Rafael Perez-Escamilla, PhD and colleagues owe women a profound apology for misogyny

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Prof. Rafael Perez-Escamilla and his colleagues at the Yale School of Public Health have joined the cadre of medical misogynists by adding breastfeeding to a long list of medical issues where women’s self reports and suffering are dismissed out of hand.

Even I, a deeply cynical person, am stunned by the viciousness of their claim.

Some have hypothesized that SRIM (self-reported insufficient milk) is simply a socially accepted excuse that women give for explaining why they are not practicing what they know is recommended infant-feeding behavior.

Apparently, those lazy, selfish new mothers are faking it so they can get out of breastfeeding.

Every misogynist healthcare provider “knows” that women lie about their symptoms and suffering.

It’s just like those “neurotic” women who self-report chest pain and are sent home from the ER having been told they are suffering from anxiety, when in truth they are in the midst of a heart attack.

Or just like those lazy women who complain of disabling menstrual pain just to get out of school or work, but in truth have severe endometriosis and are literally bleeding into their abdominal cavity every month.

Every misogynist healthcare provider “knows” that women lie about their symptoms and suffering. Don’t bother listening to them; they’re just making excuses.

However, others have postulated that SRIM may result from not understanding the lactation process, as women often report SRIM within the first 2 d after birth, a time when only small amounts of colostrum are being produced, and they introduce breast-milk substitutes in response to this (i.e., pre-lacteal feeding)… The precise proportion of women who cannot produce enough milk for satiating and meeting the nutritional needs of their infants for primary biological reasons remains unknown. However, it is likely that this proportion is low because the lactation process is mainly driven by a highly protected infant demand-maternal supply process.

Perez-Escamilla et al. seem to be afflicted with a lack of knowledge about both evolution and basic biology. First, evolution does not produce perfection. Second there are lots of critical bodily functions that are driven by highly protected demand-supply processes …. and those processes fail. These conditions include everything from irregular periods to type I diabetes. Are women with irregular periods making excuses? Are women with type I diabetes too lazy to metabolize sugar?

Here’s a radical thought: instead of postulating about whether women can be believed, let’s investigate.

Insufficient breastmilk is common, not rare.

In 2010, the Academy of Breastfeeding Medicine acknowledged:

It is important to recognize that not all breastfed infants will receive optimal milk intake during the first few days of life; as many as 10–18% of exclusively breastfed U.S. newborns lose more than 10% of birth weight.

There is a biomarker for insufficient breastmilk.

From a 2001 paper:

High levels of sodium in breast milk are closely associated with lactation failure. One study showed that those who failed lactation had higher initial breast milk sodium concentrations, and the longer they stayed elevated, the lower the success rate.

Insufficient breastmilk is NOT a figment of women’s imagination.

This was confirmed in a 2017 paper that also showed that women who felt they had insufficient breastmilk were more likely to have the biomarker present.

…[E]levated day 7 breast milk Na:K occurred in 42% of mothers with a day 7 milk supply concern, compared with 21% of mothers without a day 7 milk supply concern (unadjusted relative risk, 2.0; P = .008) (Table II). The unadjusted odds of elevated Na:K were 2.7 greater (95% CI, 1.3-5.9) with maternal report of milk supply concern (refer- ence = no concern, P = .01) and further increased after ad- justment for maternal ethnicity (3.4; 95% CI, 1.5-7.9; P = .003).

The potential brain threatening and life threatening consequences include kernicterus, hypernatremic dehydration and severe hypoglycemia.

Kernicterus, thought to have nearly disappeared, is making a comeback.

Dr. Lawrence Gartner revealed to other lactation professionals in a 2013 lecture, 90% of cases of kernicterus (jaundice induced brain damage) are caused by insufficient breastmilk.

The Academy of Breastfeeding Medicine reported in a 2017 paper:

In the U.S. Kernicterus Registry, a database of 125 cases of kernicterus in infants discharged as healthy newborns, 98% of these infants were fully or partially breastfed …

Neonatal hypernatremic dehydration is more common than SIDS.

From 2016 paper :

In a retrospective study in the United Kingdom, the frequency of breastfeeding-associated neonatal hypernatremia was found to be greater than all-causes combined of hypernatremia among late preterm and term newborns.81 In the mentioned report, the incidence of sodium level ≥ 160 was 71 per 100 000 breastfed infants (1 in 1400).

