Lactivism and the hallmarks of pseudoscience

72775232 - paradigm shift, 3d rendering, traffic sign

On the first day of medical school, they tell students that half of what they are about to learn will be overturned or changed in the next five years; the problem is that we don’t know which half. But the hallmark of science is that new information challenges old certainties and doctors must change their thinking and practice in response.

Pseudoscience, however, does not change as the facts and understanding change. It starts with a claim —for example, the claim that breastfeeding is best for every baby — and it sticks with that claim regardless of new facts that come to light.

Lactation professionals who resist changes to the Ten Steps are no different from obstetricians who continue doing routine episiotomies.

The recent response of lactivists to the growing body of evidence that aggressive breastfeeding promotion is injuring and in some cases killing infants suggests that lactivism is a form of pseudoscience. While pediatricians, neonatologists and organizations like the Fed Is Best Foundation are begging the World Health Organization to revise the Ten Steps to Successful Breastfeeding to incorporate the new findings, lactivist organizations will not budge.

Contrast the response of the science of obstetrics to the pseudoscience of lactivism in the face of paradigm shifting scientific evidence.

I was taught to perform episiotomies very early in my training.

It was the rare delivery of a first time mother that was not accompanied by an episiotomy and the rationale was persuasive. The baby’s head often tore apart the lower vagina and tears might radiate out to the labia and clitoris and well as down to the rectum. It was thought that making a precise incision that was easier to repair would spare women from multiple, ragged lacerations. Most important, obstetricians believed that episiotomies made is less likely that the rectum would be damaged. Avoiding fecal incontinence was a high priority.

It made a lot of sense, but it was wrong. Paradigm shifting research done in the 1980’s and 1990’s demonstrated that a median episiotomy (straight up and down), by weakening the tissue of the lower vagina, made tears down to the rectum MORE likely, not less. Most obstetricians (including me) didn’t believe it at first, but the scientific evidence was clear and clinical practice changed on a dime. Within a few years the rate of routine episiotomies dropped precipitously and episiotomies are now almost solely reserved for forceps and vacuum delivery.

Lactation consultants are taught that breastfeeding is best for every baby, that formula supplementation and pacifiers harm the breastfeeding relationship, that insufficient breastmilk is rare, and that extended skin to skin contact and rooming in are safe and improve the likelihood of breastfeeding success. Paradigm shifting research done within the past decade has shown that insufficient breastmilk is common (up to 15% of first time mothers), formula supplementation makes successful breastfeeding more likely, pacifiers prevent SIDS and extended skin to skin contact lead to babies falling from their mothers’ hospital beds or suffocating while in them. The leading cause of jaundice induced brain damage (kernicterus) is breastfeeding and breastfeeding doubles the risk of neonatal hospital admission leading to literally tens of thousands of hospital admissions per year.

The evidence on the dangers of breastfeeding is actually far more compelling than the evidence on the dangers of episiotomies. In a feeble response, the WHO has made some minor, inadequate changes to the their recommendations. The response of lactation professionals has been to erect a wall of denial; they are vigorously protesting even the insufficient changes.

This letter from the International Baby Food Action Network, in partnership with the Baby-Friendly Hospital Initiative Network of Industrialized Nations (BFHI), International Lactation Consultant Association (ILCA), La Leche League International (LLLI), World Alliance for Breastfeeding Action (WABA) makes clear their insistence on clinging to old, discredited claims.

Global standards

The issues babies face in developing countries are very different than those in industrialized countries. Breastfeeding provides significant health benefits in developing countries as opposed to trivial benefits in industrialized countries. The WHO has proposed acknowledging these differences by allowing individual countries to develop national standards. Lactation professionals are opposed:

we still believe this approach will allow for wide variation of practices and inconsistent standards throughout the world, undermining global indicators. Global standards are the foundation of the BFHI and they are essential to monitoring the global effort to improve breastfeeding rates.

Yes, global standards might make things easier for the BFHI but they don’t make things better, healthier or safer for mothers or babies.

