to what people say; watch what they do.”

In other words, though people may give lip service to a variety of morally elevating thoughts, their personal beliefs are reflected not in their words, but in their behavior.

Don’t listen to what Dr. Klass says about the importance of breastfeeding, follow what she did.

Perri Klass has a piece about breastfeeding in today’s New York Times and it is an excellent illustration of the aphorism.

In Practicing What I Preached About Breast-Feeding, Klass acknowledges that she didn’t always do what she counseled the mothers in her practice to do.

I had not managed [exclusive breastfeeding] with my first two children, one born while I was in medical school, the second right at the end of my residency. I had breast-fed them both, but relied on formula to get through day care days, and the breast-feeding had ended altogether by seven or eight months.

But with my third, since I was a full-fledged practicing pediatrician, I felt a moral obligation to follow the recommendations that I had been earnestly dispensing…

Like most pediatricians, I am a true believer in the benefits of breast-feeding, though I myself was bottle-fed, along with many in my cohort (what can I say, I was born in the 1950s)…

In other words, Klass felt obliged to follow the recommendations of the WHO and AAP though she doesn’t think not following them harmed her two older children. After all, she herself was bottle fed, and it didn’t seem to harm her.

But my own decision was mostly about that feeling that I had to un-hypocrite myself.

Though Klass proclaims herself a true believer in the benefits of breast-feeding, she does not present her decision to follow the standard recommendations as an effort to keep her baby healthier than her older children, or because she thinks she will thereby be a better mother. She does it so she won’t feel so guilty about being a hypocrite.

I appreciate her honesty, but it might have been better for her patients if she resolved her cognitive dissonance in the opposite way. Instead of attempting to follow recommendations that she apparently doesn’t believe to be truly necessary, she could have acknowledged that she doesn’t think that following the WHO and AAP recommendations makes for better mothers or healthier babies.

Klass doesn’t mention most of the (spurious) benefits of breastfeeding quoted by professional lactivists and she does highlight the fact that the benefits of breastfeeding in industrialized countries are far less than in countries without access to clean water.

She quotes Dr. Michael Kramer, the lead investigator in the Probit Studies that found that the benefits of breastfeeding are limited to approximately 8% fewer ear infections and 8% fewer episodes of diarrheal illness across the entire population in infants in the first year. To put that into perspective: the vast majority of breastfed infants will experience no discernible health benefit from breastfeeding.

But Dr. Kramer thinks there is a neurocognitive benefit.

For parents in a developed country, one of the main motivators is neurocognitive development, accelerated brain development,” he said.

“We really don’t know what it is about breast-feeding, whether it’s something in the milk, whether it has to do with increased physical contact between lactating mother and nursing baby, or if just the time it takes to breast-feed means increased opportunities for verbal exchange between mother and baby,” Dr. Kramer said. “I think that is an interesting topic for future research.”

The truth is that we really don’t know IF the association between breastfeeding and neurocognitive development even exists. Curiously neither Dr. Klass nor Dr. Kramer discuss the more recent and more comprehensive Colen study that found NO association between breastfeeding and neurocognitive development. That study, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons compared the association between breastfeeding and a variety of purported benefits between babies, between families, and between babies within families.

There were differences between breastfed and bottle fed children in 10 of the 11 measured variables when looking at the overall group. Those differences persisted when comparing families in which all the children were breastfed to families where all the children were bottlefed. But when the authors looked within families, there was no significant difference between breastfed and bottle fed children. That indicates that most of the purported benefits of breastfeeding are the result of socio-economic status, maternal education level, and access to healthcare, NOT due to breastfeeding.

Perri Klass is hardly alone among female physicians:

Dr. Maryam Sattari, an associate professor of medicine at the University of Florida, was the lead author of a 2016 study on the breast-feeding intentions and practices of 72 internal medicine physicians. The study found that 78 percent of the babies were exclusively breast-fed at birth and 40 percent of them at 12 months, though 63 percent of the mothers had planned to go to a year…

Nearly a quarter of the female internists in the study didn’t even bother with exclusive breastfeeding and the majority did not follow the WHO and AAP recommendations. That’s hardly more than the general population.

