The Academy of Breastfeeding Medicine (ABM) blog has been pretty quiet lately. They haven’t published a single substantive post in nearly 6 months, perhaps because their posts were being systematically torn apart by myself and others.

Now, in the face of a several major publications demonstrating that the Baby Friendly Hospital Initiative (BFHI) is a deadly failure, they’ve returned, desperate to prop up the failing boondoggle.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The Academy of Breastfeeding Medicine is desperate to prop up the BFHI, a failing boondoggle.[/pullquote]

How is the BFHI a boondoggle? Let me count the ways:

• It is a lactation consultant full employment plan
• It gave voice to lactivists’ worse bullying impulses
• It is directly contradicted by science on a variety of issues including the actual benefits of breastfeeding
• It has been known for years that it is killing babies
• It violates women’s bodily autonomy

The latest evidence includes:

• The revised United States Preventive Services Task Force (USPSTF) guidelines
• Interventions Intended to Support Breastfeeding: Updated Assessment of Benefits and Harms
• Unintended Consequences of Current Breastfeeding Initiatives

Together these papers showed that the BFHI doesn’t work, ignores the science on pacifiers, formula supplementation, and Sudden Infant Death Syndrome (SIDS) and leads to preventable infant injuries deaths when babies fall from or get smothered in their mothers’ hospital beds.

You might think that these findings would engender distress at the ABM and an immediate effort to modify the BFHI to reduce injuries and deaths.

You would be wrong.

Instead it has led to reflexive defense of the indefensible.

The piece is written by Melissa Bartick, MD who has staked her career on massively exaggerating the benefits of breastfeeding. She consistently finds the theoretical lifesaving benefits of breastfeeding despite the fact that she literally cannot demonstrate ANY actual lifesaving benefits to breastfeeding in term infants. I’ve publicly challenged her repeatedly and she has yet to present any real world data to support her extravagant claims.

The title is a bald-faced lie: Evidence is Clear: Baby-Friendly Hospital Initiative Increases Breastfeeding Rates in the US and Closes Breastfeeding Disparities. That’s precisely the OPPOSITE of what the evidence shows.

Bartick skips from one lie to another.

On the benefits of the judicious early formula supplementation:

Yet this editorial is what is garnering the most media attention. Interestingly, the editorial does support previous research by one of its authors, Valerie Flaherman, who found that small amounts of formula help women breastfeed longer. This finding, which contradicts previous evidence (here and here) that non-indicated supplemental formula is a strongly associated with breastfeeding failure.

Bartick’s claim is debunked by the ABM’s own Dr. Alison Steube who wrote in April on the very same website:

Delayed onset of lactogenesis is common, affecting 44% of first-time mothers in one study, and 1/3 of these infants lost >10% of their birth weight. This suggests that 15% of infants — about 1 in 7 breastfed babies — will have an indication for supplementation …

On the failure of the BFHI to increase breastfeeding rates:

A national survey of US Baby-Friendly hospitals compared to hospitals that were not designated Baby-Friendly, the hospitals designated as Baby-Friendly in 2001 had elevated rates of breastfeeding initiation and exclusivity, regardless of demographic factors that are traditionally linked with low breastfeeding rates…

But correlation is not causation especially because the BFHI designation is used as a marketing ploy to attract women for whom breastfeeding is a priority…

One way to look at the correlation between BFHI, the Ten Steps, and Breastfeeding Rates is to look at national data itself from the CDC Breastfeeding Report Cards and the CDC National Immunization Survey, for the years 2007 to 2013, the years in which we have data on the percentage of births in Baby-Friendly hospitals from the CDC. We can look at the following metrics: the number of Baby-Friendly designated hospitals, the percentage of live births at Baby-Friendly Hospitals, the rate of exclusive breastfeeding at 3 months … This data show that the mathematical correlation between the increase in births born at Baby-Friendly hospitals and exclusive breastfeeding at 3 months is 0.93, which is extremely high.

But the rate of breastfeeding was rising dramatically BEFORE the BFHI ever existed. The fact that the rate continued to rise is meaningless. It does NOT show that the BFHI had anything to with the rise at all.

What about the fact that the BFHI bans pacifiers despite scientific evidence that shows that pacifiers prevent SIDS?

Bartick ignores that.

What about the scientific evidence that enforced prolonged skin to skin contact leads to infant smothering deaths?

Bartick ignores that.

What about the scientific evidence that mandatory rooming in policies and closing well baby nurseries leads to infant deaths from skull fractures and smothering?

Bartick ignores that.

The bottom line is pretty simple:

I and others can demonstrate literally hundreds, perhaps thousands, of infant injuries and deaths as a result of the BFHI. In contrast, Bartick and her ABM colleagues offer not even a single term baby whose life has been saved by the BFHI.

The BFHI is a deadly failure. It’s time to end it.

Anti-vaxxers love bibliography salad. They are constantly clogging the comments sections of my vaccine pieces with citations they have carefully cut and pasted from other anti-vaxxers.