The BFHI

Given the paucity of evidence that the BFHI improves breastfeeding rates, the WHO has designated it as a “key” strategy, not the only strategy. Lactation professionals, sensing a threat to their employment prospects, vigorously disagree.

The Ten Steps

Many of the Ten Steps have been found to be harmful to babies and most have been found to be ineffective in promoting breastfeeding. No matter. Lactation professionals object to changes that incorporate the scientific evidence.

Consider the response to changing Step 9: Give no pacifiers or artificial nipples to breastfeeding infants. Pacifiers are lifesaving; indeed research shows that they are more likely to prevent SIDS than breastfeeding itself. Lactation professionals don’t care. They are affirmatively OPPOSED to making decisions based on the scientific evidence.

…[I]t was not the most appropriate method for examining the evidence related to the socio-cultural and ethical complexities of the BFHI. This method failed to portray the reality that those working and researching in this field have experienced over the past 30 years.

That’s the equivalent of obstetricians insisting that they are going to keep doing routine episiotomies because they believe in them despite the scientific evidence showing harm.

Lactation professionals have exerted tremendous pressure on the WHO to retain the outdated, dangerous Ten Steps. The WHO appears to be caving, but apparently not far enough.

WHO and UNICEF, based on an evaluation of the evidence and information submitted by the collaborative, appear to have made significant changes to the proposed initial draft, including the retention of the order, number and subject matter of each of the original Ten Steps. However, significant gaps in the alignment of our thinking with WHO and UNICEF remain.

They are encouraging their members to lobby the WHO to maintain the status quo even though the the status quo ignores the scientific evidence, is dangerous for babies leading to literally tens of thousands of newborn hospital readmissions in the US alone, and increases sudden infant deaths in hospitals.

Science necessitates change based on new information; pseudoscience resists change regardless of scientific evidence. By that metric, contemporary lactivism — cheered on by its lactation professional enablers — is pseudoscience.

  • Mimc

    There is an OB in my town that still does routine episiotomies. When I found out a switched to another clinic.

  • aurora

    Great post!

  • Sue

    Thanks for this article – a good example of the naturalistic fallacy, and the paradox of ignoring scientific progress while discussing it on the internet.

    People seem to be able to accept scientific and technological progress in transport and communications, including the internet and air travel, and yet are blind to certain advances in biomedical sciences.

    What “mommy sense” knew intuitively that putting babies to sleep on their backs would dramatically reduce the incidence of SIDS/SUDI? Shouldn’t babies know how to sleep safely without interference?

  • Young CC Prof

    Here’s a question. Why are they called the Ten Steps? Why not the Ten Guidelines? They aren’t a single algorithm or process, and they aren’t applied to facilities or individual patients in a specific order.

    They are discrete guidelines, which makes even more absurd the lactivist claim that we can’t test the “steps” individually.

    • Sue

      Sounds quasi-religious.

      • AnnaPDE

        There’s ten, not eight or eleven, for the same reason: To make them sound like some god-given law instead of guidelines made by people and to be reviewed by people.

        • Allie

          I immediately thought of the Alcoholics Anonymous ten step program, which is definitely religious-based, though I’m sure they’ve toned down the God references for an increasingly secular population. Implication: if you’re not breastfeeding, there’s something morally and/or spiritually wrong with you.

  • yentavegan

    Well , is breastfeeding a cultural parenting choice ( like baby-wearing, cloth diapering, not spanking etc…) or is it a health choice like vaccines and car seats? Does the medical industry have an ethical responsibility to support/enhance lactation or ought they leave it alone as a mother’s choice? Isn’t it more important to educate mothers on proper infant nutrition/feeding rather than promoting breastfeeding over formula? Just why did hospitals get themselves involved with breastfeeding promotion? Was it an effort to distance themselves from formula marketers infiltrating the maternity ward to the detriment of 3rd world infants?

    • Sue

      We have the scientific evidence to answer those questions.