While breast-feeding overall is on the rise, the numbers show that many mothers in this country are not following the A.A.P. recommendations. Compared to 2003, more women in 2013 were initiating breast-feeding (81 percent, up from 73 percent), and still breast-feeding at a year (31 percent, up from 20 percent).

That suggests to me that they didn’t believe the purported benefits were worth the inconvenience. The truth, which physicians know better than anyone else, is that the benefits of breastfeeding in industrialized countries are trivial and almost certainly don’t involve improvements in neurocognitive development.

Klass reports:

With my own third child, I made it to six months exclusively, me and my trusty electric breast pump. At times I felt I had gone a little off the deep end in my intense curation of those bags of frozen breast milk, carefully ferried to the day care center every day. It was a great relief when my son began avidly eating other foods, and it was then easier to go on breast-feeding him, evenings and weekends and whenever it made sense. We kept going till he was a little over a year old.

But at no point does she indicate that she thinks her third child is healthier or smarter or that her first two children suffered in any way from not being exclusively breastfed.

The shameful truth is that the WHO and AAP recommendations of exclusive breastfeeding for 6 months and continued breastfeeding for one to two years are based on little more than ‘white hat bias,’ the misrepresentation of evidence for what are believed to be righteous ends.

As Cope and Allison who first defined white hat bias note:

Certain postulated causes have come to be demonized (… formula feeding of infants) and certain postulated palliatives seem to have been sanctified. Such demonization and sanctification may come at a cost …

That cost is the mental health of mothers who have been shamed and bullied into believing that breastfeeding is far superior to formula feeding as a result of righteous indignation against the immoral activities of formula manufacturers in underdeveloped countries during the 1970’s. Yes, Nestle and other companies have blood on their hands for convincing women to switch to formula even though they did not have access to clean water. But that doesn’t mean that there is anything wrong with formula itself.

Though Klass dutifully gives lip service to the WHO and AAP recommendations, she only followed them when it was finally convenient to do so. She, like many female physicians, doesn’t really believe that bottle feeding is harmful. Therefore, my advice to new mothers is this:

Don’t listen to what Dr. Klass says about the importance of breastfeeding, follow what she did.

  • Felicitasz

    I could write a volume here – anyhow, thank you for the post.

    Several questions.
    1. “The study found that 78 percent of the babies were exclusively breast-fed at birth and 40 percent of them at 12 months, though 63 percent of the mothers had planned to go to a year…”
    surely the 12-month mark is not for EXCLUSIVELY breast-fed babies?! The post continues along the lines and topic of exclusive breast-feeding but 40% is an absurd number either way.
    2. WHO and AAP 6-months recommendation is not a clear-cut mark. I am no expert in the field but I have already translated several articles and leaflets all detailing the recommendations to breastfeed for “about” or “approximately” 6 months.
    The science behind this would be to watch the baby and not the calendar: 38 wks and 41 wks are both considered “at term” birth but the little ones in concern have huges differences in maturity, average weight, and so on. Along these lines, even if we take breastfeeding recommendations totally religiously seriously, there might still be several weeks’ worth of difference in readiness for solid food, and I see no problem with that.
    6 months is not some red line we reach and cross with a teaspoon in mom’s hand at the ready, not even in the WHO papers.
    3. I am OK with female doctors sharing their personal experience in practice. Kudos to this particular MD in the article for her courage and self-awareness.

    Once again, thanks for the post, dr. Amy, it is very insightful.

  • Emilie Bishop

    Yeah, I agree that article bothers me. It lacks some degree of self-awareness on the author’s part and just feels weird. She’s clearly given in to the guilt of not breastfeeding exclusively and then the sense of accomplishment of having done it, yet she doesn’t seem to truly recognize either feeling for what it is. I’d personally never want her as my son’s pediatrician. NOT because she managed EBF the third time around–really, I’m happy for her that she was able to do something she obviously wanted to do–but because of this lack of awareness in herself that could very well translate into pushing her patients’ mothers past their breaking points because she got past hers. I don’t feel like I explained that very well, but the whole article just puts me off a lot.