The consequences include death and potentially devastating neurologic injury as this 2017 study explains:

In our study 7 out of 65 patients died as a result of complications of hypernatremia. There was a significant correlation between severity of hypernatremia and mortality (p = 0.001). All who died had serum sodium concentration >160 mmol/L…

All infants in the control group were developmentally normal at ages 6 and 12 months, but in the case group 25% and 21% had developmental delay at 6 and 12 months, respectively. At 18 months the incidence of developmental delay was 3% for the control group and 19% for case group, and at 24 months 12% of case infants had developmental delay versus none for the control group…

Hypoglycemia also injures and kills babies.

A 2017 paper reports that the UK has paid out $250 million dollars for brain injuries due to hypoglycemia, nearly all cases the result of insufficient breastmilk.

As far as I can determine Perez-Escamilla and colleagues simply IGNORED all of this research. Indeed the words “dehydration” and “jaundice,” together accounting for literally tens of thousands of newborn hospital readmissions each year, aren’t even MENTIONED in the paper.

This is not the first time that Perez-Escamilla has let his enthusiasm for promoting breastfeeding exceed his ethical obligation to tell the truth. Last fall he was forced to retract a libelous tweet about the Fed Is Best Foundation supposedly receiving industry funding. As far as I can determine, he had no evidence; he just made up the claim to suit his personal views.

Having staked entire careers (and possibly self-esteem) on the beliefs that breastfeeding has major benefits and every woman can breastfeed, Perez-Escamilla and colleagues cannot bear the cognitive dissonance of admitting that the scientific evidence shows the opposite and so they ignore that evidence.

That would be bad enough. What is truly reprehensible is that they substitute classic misogyny in its place: it’s okay to ignore women because they can’t be trusted to accurately report their own symptoms.

Perez-Escamilla and colleagues have let their prejudices and conflicts of interest blind them to the suffering of women and babies. They owe all women an apology.

  • Lancelot Gobbo

    The number of times I’ve seen poor scrawny little infants who haven’t gained weight and are crying fretfully.
    “But I’m breastfeeding and doing everything right!”
    This baby is starving.
    “You don’t understand, I want to breast feed!”
    I do too, but the problem is you’ve got the breast part but not the food part.

    All it takes is one supplemental feed, and the miraculous change in the infant, to win the argument.

  • Sarah

    Normally I don’t give any thought to my decision not to breastfeed, but when I read stuff from dicksniffs like this, it makes me so proud. It’s so delicious to be a woman whose use of her body pisses off misogynists this much.

  • DaisyGrrl

    What an ass. This attitude toward breastfeeding pervades public health, and I find it so strange. Public health is about maximizing health on a population level, and the evidence is simply not there for spending massive amounts of money to promote universal breastfeeding as a public health measure.

    If public health practitioners want to reach parents and set babies up for a lifetime of health, then they need to meet families where they are. If that means educating about healthy feeding practices and meeting infant nutritional needs, then that should be the goal.

    My local public health unit runs drop-in breastfeeding support clinics (I suppose formula feeding mothers are free to drop in and be lectured at). I really wish these were re-branded as infant feeding support clinics. There are a multitude of services that new parents can be connected with through these clinics, and there is an opportunity for the health system to build a supportive relationship that benefits a family throughout the life cycle – improving parenting skills, overall nutrition, increasing vaccination rates, etc.

    By alienating the families who typically have the least social supports (lower socio-economic status, racialized people, people with other disabilities or trauma that prevent exclusive breastfeeding), we are perpetuating the inequalities that exist in our current system and serving as a barrier to improved health outcomes.

    I have tried pointing this out to colleagues, and they generally bemoan that they wanted to breastfeed but didn’t get enough support and had to hire a lactation consultant (and beg their doctors for domperidone). My pointing out that as middle-class, educated white women, they had access to resources that are not available to the most at-risk falls on deaf ears. It’s very rare that I dare suggest that early infant starvation* is probably a larger risk factor for many of the “risks” of formula feeding, because “low supply is a myth.”

    /stepping down from soapbox and ending rant.

