Breastfeeding and the arrogance of preventive medicine

Arrogance word concept.

Does this remind you of any providers you know?

Preventive medicine displays all 3 elements of arrogance. First, it is aggressively assertive, pursuing symptomless individuals and telling them what they must do to remain healthy. Occasionally invoking the force of law …, it prescribes and proscribes for both individual patients and the general citizenry of every age and stage. Second, preventive medicine is presumptuous, confident that the interventions it espouses will, on average, do more good than harm to those who accept and adhere to them. Finally, preventive medicine is overbearing, attacking those who question the value of its recommendations.

It reminds me of most of the prominent lactation professionals who have made it their mission to promote breastfeeding.

As the evidence mounts it is becoming clear that breastfeeding term babies is a lifestyle choice, NOT a health choice.

Professional lactivists are aggressively assertive because they are true believers. They not only pursue mothers of symptomless infants, they corral them in programs like the Baby Friendly Hospital Initiative, tell them what is “best” for their babies and then force them to do it.

They are indiscriminate in their recommendations. No nuance for them. As Dianne Weissinger, arguably the mother of contemporary breastfeeding advocacy, wrote:

All of us within the profession want breastfeeding to be our biological reference point. We want it to be the cultural norm; we want human milk to be made available to all human babies, regardless of other circumstances…

They are so presumptuous as to defy belief. They don’t know you; they don’t know your baby, but they actually imagine that care more about your baby than you do.

And they are oh, so overbearing, viciously attacking anyone who dares to question the benefits of breastfeeding as shills, liars and losers.

But the quote is not about breastfeeding. It was written in 2002 by David Sackett, a physician, epidemiologist and one of the pioneers in the discipline of evidence based medicine (EBM). He was writing about the hormone replacement therapy debacle. Estrogen/progestin was recommended for nearly all healthy postmenopausal women to protect them against cardiovascular disease. All the major professional societies backed it and it was used as a metric to judge the performance of doctors within health organizations.

The Women’s Health Initiative randomized controlled trial … was stopped when it became clear that the participating women’s risk of cardiovascular disease went up, not down, on active therapy. This damage began to develop soon after randomization, and after a mean follow-up of 5.2 years the trial was stopped for harm. In human terms, the 8506 women treated with estrogen plus progestin had about 40 more coronary events, 40 more strokes, 80 more episodes of venous thromboembolism and 40 more invasive breast cancers than the 8102 women assigned to placebo. Given the frequency with which this treatment is prescribed to postmenopausal women worldwide, hundreds of thousands of healthy women have been harmed.

How could good people have done something so bad?

I place the blame directly on the medical “experts” who, to gain private profit (from their industry affiliations), to satisfy a narcissistic need for public acclaim or in a misguided attempt to do good, advocate “preventive” manoeuvres that have never been validated in rigorous randomized trials. Not only do they abuse their positions by advocating unproven “preventives,” they also stifle dissent. Others, who should know better than to promote “preventive” manoeuvres without clinical trials evidence, are simply wrong-headed. When a 1997 systematic review of 23 trials of postmenopausal hormone therapy concluded that this treatment substantially increased the risk of cardiovascular disease, the attack on its results included a public announcement from a prominent editorialist: “For one, I shall continue to tell my patients that hormone replacement therapy is likely to help prevent coronary disease.”

The purported benefits of HRT had been shown in observational trials and the experts believed. Never mind that not only could those benefits not be reproduced in larger studies, but they were debunked by larger studies. No matter. The purported benefits of breastfeeding have not been reproduced in larger studies and have never come to pass in large populations. No matter. Prominent lactation professionals (and many medical professionals) ignore those results and criticize anyone who tries to publicize the fact that the benefits don’t exist and the harms (neonatal dehydration, starvation, injury and death) are very real. When pressed, they typically retort ‘I shall continue to tell my patients that breastfeeding is best regardless.’

