Lactivists believe women don’t understand the risks of formula feeding or the benefits of breastfeeding. New mothers aren’t making informed choices about infant feeding because they aren’t fully informed. If women only knew of the myriad risks of formula, they’d never choose it.

Lactivists are certain that offering information about formula feeding is tantamount to promoting it. That’s why they have been working assiduously to make sure, through the Baby Friendly Hospital Initiative, that hospital personnel aren’t merely prohibited from counseling women in favor of formula feeding, they are forbidden from mentioning it. Offering formula to new mothers is beyond the pale and under no circumstances should woman receive any gifts from formula companies that might be interpreted to condone the use of formula, even as a supplement to breastfeeding.

Inevitably there has been a backlash against the BFHI but the opponents claim the high ground with the retort: “We are just trying to support breastfeeding!” Lactivists believe they are providing a valuable service limiting information about formula feeding, limiting support for formula feeding and limiting access to formula.

I have a question for the folks at the BFHI:

What’s the difference between the Baby Friendly Hospital Initiative and a Catholic hospital that bans counseling about contraception?

Both insult women by presuming to decide what is the best way for them to use their bodies.
Both interfere with informed consent by withholding information.
Both violate women’s autonomy by mandating how they must use their body parts.
Both interfere with the free speech rights of healthcare providers.
Both appeal to shoddy science, exaggerating risks and inflating benefits.
Both justify their tactics by reference to what is “natural.”
Both insist that the ends (benefits for women’s infants/benefits for women’s immortal souls) justify the means.

So will someone please explain to me why many women who would be appalled by any effort to deprive women of access to contraception think it’s okay to deprive women of access to infant formula?

I don’t see the difference.

Many are rightfully upset with the CDC’s heavy handed alcohol recommendations for women of childbearing age. But as big a problem as the obvious sexism in the recommendations is — women (but not men) must not drink alcohol in order to avoid unintended pregnancy, women (but not men) must be using contraception before they take a drink, and, most egregiously, women (but not men) must abstain in order to avoid domestic violence — there’s an even bigger problem. It is a problem that afflicts many preventive recommendations issued by medical organizations: the recommendations are far out in front of the actual scientific evidence.

The biggest problem with the CDC’s alcohol recommendations for women of childbearing age is that they aren’t science; they’re supposition. The CDC doesn’t “do nuance” and if there was ever a need for nuance it is in regard to the issue of alcohol in pregnancy.

[pullquote align=”right” cite=”” link=”” color=”#FE7295″ class=”” size=””]What’s the relationship between alcohol consumption in pregnancy and FAS? We don’t know.[/pullquote]

According to the CDC:

Alcohol use during pregnancy, even within the first few weeks and before a woman knows she is pregnant, can cause lasting physical, behavioral, and intellectual disabilities that can last for a child’s lifetime. These disabilities are known as fetal alcohol spectrum disorders (FASDs). There is no known safe amount of alcohol – even beer or wine – that is safe for a woman to drink at any stage of pregnancy.

The CDC’s recommendation is based on a scientific fact:

No one knows how low alcohol consumption in pregnancy must be in order to limit problems like fetal alcohol syndrome (FAS).

But instead of explaining why no one knows, the CDC decided to portray any amount of alcohol at any point in pregnancy as having a high potential to cause harm. Instead of explaining the nuances of research in this area, the CDC chose to portray the science as settled when it is anything but.

Why can’t we determine if there is a low level of alcohol consumption that is safe in pregnancy?

Nuance #1: There is no reliable relationship between drinking in pregnancy and FAS. Sure, large amounts of alcohol can lead to FAS, but many women drink moderately without any apparent harm to the developing child. Researchers have noted the “American paradox.” Though alcohol consumption per capita (among women and men) is much higher in European countries than in the US, the incidence of FAS is much lower there. Drinking wine with meals is widespread in Europe, so many women are drinking before they know they are pregnant and when they are pregnant, yet the incidence of FAS is just a fraction of what it is here. Perhaps FAS is more common with some forms of alcohol than with others; we don’t know.