As usual, they flatter themselves by imagining that it shows how knowledgeable they are. Sadly for them, it merely confirms their ignorance. That’s because merely being published in a journal doesn’t make a claim either true or relevant.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Ask anti-vaxxers to cite systematic reviews or meta-analyses to support their claims. They won’t be able to do so.[/perfectpullquote]

Their lack of understand fuels their cynicism and the cynicism of many other lay people.

When faced with conflicting scientific claims, lay people often conclude that the truth is simply a matter of what you prefer to believe. Even worse, they occasionally conclude that there is no truth or that the truth is unknowable. It might help, though, to consider a real life example. We know that there are newspapers and news organizations will often report conflicting accounts of political disagreements. And we know that just because we read something in the newspaper, it is not necessarily so.

Reading a scientific paper is similar to reading a newspaper article. Consider the birther “controversy.” A Democratic leaning newspaper may run an article with the headline that Obama was born in Hawaii. A radical Republican newspaper may run an article with the headline that Obama was born in Africa. That does NOT mean that Obama’s place of birth is indeterminate or that we cannot know where Obama was born.

The abstract of a scientific paper is the equivalent of the headline in a newspaper. It tell you the conclusion that the author wants you to draw. It does NOT mean that the conclusion is true, anymore than a newspaper headline means that the article underneath it is true.

The body of the scientific paper is the equivalent of the body of the newspaper article. It offers facts and draws conclusions based on those facts. Even articles with false claims will offer facts. The radical Republicans offer facts for their claim that Obama was born in Africa: his middle name is “Hussein;” his father was born in Africa; there are not many black people in Hawaii. The Democratic newspaper offers facts: it might show a picture of Obama’s Hawaii birth certificate with the official seal; it may have obtained access to Obama’s hospital record from the day he was born.

So we have two articles with two different conclusions and two different sets of facts. Does that mean that we cannot know where Obama was born? Of course not. It is a fact that Obama’s middle name is “Hussein” and it is a fact that his father was born in Africa, but that is actually irrelevant in determining where Obama was born. The birth certificate and the hospital record prove that Obama was born in Hawaii.

Similarly an anti-vax website might run a piece claiming that vaccines are unsafe and ineffective. Medical websites will run pieces claiming that vaccines are safe and effective. The opposing claims do not mean that the safety and efficacy of vaccines are indeterminate or in doubt.

The citations offered by anti-vaxxers do contain facts. For example, they may show that large doses of aluminum are toxic to certain cells in petri dishes. Or they may show that some children do die of vaccine reactions. But that does NOT mean that vaccines are unsafe or that vaccine injuries are common.

So how do we decide what’s true? We look at the scientific evidence in the aggregate. That’s especially important in an area such as vaccine safety and efficacy. There are literally tens of thousands, perhaps hundreds of thousands of papers. Therefore, we look at massive studies (millions of children), and systematic reviews and meta-analyses.

There are many large studies of vaccine safety and efficacy and many systematic reviews and meta-analyses that address these issues. The overwhelming majority of them show vaccines to be safe and effective. That conclusion is NOT undermined by random papers that show large doses of aluminum are toxic to cells in petri dishes and not undermined by case reports of individual children who have rare vaccine reactions.

So if someone comes to you and offers random scientific citations to show that vaccines are either unsafe or ineffective ask them to cite at least ten systematic reviews or meta-analyses to support their claims. They won’t be able to do so … and that’s how you’ll know that their claims are nonsense.

The most important tool of any expert-in-her-own-mind birth blogger is the delete button.

Jen Kamel, commercial real estate professional, and expert-in-her-own-mind birth blogger is an excellent example. Kamel has been banning and deleting for years. Why?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Should women who disagree be seen, acknowledged and respected or silenced and banished?[/pullquote]

• She cannot tolerate disagreement.
• She is incapable of addressing scientific criticism.
• She must prevent readers from thinking for themselves.
• She wants to convince women to pay money for her worthless products (see VBACFacts Academy is the Trump University of natural childbirth)

But that’s not how Kamel sees it. Consider her justification for her recent interaction with a CNM (certified nurse midwife) who publicly exposed Kamel’s advice as dangerous and irresponsible. First Kamel deleted the CNM’s posts, which were scientifically accurate, and then banned her.

Laughably, Kamel attempts to justify her tactics as integrity when they are the exact opposite.

I think it is important to follow people whose beliefs are in alignment with your own. This way as individuals and as a community, we remain in integrity.

That’s not integrity; that’s brain washing.

In that space of integrity, I am known as someone who gets the evidence into the hands of parents, professionals, and providers.

Among obstetric professionals Kamel is NOT recognized as a person of integrity, but rather a shill who charges a fortune for information that is available for free at many other websites; who promotes process (VBAC) over outcome (healthy baby/healthy mother); and who provides false information and deletes correct information when others post it on her Facebook page.

I have had hundreds of health care professionals, such as obstetricians, family practice doctors, labor & delivery nurses, CNMs, and CPMs, attend my programs to rave reviews.

I call bullshit. I’d be surprised if there were a dozen doctors of any kind who would waste money on Kamel’s nonsense.

Most importantly, Kamel let’s us know that she doesn’t like argumentative women on her Facebook page.