Over the past few days I have been involved in a discussion on Twitter that was precipitated by a meme I posted.

1A1A93CB-05D5-463F-835B-B2D51624DAFA

Imagine we learned that a product promoted as healthy for babies was responsible for 90% of cases of jaundice induced brain damage, a dramatic increase in brain injuries and deaths from dehydration and double the risk of newborn hospital readmission. Now imagine that we refused to do anything about it. That product is breastfeeding.

The response from some providers was basically ‘how dare you?’

One participant, a nutritionist/dietician from Colombia went so far as to write:

That point of view just makes no sense. It will never come to my mind the idea of recommending something different from breastfeeding, formula will never be my first advice to patients, just in some special cases…

It no longer matters to many lactivists what the data shows. They are so arrogant that the data is irrelevant and anyone who dares to disagree is maligned and shouted down.

The most astounding comment came from a woman representing herself as a physician. Pointing to my Harvard credentials she wrote:

Sigh….how much traction would you get if your bio said you were an ob/gyn from _____unknown to most University, college.

I was taken aback by this, but the more I think about it, the more pleased I am. I try to be a voice for women/babies whose suffering is routinely dismissed. Providers should stop ignoring them, but if the alternative is they can’t ignore me/my Harvard credentials, that will do.

So let me speak directly to mothers struggling to breastfeed:

As a Harvard educated, Harvard trained obstetrician who breastfed her own four children I can assure you that the benefits of breastfeeding term babies in industrialized countries are so trivial as to be undetectable.

IT DOESN’T MATTER WHETHER OR NOT YOU BREASTFEED. It’s a lifestyle choice, not a health choice.

The lactation professionals and medical professionals who tell you otherwise are no different from those who continued to aggressively promote hormone replacement therapy despite mounting evidence that it didn’t work and actually caused harmed. They are arrogant.

Please don’t let their arrogance harm your baby’s physical health or your mental health!

  • Melissa Wickersham

    Preventive medicine needs to use the scientific method more effectively to get more accurate evidence on which interventions and choices are more effective in preventing disease and illness.
    Science is objective, impartial, and logical. Science relies on collecting and examining evidence objectively. The primary goal of science is to create an accurate picture of how reality actually works. The primary goal of science is to accurately describe how everything in the universe actually functions. The most fundamental goal of science based medicine is to use science to effectively and safely treat, cure, and prevent disease and illness, and to promote good health.

    Ideologies like Lactivism and the natural childbirth industry are not science based. The cult of Lactivism and the natural childbirth industry don’t use the scientific method at all. This is because believers in Lactivism and Natural Childbirth don’t reject their core beliefs when they are proven wrong. Lactivists and Natural Childbirth promoters come up with flimsy excuses and false evidence to support their beliefs.

    The scientific method works by creating a hypothesis, having accurate observations, discoveries, and evidence disprove that hypothesis, and having said disproven hypothesis subsequently rejected and replaced with a hypothesis/theory that fits the observations and evidence better.
    The responsibility of proving that one’s claims are true is on the shoulders of the claimant, and both Lactivists and Natural Childbirth supporters fail miserably at this responsibility.

  • The Bofa on the Sofa

    Tangentially Related: For those lactivists who insist that breastfeeding works…we are designed to breastfeed, we wouldn’t have survived if we couldn’t breastfeed, and other such bullshit:

    Happened to be watching the Irwins show on Animal Planet, talking about the animals at the Australia Zoo. In two consecutive episodes, one of the stories was …. baby failing to thrive because the mother do not have adequate milk.

    Hell, they were both marsupials, and so the babies were getting (literally) kangaroo care, but still not growing because there wasn’t enough milk.

    The denial that humans can have insufficient supply for breastfeeding and the excuses that comes with it is totally a denial of reality.

  • AnnaD2013

    “Please don’t let their arrogance harm your baby’s physical health or your mental health!”