Nuance #2: The likelihood of developing FAS depends on maternal genetics. Some ethnic groups (like Native Americans) have a much higher incidence of FAS than other ethnic groups even when comparable amounts of alcohol are consumed. In other words, some ethnic groups are “prone” to FAS while others are not.

Nuance #3: The likelihood of developing FAS also depends on fetal genetics. A study of twin pregnancy in heavy drinkers revealed an extraordinary finding; while there was 100% concordance among identical twins (if one had FAS, the other did, too), there was less than 70% concordance for fraternal twins:

… Sixteen pairs of twins, 5 MZ [monzygotic] and 11 DZ [dizygotic], all heavily exposed to alcohol prenatally, were evaluated. They represented all available twins of alcohol-abusing mothers who were on the patient rolls of the authors. The rate of concordance for diagnosis was 5/5 for MZ and 7/11 for DZ twins. In two DZ pairs, one twin had fetal alcohol syndrome (FAS), while the other had fetal alcohol effects (FAE). In 2 other DZ pairs, one twin had no diagnosis while one had FAE. IQ scores were most similar within pairs of MZ twins and least similar within pairs of DZ twins discordant for diagnosis.

So what’s the relationship between alcohol consumption in pregnancy and FAS? We don’t know.

The CDC transmuted uncertainty into certainty. Instead of acknowledging that we don’t know the safe limit of alcohol consumption in pregnancy because it depends on factors that we don’t yet understand, the CDC chose to state with certainty that NO amount of alcohol consumption is safe in pregnancy and that is almost certainly not true.

Instead of speaking to women as adults —we’re not sure of the relationship between alcohol and FAS, so we can’t tell you whether there is a safe level of alcohol — the CDC chose to speak to women as if they were children — don’t drink unless you’re using birth control, because we said so.

The CDC’s sexism in its recommendations is inexcusable, but the lack of nuance in the recommendations is hardly much better. When a public health organization doesn’t know the answer, they should acknowledge that they don’t know instead of getting out in front of the science and issuing definitive recommendations that may actually be wrong.

I’m deeply disappointed to learn that the hospitals in my state, Massachusetts, are closing their newborn nurseries. It reflects short sighted capitulation to lactivists, and doesn’t accomplish its stated aim. Most importantly, it’s unethical.

As the Boston Globe explained:

The shift is part of a national movement designed to promote breastfeeding, bonding, and parenting skills by having mothers and healthy newborns room together around-the-clock, attended by nurses who look after their needs. Many postpartum specialists now believe that nurseries, long a life raft for recovering mothers, is not the best, or most natural, way to provide care…

Women seeking a few hours of rest after hours of labor or a caesarean section often are surprised to learn that Massachusetts hospitals are increasingly restricting nursery access or, in some states, have closed the nurseries altogether. In Boston, Boston Medical Center began widespread “rooming-in’’ years ago, Mass. General followed suit more recently, and Beth Israel Deaconess Medical Center is taking similar steps. They collectively deliver more than 11,000 babies a year. Brigham and Women’s Hospital also expects to move in this direction.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]There no evidence that rooming in leads to increased breastfeeding rates and there’s no plausible mechanism by which it would do so.[/pullquote]

The national movement is the Baby Friendly Hospital Initiative. The initiative is the crowning glory of the breastfeeding industry’s effort to shame women into breastfeeding. The appellation “baby friendly” is a deliberate slap in the face to women who can’t or don’t want to breastfeed. It offers a hospital credential (for $11,000) provided the hospital can demonstrate that it has done everything possible to harass women who don’t want to breastfeed by lecturing them about its purported benefits, making formula inconvenient and humiliating to obtain within the hospital, and depriving women of gifts of free formula to use when they go home.

What’s wrong with the Baby Friendly Hospital Initiative?