      In the wealthy world, feeding choice IS a cultural parenting choice, because the health outcomes are very much the same (Bofa rule: all other things being equal). The medical profession bears the responsibility of giving advice that is consistent with what is shown by valid evidence.

      In the developing world, it’s been correct to oppose formula manufacturers trying to convince people living in abject poverty that formula is somehow “better”, in the absence of reliable clean water, and risking malnutrition due to dilution.

      Surely we should be able to distinguish wealthy life from improverished life, and understand that the strategies are different. It seems that hospital Labor/Maternity wards have come under the influence of ideology rather than evidence.

  • BeatriceC

    OT: Late last night, sometime between 8:30PM when we put the birds to bed and 11:45PM when MrC checked on them, Oscar lost his battle with liver disease. He’d been pretty stable, but he was prone to various infections and had recently been sick. He appeared to recover, but it seems like it was too much for his little body to handle. Because I take in “last chance” birds, I know this is inevitable, but it doesn’t make it any easier when it happens.

    At least now he’s no longer in pain.

    https://i.imgur.com/td5aVMj.jpg

    • Heidi

      I’m sorry to hear that.

    • BeatriceC

      And the full results of the gross necropsy are in. He wasn’t just in liver failure. He was in heart failure as well. The vet thinks that his heart probably gave out first, but it really was a race, as his liver was closer to the consistency of jello rather than liver tissue. This is damage that was done over the course of years and years, and long before I got him. He probably lived 9-12 months longer than he would have if he hadn’t come into my care. Most of those months were happy and loving, with a few weeks of illness back in July and August, and then this final illness. He was much older than we’d thought, though that’s not entirely surprised. Re-homed and rescued birds tend to be either 2 or 10, because their history is so often lost, and people like to make the birds seem more appealing to a new home. We always take the stated ages with a huge grain of salt. Lastly, he had an ovary, so he was actually a she. But he’ll always be Oscar to me. I am extremely comforted to know that we did the best we could for him and his last year and a half were lived in happiness and love and not a dark, smokey basement surrounded by unkempt dogs.

      • Empress of the Iguana People

        *hugs* It’s been a tough year for you guys and your birds

        • BeatriceC

          I take in “last chance” birds, so it’s inevitable. It still sucks when it happens. He was so vivacious until last month that I really had thought for once the age given might actually be correct. But my comfort is that these birds lived their last days in comfort, happiness, and love, and even though it’s difficult for me, it’s worth all of the tears.

          I still can’t get over the fact that he was actually female. Though he’ll be a he for as long as I live because that’s just the way it is.

      • PeggySue

        He was so lucky to have had you. No wonder he was vivacious–he was having the best of life.

    • Sue

      Sorry you had to go through this sadness.

    • momofone

      I’m sorry.

    • Mishimoo

      So sorry for your loss. I know it was inevitable, but it’s still awful. I’m glad Oscar was loved so dearly.

    • StephanieJR

      I’m so sorry. Fly free, Oscar.

    • PeggySue

      Oh, I am so sorry. He was a beautiful bird. I know you’ll miss him.

  • Mel

    I have a new favorite bullshit quote:
    [I]t was not the most appropriate method for examining the evidence related to the socio-cultural and ethical complexities of the BFHI.

    Let’s be clear: there are NO socio-cultural or ethical complexities in BFHI.

    BFHI has gotten the 10 Steps to Successful Breastfeeding emblazoned on plaques in the Special Care Obstetrics Unit of the hospital I delivered in. That’s the wing where long-term high-risk OB patients are cared for along with moms of NICU babies and moms who have had a stillbirth. Even though I know that BFHI is nearly a cult, seeing those 10 damned steps every time I went to see my son was like being stabbed. God knows how much more sadistic seeing that was for moms who had lost a baby.

    Fuck that shit; I know cults when I see one.

    ETA: changed a verb tense. I forget how to conjugate “to be” when I’m mad

  • Sarah

    Reading this, it makes me so angry that even though BFHI is optional, I still didn’t have a realistic choice of a non BFHI facility to deliver in.