Now, from time to time, I come in contact with someone in the community who doesn’t resonate with my mission. This is to be expected in life. I respect their choice to not resonate with the message shared, just as much as I hope in return they respect that I will remain true to myself… speaking out on the importance of VBAC access, the ethics of forced cesarean surgery, the public health implications of VBAC bans, and so much more…

So I if don’t resonate with you, then I humbly and graciously suggest that you might find more joy in someone else’s community.

Yet how would she feel if obstetricians took the same view, ignoring women precisely because they were argumentative over the issue of VBAC or refusing interventions or the right to bodily autonomy? I suspect she would be horrified.

Imagine for a moment that an obstetrician said to a patient:

From time to time I come in contact with a pregnant woman whose desires to not resonate with my views. I will ignore her desires and remain true to myself. If you don’t like my views, get another doctor. If you don’t like my hospital’s VBAC ban, find another hospital. Do not try to change my mind or my hospital’s policy; that would be an assault on our integrity.

Would Kamel agree with that? I doubt it.

If Kamel’s work is about anything at all, it is about making sure that women who disagree with their obstetricians are seen, acknowledged and respected, not silenced and banished. Yet Kamel refuses to make sure that women who disagree with HER are seen, acknowledged and respected; instead she ensures that they are silenced and banished.

Why? Because she cannot tolerate disagreement, can’t address scientific criticism, can’t let women think for themselves, and cannot be diverted from her primary task of making money.

That’s not integrity; that’s hypocrisy.

Homebirth midwives are nothing if not self-absorbed.

A baby is dead and Hannah Dahlen, a spokesperson for the Australian College of Midwives, has the unmitigated gall to use the preventable death as an opportunity to whine about the “oppression” of midwives.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Hannah Dahlen has never met a dead baby she couldn’t exploit for her own purposes.[/pullquote]

According to ABC Australia:

The baby, referred to as “NA” by the New South Wales deputy coroner, died during a breech birth at a property near Nimbin in northern NSW in February last year.

The coroner found in September the parents of NA were clearly warned by their doctor of the dangers of a home birth because the baby was lying sideways…

There was no midwife or medically qualified person present during NA’s birth, in a practice often referred to as a “free birth”.

The parents were warned that the baby could die at homebirth and in an amazing coincidence — who could have seen that coming? — the baby died at an unassisted homebirth. Why was the birth unassisted? Because no doctor or midwife would attend a homebirth of such extraordinarily high risk.

This was a completely preventable death. For Hannah Dahlen, it was just another oppportunity to whine.

“I think there’s a few things driving this,” professor of midwifery at Western Sydney University, Helen [sic] Dahlen, said.

“One of them is the increasing over-regulation and oppression of midwives in this country …”

Say what?

Let me see if I get this straight. According to the Coroner’s Report, the parents were warned by doctors and midwives that the baby was transverse, that a transverse birth was far too dangerous to attempt at home and that no doctor or midwife would attend them if they chose to risk the baby’s life in that way.

… In my view both parents knew that they had been warned in general terms against proceeding with a home birth. Their pre-existing views made them wilfully blind to the level of risk involved. In my view it is established that they knew the foetus was lying sideways shortly before the due date. However they did not appear to properly understand or accept that they were heading into a potential catastrophe.

What does that have to do with the regulation of midwives? Not a damn thing.

But Dahlen has never met a dead baby she couldn’t exploit for her own purposes.

Dahlen made this horrifying claim in 2011 in the wake a multiple preventable homebirth deaths:

When health professionals, and in particular obstetricians, talk about safety in relation to homebirth, they usually are referring to perinatal mortality. While the birth of a live baby is of course a priority, perinatal mortality is in fact a very limited view of safety.

Really? On what planet would that be?

On Planet Midwifery where dead babies are a small price to pay for increased midwifery autonomy.

Dahlen’s claims in this case are even worse. This baby’s death had no more to do with midwifery regulation than it had to do with physician regulation. And regulation of midwifery is no more oppressive than regulation of physicians. The point of regulation is that safety standards matter more than the desires of individual practitioners. That’s a good thing, not a bad thing.

No matter. Dahlen exploited this baby as yet another opportunity for midwifery lobbying.

Dahlen’s claims are not simply an exercises in extreme callousness, they are a symptom of the ugly self-absorption that places the feelings and interests of midwives above everything else including the lives of babies.

One of the most attractive aspects of anti-vaccine advocacy, indeed of all alternative health, is that no particular knowledge is necessary to declare yourself an expert.

It doesn’t matter that you don’t have even the most basic knowledge of science and statistics. It doesn’t matter that you don’t have any understanding at all of the complex fields of immunology or virology. Your personal experiences count for more than the collective wisdom of doctors, scientists and public health officials. Hence Jenny McCarthy, a B movie actress with no training of any kind in science is touted by herself and others as an “expert” on vaccines. Hence Modern Alternative Mother Kate Tietje and similarly undereducated mommy bloggers parade themselves as “experts” on vaccination.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]You don’t have to listen to experts; you are an expert.[/pullquote]

As the paper The Persuasive Appeal of Alternative Medicine explains:

The person-centered experience is the ultimate verification and reigns supreme in alternative science… Alternative medicine makes no rigid separation between objective phenomena and subjective experience. Truth is experiential and is ultimately accessible to human perceptions… [O]bjective diagnostic or laboratory tests that discern what cannot be felt never replace human awareness… [A]lternative medicine, unlike the science component of biomedicine, does not marginalize or deny human experience; rather, it affirms patients’ real-life worlds. When illness (and, sometimes, biomedicine) threatens a patient’s capacity for self-knowledge and interpretation, alternative medicine reaffirms the reliability of his or her experience.