1. In first world countries with easy access to clean water, the benefits of breastfeeding are trivial: a few less colds and episodes of diarrheal illness across the entire population of infants. That’s it. What about all the other amazing claims about breastfeeding? They’re based on research that is weak, conflicting and riddled with confounders.

2. The breastfeeding industry’s understanding of the relationship between rooming in and breastfeeding is precisely backward. Rooming in (baby in the room at all times) doesn’t promote breastfeeding; breastfeeding promotes rooming in, because the women most ideologically committed to exclusive breastfeeding are also ideologically committed to keeping their babies with them at all times. Not only is there no evidence that rooming in leads to increased breastfeeding rates; there’s no plausible mechanism for it to do so. The implication of forced rooming in policies is that women make serious infant feeding decisions based on trivial factors like whether or not they can get some sleep when exhausted by sending the baby to the nursery.

3. Forced rooming in is UNSAFE. Rooming in safely requires a the presence of someone to watch the baby while the mother sleeps. Why is a second person needed? Because many mothers have trouble lifting babies out of hospital bassinets and therefore keep babies in bed with them. It is potentially DEADLY for babies to sleep in hospital beds with their mothers. We know that both soft bedding (such as that in hospital beds) and maternal impairment from narcotics (given for pain relief after C-section or vaginal tears) are associated with sudden infant death.

And that is exactly what has been happening in hospitals. Healthy babies have been dying, either dropped out of bed or accidentally suffocated by their mothers’ bodies. According to the  paper Deaths and near deaths of healthy newborn infants while bed sharing on maternity wards in the Journal of Perinatology:

We report 15 deaths and 3 near deaths of healthy infants occurring during skin-to-skin contact or while bed sharing on maternity wards in the United States. Our findings suggest that such incidents are underreported in the United States and are preventable.

What factors contributed to these 15 deaths and 3 near deaths?

In eight cases, the mother fell asleep while breastfeeding. In four cases, the mother woke up from sleep but believed her infant to be sleeping when an attendant found the infant lifeless. One or more risk factors that are known or suspected (obesity and swaddling) to further increase the risk of bed sharing were present in all cases. These included … maternal sedating drugs in 7 cases; cases excessive of maternal fatigue, either stated or assumed if the event occurred within 24 h of birth in 12 cases; pillows and/or other soft bedding present in 9 cases; obesity in 2 cases; maternal smoking in 2 cases; and infant swaddled in 4 cases.

Lactivists, being privileged women themselves, envision that everyone else is like them: privileged to have a partner who will participate in in-hospital baby care, who can take time off from work to be there, and who has enough money to pay a babysitter to stay home with any older children. It doesn’t make any difference to lactivists if they can’t send their babies to the nursery while they sleep; someone else is there to watch the baby. But that’s not the case for most women; they are solely responsible for the care of their newborn even if they are exhausted by a long labor, in pain from surgery or vaginal tears, and impaired by pain relieving narcotics. Closing well baby nurseries doesn’t merely deprive these less privileged women of time to recover; it literally puts their babies at risk for death at their own hands. That is unethical.

Keep in mind that no one is preventing rooming in. If lactivists want to keep their own babies in their rooms 24/7, they are welcome to do so. But that’s not enough for them; they want to FORCE other women to keep THEIR babies in their rooms with them whether they want to or not. And the kicker is that there’s no evidence that rooming in promotes breastfeeding and no plausible mechanism by which it would.

Any initiative that results in the preventable deaths of babies can’t possibly be baby friendly and it isn’t mother friendly, either. So whose needs are being served by closing well baby nurseries? The Baby Friendly Hospital Initiative should really be called the Lactivist Friendly Hospital Initiative, because it is only the needs of lactivists that are being served. But that’s enough to give hospitals cover to save money by cutting out the nursing staff needed to maintain well baby nurseries. So privileged women have given hospitals the convenient excuse to save money at the expense of poor women and their babies.

How convenient!

How unsafe!

How immoral!

The shaming of mothers who don’t breastfeed has got to stop. Maybe, it’s time to shame the shamers.