    *I was inadvertently starved for months during infancy as a result of this nonsense, and I occasionally wonder how many ear infections might have been prevented if I had been properly fed and been able to develop normally in early infancy (would I have needed tubes? what about hearing aids?). Would I still have ADHD? I struggle with my weight, while my siblings who were sufficiently fed do not. Food is a complicated landscape for me.

    This issue is intensely personal for me and I rage at the thought of mothers being duped into starving their babies and left unsupported at such a vulnerable time in their lives.

    • Cartman36

      THIS! If we really want to improve childhood outcomes, we would be addressing the very real issues that families face such as drug addiction, incarceration, poorly funded schools, food insecurity, food deserts, providing safe places for kids in urban areas to exercise and play, etc.

      But…. addressing these issues requires work and money from the community. Its much easier to put all the onus on women by telling them that EBF will ensure their child grows up to be successful, healthy, etc

    • kilda

      instead of drop in breastfeeding support clinics, or even drop in feeding clinics, wouldn’t it be great to have drop in baby care clinics, period? I imagine there are plenty of baby care skills that new parents might need help with besides just feeding. Like safe sleeping, managing your exhaustion and stress, what to do when baby won’t stop crying, is the poop supposed to look like that, etc.

      • mabelcruet

        Do you remember Dr Miriam Stoppard? She used to be on TV in the UK years ago as a breakfast TV advice doctor, and did columns in various papers. At one point she was giving advice to a mum who was absolutely at the end of her tether-baby wouldn’t stop screaming, she’d tried everything, baby was fed and clean, but just wouldn’t stop and mum was terrified about what she might do (absolutely no suggestion that she’d hit or shaken the child, just that she was terrified she might lose control). Stoppard very sensibly advised her that if she thought the baby wasn’t hungry or had a full diaper, that she should put the baby somewhere safe and warm and close the door. She said mum needed a breathing space, that letting the baby cry for a wee while wouldn’t harm it. You should have heard to scandal that caused-they had people phoning in saying that constituted child neglect and child abuse, that she should be struck off, that the mum should be prosecuted for even thinking about hurting her baby and if she couldn’t cope with a crying baby she didn’t deserve to keep it. I feel so sorry for mums-they have everyone telling them what to do, and criticising what they do, and commenting on what they do like its some sort of public performance.

  • Mimc

    I have switched doctors multiple times because I felt like I had to exaggerate my sure symptoms to be taken seriously. Never with women doctors though. Could be a coincidence but it feels more like a pattern now.

    • Ayr

      I switched doctors from a woman to a man in the same practice because the woman just waved my concerns aside and said I was being dramatic. My current doctor, while he is a bit of a smart a** but always professional, takes my concerns seriously and listens, will always answer my questions, if he doesn’t know the answer he admits it and does research. I think it really depends on the patient/doctor personality mix. Some people like clinical and detached, I prefer someone more personable but professional. And some doctor’s are great Obstetricians but not good Gynecologists and vice versa.

  • Who?

    Off topic but maybe of interest to some-not guilty verdicts for Lisa Barrett:

    https://www.abc.net.au/news/2019-06-04/former-midwife-lisa-barrett-found-not-guilty-of-manslaughter/11173254

    • Ozlsn

      What the fuck do you have to do to be found guilty of manslaughter in those cases, seriously. Apparently being incompetent is fine, giving misleading information, failing to refer to appropriate facilities is fine, failing to call an ambulance.. honestly, why even bother taking her registration. Still at least they’ve had a prosecution attempt, which is still more than the Victorian DPP attempted.

  • MaineJen

    The poor dears just don’t understand what’s good for them. We’ll just have to EDUCATE them about breastfeeding within an inch of their lives.

    • Chi

      More like within an inch of their babies’ lives (sarcasm btw).

  • fiftyfifty1

    I read Prof. Perez-Escamilla’s paper and I’m not impressed. His paper is basically a defense of the WHO recommendation of exclusive breastfeeding (i.e. nothing other than breastmilk) until 6 full months of age. The official rec used to call for only 4 months, but it was raised to 6 mo in the early 2000’s and now there are calls to put it back to 4 months. He dismisses basically every concern that is raised. Many exclusively breastfed infants are already iron-deficient by 3 months? Well they should have practiced delayed cord clamping! Obesity is a known risk factor for delayed onset of lactation/insufficient production? Well obesity is a “modifiable risk factor.” (I’ll tell affected moms that I’m sorry that they let themselves get obese and didn’t think to “modify” that!) Sheesh.