On its face, such an appeal seems ludicrous, but it provides powerful validation for people who are frightened and confused:

• You don’t have to listen to experts; you are an expert.
• It doesn’t matter what studies show about whether vaccines cause autism; it only matters that it seems to you that vaccines cause autism.
• Your personal experience isn’t irrelevant to determining whether vaccines cause autism; it is the central, perhaps the only, thing you need to know to make a determination.

Anti-vax advocacy reflects the conviction that no particular knowledge is necessary to pontificate on a topic. Merely having a child who is autistic and has been vaccinated (against anything, at any time) automatically qualifies them to pontificate on “vaccine injuries.” It’s the equivalent of claiming that their personal experience of gravity qualifies them as experts on Einstein’s theories.

Anti-vaxxers attempt to justify the lack of understanding of immunology and infectious diseases by making disparaging claims about the value of science itself. These types of claims are made by people who clearly feel threatened by knowledge (or their lack of it). It is not coincidence that these claims have been invoked by flat-earthers, creationists and climate science deniers as well.

These claims include:

• Statistics cannot tell us everything about what happens.
• Science tells us something different than experience tells us.
• Science does not tell us the truth because it is manipulated by scientists for their own ends.
• Science does not tell us the truth because it is manipulated by business people for their own ends.
• There is no such thing as scientific truth.

These claims are not merely a justification of lack of knowledge; they are an affirmative celebration of ignorance.

Anti-vaccine advocacy is not simply based on factual errors and a pervasive failure to understand basic science and statistics, not to mention immunology and infectious diseases. It is also based on a denial of the need for specific knowledge and a disparagement of such knowledge. By elevating personal experience to the same or even higher level than knowledge of the relevant subject matter, anti-vax advocacy makes everyone an “expert.”

In other words, instead of imparting new knowledge, instead of protecting children, it merely flatters the ignorant.

Addendum: Anyone want to claim that vaccines are unsafe or ineffective?

Please post citation to at least 10 large scale meta-analyses from high impact journals that support your contention that vaccines are not safe.

If you cannot, or if you post links to old, obscure papers in low impact journals, I will consider that an admission of defeat.

Adapted from a piece that first appeared in May 2009.

Last week I wrote about the fact that so called Baby Friendly Hospital Initiative has been worse than a failure.

Not only does it fail to achieve its objective, it is actively harmful.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The BFHI is not a medical program; it’s the institutionalization of lactivist bullying.[/pullquote]

• The BFHI bans pacifiers despite the fact that the scientific evidence shows they don’t interfere with breastfeeding and that they prevent SIDS.
• The BFHI bans judicious formula supplementation despite the fact that the scientific evidence shows it doesn’t interfere with breastfeeding and prevents dehydration, brain damage and death.
• The BFHI enforces prolonged skin to skin contact despite the fact that the scientific evidence shows it leads to deaths from Sudden Unexpected Postneonatal Collapse (SUPC).
• The BFHI enforces 24 hours rooming in and encourages closing well baby nurseries despite the fact that the scientific evidence shows it leads to infant injuries and deaths from falling out of or being smothered within the mother’s bed.

The BFHI is not friendly to babies, but deadly to babies. It’s friendly to lactivist bullying.

It’s been a depressing series of decades for those who find deep and abiding satisfaction in bullying others. You can no longer bully people for being divorced or for having a child without being married. You can’t bully people of different races, sexes or religions. You can’t bully people for being gay and at the rate things are going, it won’t be long before it will be frowned upon to bully people for being overweight. But, in this world of ever decreasing bullying opportunities, there are still some tried and true opportunities available: you can still bully another women for being a bad mother.

The practice of mother bullying is practically a competitive sport. All the traditional options are still available: “I can’t believe your 14 month old is not walking”; or “My Johnny is always picked first for sports teams”; not to mention the ever popular “I’m so sorry that your child is going to a state college and not the elite college my child is attending.” Breastfeeding has provided some deeply satisfying new options for lactivists bullies. These include bullying women if they did not meet an arbitrary standard of breastfeeding duration or exclusivity, or (heaven forfend!) never breastfed at all.

The BFHI is not a medical program; it’s the institutionalization of lactivist bullying. Even better, the BFHI allows its proponents to pretend that they are bullying another mother, not merely for her child’s benefit, not merely for her benefit, but for the benefit of public health. It’s a win-win: all the fun of bullying another mother plus a heaping helping of self-righteousness.

Baby Friendly Hospitals represent breast bullying on steroids. Locking up formula in hospitals is oh so painful for mothers and so satisfying for bullies. If only they could require prescriptions for formula, breast bullies’ lives would be complete. And best of all, they are doing the shaming for the public good!