  • Young CC Prof

    Any study that examines the long-term effects of breastfeeding and also takes into account family socioeconomic status, maternal education or any related variable finds the same thing: The effect of feeding method, if there is one, is far smaller than the effect of family SES.

    The natural conclusion is that bottle-feeding in order to finish your education, maintain your family’s financial stability and/or build a successful career is the best thing for your child’s health. Somehow, I haven’t seen any of those studies come to this particular conclusion, though.

  • Liz Leyden

    Correct me if I’m wrong, but I thought doctors weren’t supposed to give medical advice based on personal experience. When I was in nursing school, especially during the peds and maternity rotations, we were warned not to base our teaching or practice on personal experience, partly to maintain boundaries, partly because one person’s experience is one person’s experience. It also excludes men, who can’t get pregnant or breastfeed.

    I applaud any pediatrician who pushes back against “all breastfeeding all the time”, but there must be ways to do that without referencing her personal experience.

    • NoLongerCrunching

      I’m not a doctor, but as an LC, we are given the same advice, which is good. Advice needs to be based on evidence, not on what you personally chose to do. That said, I often decide to share with my clients that I personally experienced delayed milk production. I think it makes people feel less alone, and they are less likely to assume it’s because they did something that caused the low supply if they hear that it can even happen to a professional breastfeeding specialist who presumedly did everything “right.” I think it could be a relief to mothers to hear that their own pediatrician thinks supplementing with a little formula is good enough for her own children.

    • Lancelot Gobbo

      I think it depends on the degree to which you would like some human contact with your doctor or nurse (or patient, depending on your point of view). As an example, I liked pediatrics as a student, and as a resident I had a couple of pediatricians try hard to convince me to quit my FP program and stay in pediatrics. Consequently, I thought when I entered practice I could do a decent job when looking after kids. Only when I had a child of my own did I really ‘get it’ though. Living in a small rural community meant that there was no way to be aloof and distant, when a patient knew full well when my son had misbehaved at school for example, and honestly, I wouldn’t want to interact with my patients any other way than as a fellow member of that community. The ‘pastoral’ aspect of family practice, where you know people and their circumstances for decades is what makes it fun, and far more easy to do your job effectively than having every patient be a stranger. Yes, you have boundaries, but people need to know you’re human too. This doesn’t mean advising based on personal anecdote, but when you receive advice on baby feeding, toilet training or something similar, would you put more trust in the advice when it comes from someone who had been through it? As the years went by, and other docs came along, it was interesting to see how young mothers and their kids would tend to visit the young docs who had young children. Quite reasonable, and in the same way, by the time I quit I had mostly a geriatric practice. You grow old with your patients. As for excluding men, say, from obstetric and gynecological issues, I don’t think it does any harm for a doc or nurse to know when they are relying purely on theoretical knowledge – book learning – and vicarious experience rather than the real thing. It doesn’t mean you can’t do it, but be aware that patients will apply a grain of salt to what you say! When I went back to work after completing chemo I found I had a new and much closer relationship with cancer patients; I knew what they were going through, and they were glad to have someone who had been in those trenches. I guess my message is that the boundaries we are to draw are not quite as black and white as our governing bodies would like to think, at least, if we want to be as effective as we can be in our work.

      • Sue

        There’s nothing like personal experience to develop insight, and therefore greater empathy with patients.

        As an emergency physician, but pre-parenthood, I used to check babies for significant illness and ask an experienced nurse to advise on the parentcraft aspects. As a parent, I can do both. I find that having confidence with settling babies gives the parents more confidence with my clinical judgement. I can also spot post-natal depression.

    • Young CC Prof

      I don’t think that’s quite the point here. I would imagine there are very few pediatricians who deviate from guidelines on, say, car seats or vaccines when it comes to their own family, but many deviate from guidelines on breastfeeding. This suggests that they don’t take the guidelines all that seriously, or believe that the benefit is small.

      • Felicitasz

        I like your perspective and comments. Just sayin’ 🙂 I like to read you.

    • Dr Kitty

      I reference my personal experience when I think it is helpful.

      Like the fact that my son wouldn’t take EBM from a bottle, but happily took formula, and forget the expensive Medela nipples, he just wanted the cheap and cheerful ones, so try the expensive nipples last, not first!