I hereby solicit nominations for a new set of awards, the Golden Boob Awards!

I’m envisioning awards in several categories:

Most outrageous breastfeeding “fact” (amateur)
Most outrageous breastfeeding “fact” (professional)
Most vicious attempt at shaming (amateur)
Most vicious attempt at shaming (professional)
Grand Prize for most despicable claim (both amateurs and professionals are eligible)

The winner of the Grand Prize will receive the tasteful statuette shown above, (available from Amazon UK as a party decoration for bachelor and bachelorette parties).

Please share your suggestions for nominees along with the statement or statements that you think qualify them for this prestigious award. Screen caps would be deeply appreciated.

In my view, the shamers, both amateur and professionals, truly are boobs and their contributions to breastfeeding discourse ought to be honored appropriately!

“Trust your intuition, Mama!” It’s the all purpose battle cry of the natural parenting industries.

Want to have a homebirth even though ACOG says it increases the risk of perinatal death? Trust your intuition, Mama! You’re safest where you feel safest!

Want to give birth underwater even though the American Academy of Pediatrics says it’s dangerous? Trust your intuition, Mama! Everyone knows, according to the geniuses at the Midwives Alliance of North America (MANA), babies don’t breathe “until they experience gravity!”

[pullquote align=”right” cite=”” link=”” color=”#999999″ class=”” size=””]We have a word for those who think they know more about what patients are experiencing than patients themselves: paternalism.[/pullquote]

Want to skip vaccinations for your children even though every health organization IN THE WORLD says vaccines don’t cause autism? Trust your intuition, Mama! You know that your child’s difficulties were caused by a “vaccine injury.”

Want to supplement your exclusively breastfed baby with formula because he’s losing weight and screaming constantly from hunger? Trus… Wait!! You can’t possibly trust your intuition about something so important!!

You might think that your baby is starving, but, Mama, you’re just an unqualified layperson who should never trust her intuition on such an important matter. ONLY a professional lactivist is entitled to determine whether your baby needs supplementation. No one cares what you think; only someone like lactivist Maureen Minchin is qualified to decided whether your baby is starving — and Maureen already knows, before hearing your story and without ever examining your baby — that he isn’t.

The utter disrespect and dismissiveness with which lactivists treat mothers is one of the ugliest of the ugly, ugly, ugly tactics of contemporary lactivism.

In response to Dr. Alison Stuebe’s Academy of Breastfeeding Medicine post about exclusively breastfed babies suffering brain damaging, life threatening hypernatremia, Minchin offer this charming comment:

… I have my doubts that it was just four days of ineffective feeding that resulted in Meagan’s boy’s neurodevelopment problems… And the clues to what else happened to this child are there in Meagan’s post. He struggled to tolerate any formula and in the end would take ONLY ready-to-feed Alimentum, which as a liquid end-sterilised concentrate was most likely to contain high levels of AGEs and could have had many other problems …

Maureen has her doubts! And why should anyone care what Maureen thinks? She wrote a self-published book and everyone knows that a self-published book is the ultimate mark of expertise!

Maureen is a font of scientific sounding stupidity:

… My book argues that a milk hypothesis makes a lot more sense and has a more substantial scientific basis than the commonly accepted hygiene hypothesis or the biodiversity hypothesis, both of which are discussed. And 2. allergy studies to date have not looked for the intergenerational impacts of artificial feeding, which become very evident when you deal with these families as I have for decades, and can be explained by epigenetics. We are what our grandmothers ate: many first generation formula feeders gestated in bodies that were breastfed probably did better than second and third generation formula-exposed babies gestated in the bodies of women formula-fed as children (even if those women EBF). I have lived through both the 1960-1970s formula invasion (when every child in many hospitals was formula-exposed and most women breastfed for very short periods) and the allergy epidemic in Australia, which has grown with every generation for reasons both genetic and epigenetic.

Won’t someone think of the great grandchildren????????!!!!!!!!!