    Thank you for saying this! I had a lot of anxiety over breastfeeding not working out when my daughter was a newborn. I am sorry to say I actually spent hours crying, perseverating, pumping, and going to appointments with a lactation consultant trying to make it work. It was a waste of time — I wish I had this information and supportive message back then. I would have weaned my daughter earlier, slept more, and enjoyed my daughter as an infant.

  • mabelcruet

    Sometimes I come across a comment that leaves me reeling. A comment that I simply cannot comprehend why some one would make it, why they thought it would be a reasonable comment to make. I did an autopsy this week on a baby with multiple abnormalities-incompatible with life, absolutely no chance. Parents had been offered compassionate induction earlier in gestation (medical termination) but declined. They had been counselled, plans put in place for ‘comfort care’ if the baby survived birth. These mums get a sticker on the front of their notes to discretely let people know they are loss parents (or will be loss parents).

    Mum is a smoker-ok, that’s not good and I agree efforts should be made to cut down or stop whilst pregnant, but if she’s dealing with a pregnancy where she knows her baby is inevitably going to die, and smoking is a stress reliever for her, I can understand. But every single antenatal visit there is a comment from a midwife (different ones) all along the lines of ‘advise to stop smoking given, declined referral to safe-stop’. One even commented on advice given about the effect this will have on the baby (the baby that is so malformed it has no chance of survival). It’s there in black and white on the front page of her notes and dozens of letters from the fetal medicine specialist team-can they actually read?? Or are they so protocol driven and inflexible and determined to tick the boxes that they don’t actually think? Worst of all, in one of her 3rd trimester visits, there is a comment made about breast feeding, that mum has refused to try breast feeding so midwife has given her leaflets about the benefits. Breast milk might be good stuff, but it’s not magically going to regrow all the organs this poor babe had missing. Horrible to read-poor mum must have had some awkward conversations with them.

    • Ozlsn

      I swear some people just don’t read the notes properly (or at all I suspect). We had stickers in the NICU where my son was to alert staff when a twin hadn’t survived – they were on the nameplate and in the notes. And the number of women I knew who were still asked which room the other twin was in was appalling.

      You really need very compassionate people in a situation like that one – not just allocate them to whoever does that area. I had one week where I was waiting to be told my son had died in utereo and I would not wish that week on my worst enemy. I am in awe of families who have to deal with that for longer periods, because it is excruciating.

      • mabelcruet

        I was wondering if it’s because mums care is being shared by two units-the professorially led fetal medicine unit, and the local hospital maternity unit. She seems to have been seen every month or so at the specialist, but also every few weeks for routine maternity care, blood pressure/urine monitoring, that sort of thing. The mums here have hand held notes-they keep their own records and bring them to whatever clinic they are at, it’s shared notes so everyone has access to all the information. The sticker is quite subtle (it’s a flower), but there are piles of letters, reports and scan results from the specialists and it’s there on the front page-palliative care planned. I think they don’t read them-one track mind for measure BP, dipstick pee, measure bump, bully into stopping smoking, tweak nipples to encourage breast feeding. Honestly, just reading the notes made my palms itch to slap someone. So incredibly thoughtless.

        • Ozlsn

          At that point I don’t think care should be shared – if you’ve moved into that area then it should be the fetal-medicine team seeing you, even if that means they have a specialist midwife or an obstetrician doing “routine” appointments, not least because things like discussing counselling services, answering questions and discussing what the possibilities are at birth is a much higher priority. I was in the high risk pregnancy ward for two weeks – the midwives organised for a NICU visit, I talked with neonatologists, obstetricians and the midwives about my baby’s potential outcomes in NICU and whether he was likely to get that far, not about “normal” things that were completely off my radar like breastfeeding or learning to change nappies or birth or whatever the hell else they discuss in the 3rd trimester. (Tbh I didn’t discuss counselling because I was so focused on getting through each day and until I needed it it wasn’t relevant to me. Actually the only time breastfeeding came up was when I was told that he would be stillborn that week, and the obstetrician mentioned they could give me a drug to dry up my milk – I distinctly remember it being a really jarring comment to me, and thinking that I didn’t care about milk, that the only thing that mattered was him surviving.)
          If the ‘baseline’ midwives can’t even recognise that a thicker folder is indicative of something out of the norm going on then I worry – actually if they’re so busy they are only focused on their checklist that they don’t read the notes at all then that is a major concern. Also I thought the whole idea of”midwifery-led care” was that you had consistency in who you saw, and a better provider/patient relationship? Or is that only here? Either way, she should have been moved out of the “routine” stream and treated with a lot more compassion.