      Or that despite the fact that both of mine inevitably nursed to sleep as infants, against all current advice. Yet both of them learnt to sleep through the night without a problem after a couple of weeks of sleep training when we stopped breastfeeding at about a year, and that the sleepless nights will pass.

      If someone feels guilty about using jarred baby food or not doing BLW, I tell them that as long as the baby is fed, it doesn’t matter, and sure I used ready meals and jarred food for mine and the waste and mess of BLW meant it wasn’t for me!

      I’m not recommending anything unsafe, or weird, or non evidence based that I do and no-one else does.

      Patients seem happy enough.

      Doctors can absolutely give advice based on personal experience, as long as it is framed as that, and if it goes against current advice that is stated clearly.

      • demodocus

        My ob does it once in a while, usually something family related.

      • Sue

        It’s acceptable, and useful, to give “parentcraft” information based on personal experience. Medical information needs to be evidence-based.

  • OkayFine

    Our pediatrician combo fed all of her children and even let them CIO and she is one of the most popular Peds in our part of town. *GASP* Has a wait list to into her practice.

    • MI Dawn

      My kids’ first pediatrician was a male, but he and his wife had 6 children and, as far as he could (busy group practice – they were one of the best and most popular in the city, on call nights/weekends), he was very hands’ on. He gave me more practical advice for caring for my babies than I’d ever learned in nursing school – or that he’d learned in med school/residency, saying he’d learned it in the school of hard knocks.

      • BeatriceC

        My kids pediatrician was a damned near saint. He and his wife had two biological kids, 16 adopted kids who all had Down Syndrome, and a foundation that took care of of dozens more that had major to catastrophic disabilities. After 1992, when his foundation home was destroyed in Hurricane Andrew and he was nearly run out of town (stupid people in upscale neighborhoods), he and his wife bought a huge property in NC and opened up a long term home for adults with Down Syndrome who’s caregivers had passed away or become too elderly/ill to care for them. He financed all this with his pediatric practice (and donations to the foundation). He was very hands on with the kids in Miami and traveled to NC as often has he could. Given that experience, he was pretty much the most practical pediatrician ever. He didn’t sweat little stuff. Kid is growing and healthy? It’s all good. And he was amazing at coming up with suggestions to work within a family’s lifestyle and means to have the healthiest kids possible. I miss that man. I moved away, and then he passed away a couple years ago. The world lost a fantastic doctor and an incredible man.

  • Nicole Ray

    I wanted to breastfeed, because it’s the cheapest option. I did my best. My youngest was a puker from the start, but I knew some babies were like that. It only got worse as time went on. He got to the point where he would throw up half or more of what went in, then he’d demand more. It was a vicious circle, and would only stop when he either passed out in exhaustion, or got enough to stay down, not sure which. I need to use some formula in order to keep up, given all the vomiting. I realised something was wrong, and had a doctors appointment (some probably would have clued in before that point, but my older boy hadn’t been a puker at all, and it took me a bit to realise just how bad it really had gotten.) But I also needed a new tin of formula. There is a family history of lactose intolerance, so it was in the back of my mind. I saw the lactose free formula, and decided it couldn’t make things any worse. My son had the first feed without vomiting ever, with that formula.
    I did have a bit of a break down. I didn’t want to touch him any more. I felt so guilty for breastfeeding when it was hurting him. I was worried about making more mistakes, and hurting him more. My husband was able to snap me out of it, b I still wish I’d figured it out sooner. Why can’t a specialized instruction manual pop out after the kid?

  • Roadstergal

    “But with my third, since I was a full-fledged practicing pediatrician, I felt a moral obligation to follow the recommendations that I had been earnestly dispensing…”

    But she didn’t feel a moral obligation to let struggling moms know that she herself had used formula to get through tougher times with no ill effects?

  • The Bofa on the Sofa

    Though Klass dutifully gives lip service to the WHO and AAP recommendations, she only followed them when it was finally convenient to do so.

    It’s almost like she understands that, all else equal, breast is best, but she recognizes that in her case, all else was not equal.

    And hopefully she can apply that to others.

    • Sue

      The Bofa Principle. It always applies. I have quoted it numerous times.