What’s Maureen’s problem (besides ignorance and grandiosity)? Maureen, like many lactivists, is suffering from cognitive dissonance. In Maureen’s fantasy world where breastmilk is ALWAYS the perfect food for every baby, regardless of circumstances, some babies have the temerity to sustain brain damage and even die because their mothers couldn’t produce enough breastmilk for them. How could that possibly be true? As far as Minchin is concerned, it couldn’t.

As Prof. David Dunning (of the eponymous Dunning-Kruger Effect) explains in regard to “confident idiots” afflicted by the Effect:

Some of our most stubborn misbeliefs arise not from primitive childlike intuitions or careless category errors, but from the very values and philosophies that define who we are as individuals. Each of us possesses certain foundational beliefs — narratives about the self, ideas about the social order—that essentially cannot be violated: To contradict them would call into question our very self-worth. As such, these views demand fealty from other opinions. And any information that we glean from the world is amended, distorted, diminished, or forgotten in order to make sure that these sacrosanct beliefs remain whole and unharmed.

To contradict the superlativeness of exclusive breastfeeding would call into question Minchin’s self-worth. Information about babies who sustain brain damage or die from insufficient breastmilk must be amended, distorted, diminished or ignored in order to make sure that Minchin’s sacrosanct belief in the perfection of breastmilk remains whole and unharmed.

When it comes to weighing brain damaged and dead babies against Minchin’s self-worth, it’s no contest, Minchin’s need for personal validation is far more important to her than what is actually happening to babies and mothers. Minchin is not alone. Other lactation professionals are equally adept at dismissing or outright ignoring what mothers tell them about their babies’ suffering.

So trust your intuition, Mama — unless it conflicts with the intuition of birth workers and breastfeeding professionals.

We have a word for healthcare professionals who think they know more about what patients are experiencing than patients themselves; that word is paternalism. Unfortunately, midwives and lactation professionals, who spend tremendous time and effort bewailing the paternalism of obstetricians and pediatricians have adopted the very attitudes they claim to despise.

Like Minchin, lactation professionals are not listening — and mothers and babies are suffering deeply as a result.

Well, that didn’t take long, did it?

The potential association between a Zika virus outbreak in Brazil and a startling increase in the serious birth defect microcephaly had barely reached public consciousness and anti-vaxxers were spinning a startling new conspiracy theory: the rising incidence of microcephaly in Brazil is caused, not by Zika virus infection, but by … you guessed it … vaccines!

It’s been a tough decade for anti-vaxxers. Their insistence on a link between vaccines and autism has been thoroughly discredited; their insistence that disease like measles disappeared before the introduction of the vaccine has been thoroughly discredited; their insistence that vaccine preventable diseases like pertussis don’t kill babies has been thoroughly discredited. They desperately need a new conspiracy theory.

[pullquote align=”right” cite=”” link=”” color=”#91D6F1″ class=”” size=””]The anti-vax movement has a perfect record; it has never been right about anything.[/pullquote]

Before going further, I must give credit where credit is due: The anti-vax movement has a perfect record!

That’s right. In the 200+ years since the anti-vaccination movement started, it has never been right about anything!

Apparently, anti-vaxxers are determined to continue their uninterrupted losing streak with the Zika virus conspiracy. The essence of the conspiracy is this: It might look like Zika virus infection of pregnant women causes microcephaly, a severe brain deformity, but it’s really caused by Tdap, the vaccine that prevents tetanus and pertussis. Anti-vaxxers point darkly to the fact that, following in 2015 Brazil began routinely offering pregnant women Tdap in the 3rd trimester to protect newborn babies from getting pertussis.