          • mabelcruet

            Normally if there is a mum with a baby where anomalies have been identified, they would involve the neonatologists at an early stage and talk through all the options about care after birth. But I think with this one, there was no question that the baby would be admitted or resus attempted, so they didn’t. I wonder if the midwives who saw her were a bit blinkered-abnormalites aren’t part of their remit, so they ignored it and just did the usual. Another sad thing with this case was that in the mums notes under the section for ‘next of kin’ and ‘who to contact in an emergency’ there is the statement ‘I don’t know who to put down’. So it looked to me that she could potentially have been a bit isolated or had little family around, but there was nothing to state that she had been offered bereavement support. It said in the notes that the father was no longer in a relationship with mum. I really hope she was given bereavement support-the thought of her having her baby die and then going back to an empty house is just awful.

          • Ozlsn

            Oh my God that is just awful. To not even know who to put as next of kin is just terrible. I agree, I hope she was linked in to the services, and that someone cared for her too.
            I agree neonatologists wouldn’t be the right people here, but surely counseling in or out of the hospital? I hope she could stay with her baby as long as she needed to, and that someone was there for her.

          • mabelcruet

            I’m normally quite objective when it comes to my work and not get too involved, and instead just try and think positively about what can I find that will help the family-getting answers helps in the grieving process, I think, so that’s how I normally deal with it. But every so often I get a case that shakes me-this wee one definitely did. His little face was just perfect and he survived a few minutes, long enough for her to say hello and goodbye. I really hope she’s not as alone as her notes made it sound.

    • MaineJen

      *Breastfeeding*. For a baby who is not going to live. Jesus wept.

      • space_upstairs

        “But it prevents breast cancer and helps you recover your figure!” And tears up you nipples and can give you mastitis…

    • rational thinker

      Is it not enough that the mom knew she was going to lose her baby, she could have done without the cruel insensitive comments about breastfeeding a baby that is already known is going to die post partem. What a horrible thing to say to that poor woman who is already under enough mental strain as it is.

    • demodocus

      Jeezuz.

    • Spamamander ctrl-alt-right-del

      I … can’t imagine. The poor woman. Just the POSSIBILITY that my son had Trisomy 13 was devastating. Thankfully his karyotype from the amnio turned out to be 46, XY. If it hadn’t and someone was this horribly insensitive I likely would have been jailed at some point.

    • KeeperOfTheBooks

      That is absolutely horrifying, especially the breastfeeding stuff. My stars…I honestly cannot begin to fathom what mom was going through.

  • PeggySue

    One eeny weeny teeny tiny typo. Third to last sentence, right before “They are arrogant,” did you mean “harm” rather than “harmed?”

  • rational thinker

    Maybe some women think they must breastfeed to prove they are a real woman or at least feel that way due to aggressive breastfeeding promotion. That is a horrible thing to think and a horrible feeling some zealots try to push on women in the form of a guilt trip and it needs to stop.

    • mayonnaisejane

      They do. That’s the problem.