To hear lactivists tell it breastfeeding prevents every disease known to man; it cures every disease known to man; there is no problem that exists that cannot be solved by squirting breast milk at it! A mother who can’t or (worse!) chooses not to breastfeed is purportedly harming her child, AND being a selfish slob who puts her convenience ahead of her child’s brain functioning.

Nothing could be further from the truth. In countries with easy access to clean water the benefits of breastfeeding are trivial.

Being a bully is fun. Being a breastfeeding bully is better than fun; it is a public service! The BFHI isn’t friendly to babies; it leads to their suffering and even death. The BFHI isn’t friendly to mothers; it torments them for failing to mirror lactivist beliefs back to the lactivists who created it. The BFHI is friendly only to bullies and should be dismantled and replaced as soon as possible.

We can and should support breastfeeding without supporting bullying and we should not allow lactivists to convince us otherwise.

Why does childbirth hurt?

Natural childbirth advocates often claim that the pain of childbirth brings a variety of benefits. Some claim that the pain triggers a hormone cascade that is necessary for maternal infant bonding. Others insist that childbirth is not painful and is actually “ecstatic” and provides sexual pleasure. These varying theories hinge on the notion that the pain of childbirth adds something of value to the experience birth, and that the pain is good and beneficial.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Far from being beneficial, labor pain may now have only harmful effects.[/pullquote]

However, evidence derived from the study of ancient childbirth suggests that natural childbirth advocates have it precisely backwards. The pain of childbirth is not needed to trigger good things, it is vital to prevent maternal and neonatal death, and is a vestigial response that is no longer needed.

Before we consider ancient childbirth, it makes sense to think about the role of pain in the human body. Pain is almost always a sign that something is wrong, perhaps seriously wrong. Indeed, pain is so important to human survival that it can stimulate reflexive reactions. Put your hand on a hot object and you will actually begin pulling it away before you consciously feel the pain. That’s because there are nerve circuits in the spinal cord that allow you to unconsciously perceive the pain and pull away, skipping the step of consciously noticing the pain so as to save time and limit damage.

When you think about it, there is no instance in which pain is not designed to protect against damage. At the level of the skin, pain tells us what is safe to touch and what is dangerous. At the level of bone, the pain of a broken bone is so great that it forces immobility, and that probably helps the bone to heal properly. The pain of disease makes people search for ways to diminish the pain, and perhaps improve survival from the specific problem. So, at the most basic level, there is no reason to believe that the pain of labor is beneficial in and of itself. Unless labor pain is different from all other types of pain of human existence, labor pain exists to warn.

Human childbirth has existed in its present form for millions of years. During that time, the death rate of both mothers and infants was extraordinarily high. Evolution would certainly have favored strategies that lowered the risk of death. Perhaps labor pain, like all other forms of human pain, existed to warn women to seek assistance.

Seeking assistance in childbirth may have lowered infant mortality by having help in situations like breech birth (which usually cannot be accomplished without some manipulation of the baby’s body) and may have lowered the death rate from postpartum hemorrhage, because the assistant could massage a woman’s uterus after birth. Assistance in childbirth must be very important from an evolutionary perspective because anthrologists report that all human societies have birth attendants.

According to Karen Rosenberg (a paleoanthropologist who studies human birth) and Wenda Trevathan (a biological anthropologist and trained midwife) writing in Scientific American special edition, New Look At Human Evolution, 2003:

… [W]e suggest that natural selection long ago favored the behavior of seeking assistance during birth because such help compensated for these difficulties. Mothers probably did not seek assistance solely because they predicted the risk that childbirth poses, however. Pain, fear and anxiety more likely drove their desire for companionship and security.

Psychiatrists have argued that natural selection might have favored such emotions—also common during illness and injury—because they led individuals who experienced them to seek the protection of companions, which would have given them a better chance of surviving. The offspring of the survivors would then also have an enhanced tendency to experience such emotions during times of pain or disease. Taking into consideration the evolutionary advantage that fear and anxiety impart, it is no surprise that women commonly experience these emotions during labor and delivery.

How ironic for natural childbirth advocates if the role of pain in labor is to alert women to the inherently dangerous nature of childbirth so they will seek assistance. It would also mean that labor pain has outlived its usefulness. Far from being beneficial, labor pain may now have only harmful effects.

An extraordinary editorial in the latest issue of JAMA confirms what I have been writing about for years: the Baby Friendly Hospital Initiative is worse than a failure. It not only doesn’t work at promoting breastfeeding, but it actually harms infants and mothers in the process.

The editorial accompanies publication of the new USPSTF (United States Preventive Services Task Force) breastfeeding promotion guidelines. Interventions Intended to Support Breastfeeding Updated Assessment of Benefits and Harms by Flaherman and Von Kohorn is remarkable for its honesty.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s the inevitable result of replacing scientific evidence with lactivist ideology.[/pullquote]

The BFHI doesn’t work.

…[O]nly individual-level interventions demonstrated effectiveness at improving breastfeeding, whereas system-level interventions, including the World Health Organization’s Baby-Friendly Hospital Initiative (BFHI), did not.