    • Mimc

      There’s also evidence that starting other foods at 4 months might help prevent food allergies.

      • fiftyfifty1

        Oh he dismisses that argument, too. According to him, starting food by 6 months is probably soon enough to prevent most allergies. Besides, allergies aren’t *that* common, and those studies that show that earlier food introduction is better were done in high risk infants, and most infants aren’t high risk. Blah, blah, on and on. Can you imagine him making the same excuses in reverse if exclusive breastfeeding had been shown to be superior for preventing allergies?: “4 months is probably delay enough, besides allergies aren’t *that* common, besides those studies showing 6 months of exclusive breast is better were done in high risk populations and most infants aren’t high risk.” LOL, NEVER!

        • Mimc

          Allergies not common? Exactly how many people have to have something before he’ll call it common?

          • fiftyfifty1

            Well, the reported prevalence ranges from country to country, and were the allergies adequately confirmed, and it’s controversial…

    • DaisyGrrl

      Ugh that 6 month recommendation! My nephew was clearly ready to start trying solid foods at 4 months. Even going so far as to try and grab food out of our hands and shoving it in his mouth! While his mother had more than enough milk, the kid was clearly ready to start exploring other foods, and I’m not sure what benefit was supposed to appear from making him wait (his older sister, meanwhile, was clearly in no hurry to start other foods, and started various baby foods at 6 months, exactly on “schedule”).

      I feel like parents in developed countries would be better served by feeding guidelines that explain how to tell if a breast-fed baby needs formula supplementation and what the signs are that a baby is ready for non-milk foods. The moral judgement that comes with breastfeeding appears to erase all logic.

      • Kelly

        My child did not fully chunk up until we started feeding her food and the same happened with my friend’s kids. I always started my kids at 4 months due to my pediatricians suggestion but didn’t with this one due to some GI issues she had. Turns out, feeding her food fixed a lot of the issues she had and allowed her to get enough nutrients.

  • Amy Tuteur, MD

    I left a comment on Prof. Perez-Escamillo’s Facebook page. He immediately deleted it.

    • rational thinker

      Of course he did, I am not surprised at all.

      • fiftyfifty1

        I am surprised. Maybe I shouldn’t be, but I continue to be shocked each and every time that an academic deletes a comment by Dr. Tuteur. What is the point of being an academic if you refuse to engage in an challenges to your opinion? Debate and discussion are at the very center of what it means to be an academic.

    • Russell Jones

      Shocking. 🙂

  • rational thinker

    There are some things these people need to get through their heads. While modern medicine expects nearly all babies to survive birth and infancy that is certainly not how evolution in nature works. Nature does not give a shit how much you want to breastfeed. If you cant produce enough milk then you cant produce enough milk and all the wishing and pumping you do won’t change that. THIS is the REASON formula was invented.

    • Not to mention that wetnursing was a profession in existence for millennia…

      • Ozlsn

        Not according to the woo crowd. Wetnursing apparently only came into being in the Victorian era when aristocratic women wanted to not breastfeed. I was kind of bemused when I was told that.

        • PeggySue

          Ummm, no.

  • Alia

    To use a quote: “There are no words in a civilized person’s vocabulary that are insulting enough to describe this” (meaning the whole idea of SRIM)

  • mabelcruet

    Typical weaselly phraseology: “Some have hypothesized that…”

    So he can claim that its other people claiming this, not him or his group. How dare you accuse him of misogyny? All he wants to do is help women achieve their breast feeding goals, how sad they would be if they couldn’t breast feed, how sorrowful that they can’t experience being a real mother….and so on. Pillock.

  • NoLongerCrunching
  • sheistolerable

    Dr. Tuteur–are there any efforts underway to encourage the AAP to change its guidelines in response to the evidence that simply presenting breast as best endangers women and babies?

    Is anyone studying the connection between PPD and breastfeeding promotion? Why is formula feeding (enabling sharing the labor and protecting mom from chronic sleep disruption) not recommended as a first line of defense against PPD?