    • MelJoRo

      This. Despite having excellent medical options in so many ways, for delivery I had suboptimal options. I delivered in a BFHI hospital and it was fine, but I wish I would have had a choice: my baby lost more weight than I was ok with, and I feel like a different hospital would have done more frequent weight checks or taken my concerns more seriously. I said I was fine with supplementing with formula and ended up doing it IN SECRET because baby was hungry. He still
      Got to 10% weight loss because when my milk came in I assumed we were good (and everyone told me we were) but he wasn’t transferring enough. Fortunately my outpatient Ped helped us currect the issue quickly, but we got lucky rather than good care.

      • Sarah

        That’s awful. I’m fortunate that mine didn’t actually observe the BFHI rules they’d signed up to, but nonetheless the point remains.

  • Christine O’Hare

    Well, looking at the 10 steps I failed at:
    – #6 nothing other than breast milk (gave hungry baby formula b/c I was too tired and drugged up to nurse more than 5 minutes)
    – #7 rooming in (being tired and drugged up I actually wanted to sleep)
    – #9 no pacifiers (I would rather baby have the SIDS prevention and soothing that comes from sucking)
    – #4 initiate breastfeeding within 30 minutes of birth (that C-section thing where they sliced my guts open interfered with that timing)
    – #10 I was referred to the support group but sure as hell didn’t go (because I deemed healing at home from my surgery more important than being browbeaten about how I was feeding my baby).
    Shockingly baby and I are doing just fine despite not following their pseudoscientific rules…go figure. But you know, that’s just my anecdotal experience.

    • Mel

      Let’s see:
      1) , 2), and 10) aren’t actually for the women who are breast-feeding – but they are stated on every pamphlet I’ve ever received. I guess creating media for the 7 steps was too complicated – or should I say socio-culturally-ethically complicated?

      3) Crazy LC said that I had to pump every 2 hours round the clock for the first two weeks after my son was born to initiate lactation. She emphasized that breast milk was critical to my son’s survival. I didn’t pump round the clock and my micro-preemie son had access to donor milk if he needed it – but damn, those two statements messed with my severely anemic, exhausted, nearly in a hypertensive emergency brain.

      4) Actually, I did pump in recovery. I was so relieved that my son and I were alive and that I didn’t need a transfusion that I could have flown if someone asked me to. Much to my surprise, I did produce a few drops of colostrum. I still maxed out at 11oz of milk production a day.

      5) Breast pumps aren’t that hard to use. I did get into an argument with the lactation consultant about the diameter of my nipples when I requested a larger size flange. My son wasn’t doing well that day and all I wanted was the right god-damned sized flange so I told her that I’d pump in front of her to show her what happened when my nipples got engorged – and started pulling out the nearest pump. She got me the flanges I think to stop me from undressing in front of the male neonatologist and RTs. Personally, I could care less who was watching; it’s not like my breasts are substantially different than the standard equipment – and I really wanted to go back to focusing on my son.
      6) LOL. Spawn was on TPN for a few days followed by fortified breast milk. By 34 weeks, they switched the fortifier from the insanely expensive human milk derived fortifier to the bovine milk derived one since his risk of NEC had plummeted. Did I mention I maxed production at 11oz a day? BFHI probably blames that on the TPN and fortifiers….
      7) When your baby is sick enough that he needs 2 nurses to do basic care, rooming in sounds like hell.
      8) Ummm…my son was born without a suckling reflex. Oh, and my non-engorged nipple was larger than his mouth. I think a fully engorged nipple would have suffocated him.
      9) He got his first paci at 27 weeks gestation. In the “Notes from Parents” section of his board, I wrote “Paci the kid early and often. Let’s avoid oral aversion!” By 28 weeks gestation he was making loud sucking noises with his paci that sounded exactly like Maggie Simpson.

      In terms of breast-feeding support groups, I did have one micro-preemie mom friend. Apparently we were both known as sweet rebels – or something like that – because the lactation consultant tried to argue that us talking to each other about our breastfeeding issue was against HIPPA. Alas, she got the wind up when I asked her to put that in writing for me.