That’s a stunning admission. After millions of dollars in expenditure and countless tears of starving infants and guilt ridden mothers, the BFHI doesn’t even achieve its only objective: to increase breastfeeding rates.

If that weren’t bad enough, it has become clear that the BFHI is actually harming babies.

How?

The BFHI bans pacifiers in contradiction to the scientific evidence.

Counseling to avoid the use of pacifiers in the newborn period is an intervention commonly used to support breastfeeding. However, evidence has been building that infant use of a pacifier may be associated with a reduced risk of sudden infant death syndrome,7 the most common cause of postneonatal death in the United States. The evidence review showed that avoiding pacifiers was not associated with any breastfeeding outcomes assessed in the evidence review. A recent Cochrane systematic review reached the same conclusion. Thus, routine counseling to avoid pacifiers may very well be ethically problematic.

The BFHI bans formula supplementation in contradiction to the scientific evidence.

Counseling mothers to avoid giving infants any food or drink other than breast milk during the newborn period is step 6 of the BFHI and one of the primary care interventions most commonly used to support breastfeeding. Three randomized trials have specifically examined the effectiveness of counseling to avoid giving newborns any food or drink other than breast milk; none showed a beneficial effect of such counseling on breastfeeding duration.

And that’s harmful:

… For women who have scant colostrum and no copious milk production for 4 to 7 days, exclusive breastfeeding in the first few days after birth is associated with increased risk of hyperbilirubinemia, dehydration, and readmission.14- 16 Although these conditions are generally mild and often resolve rapidly, their frequency is high; 1% to 2% of all US newborns require readmission in the first week after birth, and the risk is approximately doubled for those exclusively breastfed.15,17 If counseling to avoid food and drink other than breast milk is not an effective method to support breastfeeding, the frequent low morbidity and rare high morbidity outcomes could potentially be avoided without reducing breastfeeding duration.

That’s in addition to previously described harms.

As noted in Unintended Consequences of Current Breastfeeding Initiatives:

Enforced prolonged skin to skin contact leads to deaths from Sudden Unexpected Postneonatal Collapse (SUPC).

Reports of SUPC include both severe apparent life-threatening events (recently referred to as brief resolved unexplained events) and sudden unexpected death in infancy occurring within the first postnatal week of life. A comprehensive review of this issue identified 400 case reports in the literature, mostly occurring during skin-to-skin care, with one-third of the events occurring in the first 2 hours after birth …

Infant injuries and deaths as a result of enforced 24 hours rooming in and closing well baby nurseries.

An overly rigid insistence on these steps in order to comply with Baby-Friendly Hospital Initiative criteria may inadvertently result in a potentially exhausted or sedated postpartum mother being persuaded to feed her infant while she is in bed overnight … This may result in prone positioning and co-sleeping on a soft warm surface in direct contradiction to the Safe Sleep Recommendations of the National Institutes of Health. In addition, co-sleeping also poses a risk for a newborn falling out of the mother’s bed in the hospital, which can have serious consequences.

How did a program designed to promote breastfeeding end up harming so many babies? It’s the inevitable result of relying on lactivist ideology instead of scientific evidence. Sadly, hospitals, doctors and nurses allowed the breastfeeding industry, including lactation consultants, to set policy.

Lactivists and lactation consultants appear to believe that only continuous, extended, exclusive breastfeeding has value, but that’s not what the scientific evidence shows. Instead of promoting science based support of breastfeeding, the BFHI promotes depriving infants of vital formula supplements, life saving pacifiers and safe sleeping arrangements. Instead of promoting science based support of women who want to breastfeeding, the BFHI focuses on shaming and blaming mothers who can’t or don’t wish to breastfeed.

The deadly results that I and others have been warning about for years were tragically inevitable.

Pediatricians have taken critical first steps in acknowledging that the tenets of the BFHI lead to preventable infant deaths, but it’s long past time to start dismantling the BFHI. How can we possibly justify maintaining a punitive program designed by lactivists designed to enforce an unscientific ideology in hospitals, facilities devoted to promoting infant and maternal health?

It is now widely accepted that breastfeeding prevents SIDS (Sudden Infant Death Syndrome), but is that what the scientific evidence really shows?

The short answer: yes, but it’s complicated.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Yes, but it’s complicated.[/pullquote]

Yesterday I wrote about the claim that roomsharing prevents SIDS and concluded that the evidence is both extremely limited and very weak. In contrast, there have been a multitude of studies supporting the claim that breastfeeding prevents SIDS; the problem is confounding variables and exaggeration of the benefits.

The following graphs illustrate the difficulties.

This first set of graphs comes from the 2016 paper Overall Postneonatal Mortality and Rates of SIDS by Goldstein et al. The first graph shows the decline of SIDS and non SIDs infant and postneonatal deaths over the past 3 decades. The second graph breaks out trends in various causes of unexplained neonatal mortality of which SIDS is only one possible diagnosis.