  • Madtowngirl

    Tangentially, I am currently sitting in the hospital, postpartum from my second C-section. This same hospital gave me hell with my first because of my breastfeeding difficulties. I am happy to report that this time around, I have had nothing but support for my decision to formula feed. The nurses have offered to take my baby to the nursery so we can sleep. I still got the stupid form letter in our information packet “urging” us to breastfeed because it is “one of the most important health decisions you will make for your child,” but in practice, all of the language around feeding has been presented as a choice. It has been overall a completely different and better experience, and i hope that more hospitals ditch the aggressive BF promotion.

    • Who?

      Congratulations on the baby!

      Glad you’re having a better time with the hospital than last time.

    • PeggySue

      Huge congratulations! Hope everything goes super well!

    • demodocus

      congratulations!

    • Amazed

      Congrats on the new arrival!

    • momofone

      Congratulations!

    • StephanieJR

      Congratulations!

    • fiftyfifty1

      Congrats!

  • Mad Hatter

    Lifestyle choice for sure. I can’t believe how many moms I see begging strangers for donor milk on Facebook! I saw a post yesterday in a baby bst group. A mom going through chemo is asking for donor milk for her 12+ month old baby. Why? Because her daughter likes it, and its good for her daughters immune system which helps mom stay healthier.

    • Mel

      When my son was born really early, a well-meaning friend offered their breastmilk stash for him. I had to figure out a way to say “Thanks, but no thanks” without shuddering at my microbiology class-based fear of what kind of issues breast milk stored improperly could do to a micropreemie.

      • Who?

        ‘…perfectly reasonable fear…’

        Fixed that for you 😉

      • Ozlsn

        I have a friend who was totally skeeved out by the online donor milk exchanging. Apparently working in food safety gives you a very different perspective on the idea. I have to admit to looking up what pasteurisation does to breastmilk, and confirming my own suspicion that any antibodies are denatured…

        • space_upstairs

          I think it’s that these people have such an extreme appeal-to-nature fallacy that they don’t believe the germ theory of contagious disease on the basis of “but germs are Natural! They can’t be bad for you without the help of something Artificial and thus Toxic!”

          And that’s the problem with preventive medicine in general: it assumes health problems and their solutions are simple, if taken too far. Obviously, of course, things like decent diet, exercise, and vaccines can reduce your *odds* of disease, like my elective induction followed by an elective C-section for stalled labor reduced my *odds* of having a complicated birth. But not everything can be prevented even with the best efforts. In an H1N1 season, you still have 40% of the chance of getting the flu with the shot compared to without it. And maimtaining a normal weight before pregnancy and normal gain during pregnancy didn’t stop my baby from growing to my own massive birth weight without my having my mother’s broad hips to push her out with little trouble as she did with me.

      • alongpursuit

        I had many problems with breastfeeding and saw multiple LCs and nurses. One of the public health nurses I saw later found me on Facebook and sent me a message saying that her friend had a frozen breastmilk stash she could give me for my baby. I’m still tempted to report her, but the whole health system where I live seems to be extremely pro-breastfeeding.

      • Mad Hatter

        I had a nurse friend mention she had a lot of milk stashed. She gave it all away. Anything I had frozen went down the drain when I weaned my kids.

    • EmbraceYourInnerCrone

      Would she give her daughter an untested blood transfusion from a stranger? How is giving her daughter breast milk from someone else any different? She has no idea what diseases they might have or what medications they might be on…and that’s not even mentioning that people don’t always store breastmilk under proper refrigeration before or during shipping.

      • rational thinker

        But breastmilk is “magical” so there couldn’t be anything wrong with it even if the donor had hiv/aids, herpes, or hepatitis. Even if it did have a disease in it it would still be much safer than formula. (Yes I have actually heard that one before)

        • Mad Hatter

          My kids were just as healthy on cows milk as breastmilk. I weaned them within a month or two of turning 12 months. I think my local grocery store must stock from magical cows.

    • Allie

      Ha, at 12+ months, there’s all sorts of inexpensive “donor” milk available at the grocery store. It comes in gallon bottles : )

  • BeatriceC

    I am watching helplessly as disaster unfolds in my own circle. It’s heartbreaking.