    • Amy Tuteur, MD

      There are lots of efforts underway in a variety of professionals societies but they are meeting tremendous resistance. The scientific evidence is being ignored in favor of discredited “conventional wisdom.”

  • RudyTooty

    I tell women that EVEN IF THEY’RE PRODUCING gallons and gallons of milk from their breasts, they don’t have to breastfeed if they don’t want to.

    Not wanting to – for any damn reason- is reason enough to not breastfeed.

    When we play into this idea that if one’s breasts produce milk, then one must produce milk, and that the only ‘excuse’ is not having enough milk – it totally negates the person’s desire to lactate and/or breastfeed.

    It is moralizing the functions of women’s bodies. It’s disgusting.

    But am I saying the same thing as Prof. Rafael Perez-Escamilla?

    I’m trying to not police women’s bodies – and the amount of milk that they make or don’t make – and whether they are being ‘honest’ about their milk production.

    I *do* think the lactation consultants and lactivist industry have made low milk supply one of the only acceptable reasons for not breasfeeding – women feel ashamed when they say they don’t want to breastfeed, or that they don’t like breastfeeding. So they are looking for an excuse to not breastfeed that the lactivists will validate.

    Well, the lactivists won’t validate any of it – because the agenda is extracting milk from breasts. Milk production period. In the name of shame and ‘good’ parenting. None of these folks will validate a woman’s choice to not breastfeed.

    If we respected women – and mothers in particular – and didn’t shame them for being who they are and using their own bodies as they want to, no one would need any excuse for anything.

    • EmbraceYourInnerCrone

      It’s been going on longer than you think, I had my kid in 1994 and even then (this was in Southern California) the attitude of everyone from the nurse teaching the Lamaze class to my co-workers to the nurses on the OB floor was “Well of course you are going to at least TRY!” “You ARE breastfeeding AREN’T you” Fortunately back then there was still a well nurssery, although even then you were expected to take care of your baby and room-in most of the day. You were allowed to roll the baby back to the nursery so you could sleep for a couple hours now and then. And the bassinets had premade ready to feed bottles , thank heaven. I notice the hospital I had her at is now Baby Friendly…not a surprise…

      Why people think it’s OK to make judgmental comments to strangers is beyond me.

      • Cartman36

        I am a firm believer that we all have this narcissistic fantasy that we are the only person in the world that has life figured out and that if other people would just do what we do, they would be successful. No need to take into account other people live in a different situation.

        My mother is a judgemental Judy and I tell her all the time, advice that was not asked for is not advice, it is a criticism.

    • Brenna Goode

      So true! I don’t understand how women can argue and agitate and scream for reproductive freedom, and yell at politicians about staying out of their uterus, then turn around and insist that all women breastfeed, push for BFHI, and shame mothers who don’t breastfeed. My bodily autonomy DOESN’T END at the edge of my uterus. Boobs are included. And if I don’t want to use them to produce milk, that’s no one’s business but my own.

    • demodocus

      That’s me; I get oversupply, but god help me, I still can’t stand to have my breasts touched and kid1 was weaned 4.5 years ago. Kid2 was eff.

      • Kelly

        Me too! I had an oversupply but latching issues and exclusively pumping pushed me to formula feed my last two and I have never looked back.

    • StephanieJR

      ‘I don’t want to’ is a valid explanation – not even an excuse – for anything.

      For example, I don’t want to have children. I could give you reasons if I felt like sharing, but I am never obligated to explain anything I shouldn’t have to. Neither are you.

      If you don’t want a vaginal birth, that’s fine; you don’t have to say why, not to strangers, friends or family.

      If you don’t want to breastfeed, that’s fine; you don’t have to say why, not to strangers friends or family.

      You are not obliged to swallow anything you despise.

      • mayonnaisejane

        This is dismissive and judgmental language about breast feeders! To treat these things as equal is an attack on breasfeeders! It makes them feel like they went to all that effort for nothing! Also saying breastfeeding mothers are working harder to give their child the better option isn’t an attack on formula feeders because fact’s aren’t attacks. /S

        *Mutters something about oversensitive breast feeders who can turn everything positive about other options into an attack on themselves, and their own attacks on others into “facts.”*