The authors explain:

It has been recognized that SIDS mortality has decreased since inclusion in the International Classification of Diseases in 1973, decades before the promotion of supine sleep positioning. Without diminishing the remarkable contributions of BTS, this 30-year analysis raises important considerations that changes in mortality were also associated with concurrent influences on postneonatal mortality and those affecting intrinsic risk… Additional support that SIDS and non-SIDS mortality share common influences is provided by the cluster analysis, where SIDS mortality trends most closely follow specific conditions with improvements attributable to advances in prenatal and neonatal care.

In other words, there are a myriad of confounding variables that plague all studies of SIDS. The recent decline in SIDS deaths takes place against the background of an overall decline in postneonatal mortality, an overall decline in prone infant sleeping, and an improvement in classifying deaths that are typically attributed to SIDS.

Most studies claiming that breastfeeding is protective against SIDS are case-control studies. Both cases and control should presumably reduce the effect of background changes in SIDS incidence. However, the ambiguity and changing classifications of previously unexplained infant deaths/SIDS deaths could have a disparate impact.

The authors note:

Although some changes in diagnostic preferences may reflect attitudes toward particular nomenclature, such as the use of “cause unknown” instead of “SIDS,” others imply significant differences in the decision-making process for the classification of sudden infant deaths. The increased use of “accidental suffocation and strangulation in bed” instead of “SIDS,” for example, reflects awareness of potentially lethal asphyxial conditions from improved scene investigations but also debatable judgments about their contribution to death in an assumed normal infant…

Breastfeeding rates are closely associated with socio-economic status. Are there differences in cause of death diagnosis between wealthy communities and poorer communities? We don’t know.

Keeping these issues in mind, let’s look at the actual studies that analyze the impact of breastfeeding on SIDS rates.

Breastfeeding and dummy use have a protective effect on sudden infant death syndrome by Alm et al. is a literature review on the protective effect against SIDS of both breastfeeding and pacifier use.

We conducted a literature review on the effect of breastfeeding and dummy (pacifier) use on sudden infant death syndrome (SIDS). From 4343 abstracts, we identified 35 relevant studies on breastfeeding and SIDS, 27 on dummy use and SIDS and 59 on dummy use versus breastfeeding.

What did they find?

We examined 17 observational studies and found that breastfeeding was reported to have provided a protective effect on SIDS in ten studies. No protective effects were found in the other seven.

All three of the meta-analyses that our search identified showed that breastfeeding had a protective effect on SIDS.

How about the impact of pacifiers?

We found 11 observational studies that consistently showed a risk reduction of about 50% if the infant used a dummy.

There were also two meta-analyses that gave approximately the same odds ratio of about 0.5.

What was the impact of pacifier use on breastfeeding rates?

[F]ive randomised controlled studies (RCTs) have been performed to date. Four of them did not find that a dummy reduced the duration of breastfeeding, while one found an increased risk of earlier weaning.

In 2011, Jaafar conducted a meta-analysis on the RCTs carried out by Jenik and Kramer, which concluded that using a dummy did not affect the chance of exclusive breastfeeding at three months.

This plot of pooled odds ratios shows the impact of breastfeeding and pacifiers on SIDS and well as the impact of pacifiers on breastfeeding. It demonstrates that pacifier use reduces the risk of SIDS as much or more than breastfeeding!

More importantly, the protective effect of pacifiers or breastfeeding is dwarfed by the harmful effect of bed sharing. While pacifier use and breastfeeding appear to decrease the risk of SIDS by 50%, bedsharing increases the risk of SIDS by 400% or more.

So does breastfeeding prevents SIDS?

The evidence suggests that it does, but using a pacifier has an equal if not greater effect on reducing the risk of SIDS, and avoiding bedsharing has a far greater protective effect than either. Of course, placing an infant to sleep on her back has the greatest protective effect of all.

Sadly the lay literature does not accurately portray the risks. That’s because lactivists are so intent on promoting breastfeeding  that they have exaggerated its benefits, minimized the benefits of pacifiers and, to a large extent, ignored the risks of co-sleeping. Moreover, lactivists have failed to situate the benefit of breastfeeding in preventing SIDS within the larger context of the risks of insufficient breastmilk which can cause seizures, permanent brain damage and death.

Should you breastfeed if you can produce enough milk? Sure; it can reduce the risk of SIDs. But you can also give your baby a pacifier which reduces the risk of SIDS by the same amount. And the benefit of breastfeeding is dwarfed by the risk of co-sleeping.

If we truly want to save lives we should be aggressively promoting pacifier use and strongly discouraging co-sleeping. And breastfeeding can help, too.

The American Academy of Pediatrics is finally acknowledging that many principles of lactivism are contradicted by the scientific evidence. Sadly, they have replaced old unsupported recommendations with a new unsupported recommendation.

In August, the AAP finally acknowledged that The Baby Friendly Hospital Initiative, a hospital based effort to promote breastfeeding, leads to serious iatrogenic infant injuries and deaths. The relentless promotion of prolonged periods of skin to skin contact and forced rooming in (by closing well baby nurseries) has led to an epidemic of preventable infants deaths from smothering in the mother’s bed and skull fractures caused by falling out of it. Moreover, the lactivist insistence that co-sleeping improves breastfeeding rates has led to infant deaths from SIDS (Sudden Infant Death Syndrome) at home.