      • BeatriceC

        They didn’t like me much when I told them to stuff it when they tried to come in and get me to pump immediately after YK was born. I don’t even recall most of the first few days because I was in and out of consciousness and mostly delirious from the severe pre-eclampsia/eclampsia that necessitated his very early delivery. What I do recall is that I pumped when I felt up to it, and slept when I didn’t. And like clockwork, just as with every other one of my pregnancies, halfway through day three, my breasts became the size of middle school standard basketballs in the shape of footballs, and I produced literally a gallon or more per day. The kid was on TPN to begin with, and wouldn’t come off TPN for several weeks, so that early milk would have been a waste, and by then I’d figured out that my milk came in at the same time no matter what I did. It came in (although not nearly as copious) with the twins who died and I was actively trying to stop that from happening. It came in more than abundantly with OK who I pumped religiously around the clock every two hours for, it came in a tiny bit, but not much, with the singleton who was also way too early to attempt to save, and it came in even more abundantly than for OK with MK, even though I only pumped ever three hours and made sure I got at least one six hour stretch of sleep a night, and my worst oversupply problem of all of them was with YK, who I only pumped those first few days a handful of times when I felt up to it.

        If we’re going by my experience, supply increases with rest and recovery even if that means far fewer pumping sessions.

      • Ozlsn

        I had to translate 11oz into metric, that sounds about where I was at too (although I decided early on that baby was sleeping overnight and dropped that expression – both husband and myself were exhausted, and I noticed no change in overall volume other than getting a higher volume in the first expression of the day. I stressed for a long time that I was missing out on the magical hormones that apparently peak at 3am though and that my volumes could theoretically be higher). In retrospect I’m glad no one told me about the NEC risk – I quite likely would have gone even harder trying to get more milk.
        Also glad that where I gave birth the midwives were supportive with me – that may well have been because I said upfront I wanted to breastfeed, it may also have been because they understood a lot more clearly than I did that the odds weren’t great for my child. As it was he had TPN, EBM – straight, fortified, super-fortified, with lactase added, without lactase added – lactose-free formula and even some puree by the time he was discharged! Also had a pacifier to encourage development of sucking… which didn’t translate to bottle feeding at all, dammit, despite him hanging on to it until he was about 3.5 years old (and was chewing the crap out of them, at which point I got the OT recommended chewy things for him to use). He still doesn’t suck through straws, although he has now gotten the concept of blowing bubbles.
        Given how many NICU mums I knew that were killing themselves trying to produce milk having the 10 steps up on the wall would have been utterly devastating for a lot of them.

  • Cartman36

    Bless you Dr. Amy. I am so glad to have found your blog

  • Cartman36

    My god BFHI, have tho no shame? “Global standards are the foundation of the BFHI and they are essential
    to monitoring the global effort to improve breastfeeding rates.” They might as well say, we don’t care if it hurts, injures, or kills babies, this is our process and we don’t want to change it.

    • EmbraceYourInnerCrone

      Also ” We don’t care how you want to use your own body, we don’t care how exhausted you are after labor, surgery or difficult instrument delivery, We don’t care if you don’t want to bare your breasts in front of strangers/your inlaws/random hospital people. You WILL breastfeed your baby, or we WILL make you feel like the worst mother EVER!!!!” And why exactly is it so damned important to IMPROVE BREASTFEEDING RATES?

      I honestly don’t believe that breastfeeding will magically protect me from cancer or diabetes. I don’t believe that breastfeeding would have made my kid magically healthier (anecdata- my sisters 4 kids were all breastfed for over 6 months, my 1 kid was never breastfed, my sisters kids have always caught everything that was going around and her daughter was diagnosed with cancer at 31)

      • Cartman36

        Which is weird because my local BFHI makes a HUGE deal out of how they support your choice on how to give birth (midwife or OB, waterbirth, hypnobirth, epidural) but I guess your right to choose (nursery or rooming in / pacifier or no, EBF, EFF, or combo) goes out with the placenta.