    • PeggySue

      Oh, that’s hard.

  • The Bofa on the Sofa

    OT: just wanted to share. In a somewhat paradoxical position, I am very pleased to hear that the judge as ordered the termination of parental rights for the baby for whom I CASA. It’s been 16 months and the parents have done NOTHING to establish any relationship with him (to the point where the mother, upon being released from jail to the custody of her sister to take her to rehab, didn’t go). Unfortunately, given a Child Services snafu, the hearing got delayed 3 months, and so we still had to deal with it.

    But now parental rights are terminated (Dad is in the federal pen, so not an issue), and he can be a permanent part of a loving home with his current foster parents.

    You don’t like to hear about parental rights being terminated involuntarily, but this is a good day for my baby!

    I am very excited. He started with a month in the NICU, but the result is going to be great!

    PS He was never breastfed.

    • Russell Jones

      “He was never breastfed.”

      And he’s still alive? How’s that even possible, what with all the toxins and autism in stuff-other-than-breast-milk?

      Srsly, though, that’s great news for the young ‘un.

      • The Bofa on the Sofa

        I know, right? Just because his mom was out in the parking lot of the hospital doing meth the day after he was born is no reason she shouldn’t have been breastfeeding him!

        • Cristina

          I know you’re joking but it literally happened to my adopted cousin. His mom was doing hard drugs in the parking lot and then breastfeeding him

          • rational thinker

            OMG that’s awful. I have a friend that was breastfeeding while on methadone and having hep c.

          • The Bofa on the Sofa

            To be honest, I cannot say for sure there were no attempts to breastfeed. All I know is that mom never saw the baby after about day 2. Cord blood came back seriously positive for meth and opiates, and he had severe NAS.

            And the part about doing meth in the parking lot is also not necessarily true – it could have been heroin.

          • Cristina

            My aunt was a foster parent for this baby before she adopted him and they knew as soon as the mom was pregnant that he would be removed from her custody (for drug use and she had prior children removed from her care for the same reason) so I don’t understand why they allowed her to breastfeed or if she was being sneaky about it

    • Sarah

      It’s never too late. I’m sure someone can hook you up with a stash of illegally obtained domperidone.

  • demodocus

    Honestly, doc, some of us consider a Yale or Harvard degree to be somewhat detrimental, at least to arrogance level.

  • QuantumMechanic

    Possible typo? You said “I can assure you that the benefits of breastfeeding term babies in developing countries are so trivial as to be undetectable.”

    Did you really mean “developing” there or did you mean to type “developed

    • Amy Tuteur, MD

      Thanks!! Fixed it!

  • Cartman36

    This is why I love you Dr. Amy. I found you when I needed you, as a Harvard trained physician, the most to tell me that my worth as a mother was not predicated on producing and providing BM. I am so glad that you continue to share your message to new moms that are inundated with BS from the best is best bullies.

    Also, how the hell have we gotten to a point where educated successful women who work so hard and do so much for their children are made to feel like a bad mother. It pisses me off

    • demodocus

      For half a second, I misread BM as bowel movement, which is hysterically wrong in that sentence.

      • alongpursuit

        In a way making breastmilk is just as magical as bowel movements. 😉 I have bowel movements, what’s your superpower?

        • MaineJen

          Colostomies are unnatural. Those people just aren’t *trying* hard enough. REAL warrior mammas poop. /sarc

    • Megan

      Seconded. I found Dr. Amy right when I needed her too after having a horrible time breastfeeding my first child and was trying to decide whether to try again with my second child. I now share with the family med residents and medical students that I teach that there is no evidence-based reason to guilt moms into breastfeeding and I felt confident enough about the primary literature on breastfeeding to choose to formula feed my third child (who incidentally, was the only one to not get readmitted for jaundice and whom I found I most enjoyed the immediate postpartum period).