Sadly, the new recommendations, while an improvement, continue to promote the prejudices of lactivists that women should be as close to their babies as possible for as many hours of the day as possible in place of the actual scientific evidence. Specifically, the AAP strongly recommends roomsharing despite the fact that the scientific evidence for a protective effect is extraordinarily weak.

According to the new guidelines:

It is recommended that infants sleep in the parents’ room, close to the parents’ bed, but on a separate surface designed for infants, ideally for the first year of life, but at least for the first 6 months.

There is evidence that sleeping in the parents’ room but on a separate surface decreases the risk of SIDS by as much as 50%.

Actually, as far as I can determine, there is little evidence that sleeping in the parents’ room prevents SIDS. There are four case control studies, two from 2005 and 2004 and two from the 1990’s that show an association between infants sleeping in the parents’ room and decreased risk of SIDS. But as basic statistics teaches us, correlation is not causation.

1. The 2005 study is Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: a case-control study that took place in Scotland involving 123 infants who died of SIDS between January 1, 1996 and May 31, 2000, and 263 controls.

The authors found:

Sharing a sleep surface was associated with SIDS (multivariate OR 2.89, 95% CI 1.40, 5.97). The largest risk was associated with couch sharing (OR 66.9, 95% CI 2.8, 1597). Of 46 SIDS infants who bedshared during their last sleep, 40 (87%) were found in the parents’ bed…

In other words, the association between roomsharing and prevention of SIDS was so minor that they didn’t even include it in the abstract.

What did they find when they looked at roomsharing?

Separate room not sharing was not associated with a risk of SIDS on univariate analysis (OR 1.32 95% CI 0.67, 2.60) but became a risk on multivariate analysis (OR 3.26 95% CI 1.03, 10.35)… Further stratified analysis showed that separate room was associated with a significant risk of SIDS only if a parent smoked (OR 12.2 95% CI 2.25, 66.4) and not if parents were nonsmokers (OR 1.25 95% CI 0.16, 10.06)

Roomsharing was protective ONLY when parents were smokers. That’s not evidence that roomsharing is protective against SIDS.

How about the other citations?

2. Sudden unexplained infant death in 20 regions in Europe: case control study was published in 2004.

…Highly significant risks were associated with prone sleeping (OR 13·1 [95% CI 8·51–20·2]) and with turning from the side to the prone position (45·4 [23·4–87·9])… If the mother smoked, significant risks were associated with bed-sharing, especially during the first weeks of life (at 2 weeks 27·0 [13·3–54·9]). This OR was partly attributable to mother’s consumption of alcohol. Mother’s alcohol consumption was significant only when baby bed- shared all night… About 16% of cases were attributable to bed-sharing and roughly 36% to the baby sleeping in a separate room.

Curiously the authors found that a history of roomsharing but not room sharing at the time of death was associated with relative risk of 0.48, while a history of roomsharing and roomsharing at the time of death was associated with a relative risk of 0.32. The authors acknowledge that they have no idea how roomsharing decreases the risk of SIDS death let alone how a history of previous roomsharing could decrease the risk of death. That suggests that confounding variables may lead to a spurious association.

3. Co-sleeping increases the risk of SIDS, but sleeping in the parents’ bedroom lowers it is part of a 1995 Norwegian monograph, Sudden Infant Death Syndrome: New Trends in the Nineties. I have been unable to access the monograph.

4. Babies sleeping with parents: case-control study of factors influencing the risk of the sudden infant death syndrome is a 1999 British case-control study.

The findings are shown in this chart:

The authors acknowledge problems with interpreting their data:

… Certain factors characteristic of infants found in the parental bed were systematically different from those where the infant was found in a cot: bed sharing infants were much younger, few were put down in the prone position, and few were found with their heads covered. Conversely these factors were reversed among infants who slept separately from their parents.

That’s not a definitive result.

So we have 3 studies with widely disparate findings that indicate potential association, but not causation.

The potential protective effect of roomsharing on SIDS fails to meet the majority of the Hill’s Criteria typically used to determine causation.

•  The strength of the association is unknown.
• The dose-response relationship is unknown.
• The potential protective is not consistent. It varies widely among the studies and in one study applies only to parents who are smokers.
• No one has offered a remotely plausible mechanism by which roomsharing could prevent SIDS.
•  The possibility of a chance finding orconfounding variables has not been ruled out.
• There are no experiments or even prospective studies that look at this issue.

In other words, the claim that roomsharing is associated with protection against SIDS is based on data that is weak and conflicting. More importantly, there is no evidence that roomsharing is the cause of any protective association.

Roomsharing is not harmful. No babies will be hurt by following the recommendation.

What’s at risk is the credibility of the AAP and other physicians. When we make recommendations based on weak data, we face the likelihood that the recommendations will be overturned by better research. That has happened repeatedly with recommendations about breastfeeding.

In 2016 we are finally acknowledging that practices beloved of lactivists — exclusive breastfeeding, co-sleeping, pacifier bans and formula restriction — have risks. Thankfully, the AAP is revising its recommendations in response. The last thing they should be doing is making new recommendations that are no better supported by scientific evidence than the old ones.