        • EmbraceYourInnerCrone

          This is from the website of the biggest Uni hospital in my region:
          “Right after you’ve given birth, your labor nurse will help you put your baby skin-to-skin to begin the bonding process. If you have chosen to breastfeed, your nurse will also help you with the first feeding. This is a time to rest and bond with your newborn.
          Hormones that cause your uterus to contract will stimulate “mothering” feelings after birth. As you touch, hold and gaze at your baby, they are released. They help you and your baby feel calm, responsive and warm.”

          No mention of skin to skin ONLY IF you want it, no mention ANYWHERE on the hospitals web pages about how to prepare formula safely or whether you need to bring it or if they provide it. And I guess if you don’t immediately feel calm, responsive or warm you lack “mothering” feelings.

          IDK about anyone else but for hours after I gave birth I had the shakes and could not sleep, although I was exhausted, even though this was in a private room with it’s own bathroom. I was glad they had my daughter in the nursery for observation because if I had had to pick her up I would have dropped her. My husband had to go home because he had been up for 2 days (work) and there was no place for him to really sleep.

          • Cartman36

            My BP tends to drop REALLY low after my c-sections. I can remember telling my husband he needed to take the baby because i felt like I was going to black out. thankfully the nurses were right there and got my BP back up but this is why skin to skin scares me if there isnt a nurse there to monitor.

          • maidmarian555

            Mine did that in theatre. One of the reasons I’m really glad we didn’t do skin to skin until I was in recovery and feeling better. There’s a big push here in the U.K. right now from the usual NCB suspects to make skin to skin a thing that’s done as standard during c-sections and *none* of the people beating that drum are even mentioning that it’s not uncommon to start feeling pretty strange during (or, indeed right after) the surgery (I mean they will say all sorts of things about how terrible CS is but not this particular issue when they’re trying to sell skin to skin apparently). I did not want what should have been a lovely, snuggly, intimate moment to involve having a midwife leaning over me helping me to not drop my babies when their Dad was sat right next to me not having his abdomen stitched up with a pair of fully functioning arms.

          • EmbraceYourInnerCrone

            I had an episitomy and 2 tears so they handed my daughter to my husband while the doc stitched me up, hubby didn’t do skin to skin either they wiped her off a bit and wrapped her in a blanket, possible the fact that they had to suction her etc meant they wanted to make sure she was warm enough and yes even in 1994 they were pushing breastfeeding and skin to skin just not as hard. Amazingly enough she seems to have bonded just fine! Granted she is 23 years old so maybe it’s too early to tell…

          • EmbraceYourInnerCrone

            It’s just irritating that hospitals think the default should be insisting people snuggle with their slippery naked baby, while the person is also partially undressed. Sorry, call me a prude, I don’t feel “calm, or secure” when everyone else is fully dressed and I am not. It has never been something I was comfortable with and women have enough of their bodily autonomy walked all over without feeling the default hospital policy does not care about their preferences or their feelings. Did not appreciate the LC grabbing my boob and shoving my kids face on it…I pretended I was going to breastfeed because I felt guilty doing anything else. I was lucky enough that it was 1994 and they still gave you formula and let you take the kid back to the nursery so you could sleep (although even then, in SoCal, rooming in was the default/expected)

          • swbarnes2

            It’s so ridiculous. So many kids have to go to the NICU right after birth, and clearly they bond fine with their parents. Adopted kids bond fine with their adoptive parents. It can’t matter that much, or we’d see bad outcomes in kids like that.

    • Sue

      There is no “Global” in this context.

      There is the wealthy world, with excellent hygiene and plenty of money for formula, where health outcomes are not much dependent on feeding method.

      There is the world of abject poverty, where dirty water leads to gastrointestinal infections and poverty leads to dilution, causing malnutrition.

      Imagine if all the energy, commitment and funds for “BFHI” were re-channeled into improving the lives of infants growing up in disadvantaged families…

    • PeggySue

      That is exactly what they are saying.