The Zika/Tdap conspiracy follows the usual anti-vax tropes. In “All manner of ills”: The features of serious diseases attributed to vaccination, authors Leask, Chapman and Robbins explain that diseases attributed to vaccines share a variety of common features:

• Unknown cause
• Apparent risk in incidence
• Face value biological plausibility
• Dreaded outcomes
• Close proximity to vaccination

All the elements are present in the Zika tragedy. Although the working hypothesis is that the increase in cases of microcephaly are cause by infection with Zika virus, that has not yet been definitely established. There has been a rise in incidence of microcephaly in Brazil. It is biologically plausible. The outcome of microcephaly is usually severe intellectual and physical disability. And the birth of babies with microcephaly may have followed third trimester vaccination with Tdap.

But there’s no evidence that Tdap vaccination in pregnancy leads to microcephaly and considerable evidence that it does not.

Third trimester Tdap vaccination has been instituted around the world. Why is the increased incidence of microcephaly restricted to areas where Zika virus is endemic?

Microcephaly is a defect that originates in the early weeks of pregnancy when the brain is forming. How could an event in the third trimester have any impact on a process that was complete months before?

In contrast, there is considerable evidence that Zika virus infection of pregnant women is the likely cause:

There are a variety of viral illnesses that can cause serious brain defects in the embryo if contracted by pregnant women during the first trimester.

The incidence of Zika virus infection has been rising in Brazil. This is not the first Zika outbreak in the world, but it is the largest. Moreover, there is evidence that the Zika virus has mutated as it traveled around the globe since its discovery in Africa in 1947. The viral mutations appear to allow it to infect humans with greater ease.

Zika virus has been isolated from babies born with microcephaly and from pregnant women who gave birth to microcephalic babies.

Moreover, the conspiracy theory makes no sense in light of the actions of world health authorities:

If microcephaly were caused by Tdap, wouldn’t health authorities be trying to hide the issue not publicize it?

Why would health authorities issue travel advisories to countries where Zika is circulating if they knew that the cause was not Zika?

Why would the US spend money on the development of a vaccine for Zika virus is it’s not the cause of microcephaly?

In summary, there’s considerable evidence that Zika virus infection in the first trimester leads to microcephaly, that the incidence of microcephaly has been rising in parallel with the incidence of Zika infection, and that Zika virus is presented in affected babies and their mothers. There’s absolutely no evidence that Tdap leads to microcephaly and no logical mechanism by which a third trimester vaccination could cause a first trimester defect. Finally, a massive public relations campaign to highlight microcephaly in Brazil makes no sense if health authorities are trying to hide a causal association with Tdap.

But logic has never been the strong suit of anti-vaxxers and I don’t anticipate that there will be an outbreak of logical thinking now. Anti-vaxxers never learn; not matter how many times you destroy their arguments, they keep coming back for more.

Australia’s Parliament recently voted to allow female representatives to breastfeed in the chamber. Lactivists are hailing it as a victory. It’s not; it is, paradoxically, a defeat.

Why? It undercuts the professionalism of women and it is a poor exchange for what they really need: generous maternity leave.

Women have struggled for decades to be taken seriously as professionals; breastfeeding at work, while actually working, is unprofessional.

[pullquote align=”right” cite=”” link=”” color=”#f27591″ class=”” size=””]Allowing women to breastfeed at work and therefore skip maternity leave is like allowing workers to eat at their desks and therefore skip a lunch break.[/pullquote]

When my children were babies, my husband occasionally brought them to the hospital to eat when I was available. I nursed them in the privacy of the on call room. I loved seeing them and nursing a baby is so much more enjoyable than pumping.

BUT … I never took my babies into patient rooms; I never brought them to the emergency room and nursed them while performing a D&C for miscarriage; I never had a baby nursing under my surgical gown when performing a hysterectomy or a C-section. It wouldn’t have been not merely unprofessional (although it would indeed have been unprofessional), it would have been disrespectful to patients. They deserved my full, undivided attention whether I was operating on them, examining them or merely talking to them.

I would be appalled if engaged a lawyer and she nursed her baby during a consultation, during a deposition, while arguing with opposing counsel or in court in the middle of a case.

I would be appalled if got on an airplane and the pilot were nursing her baby during my plane flight or even (perhaps especially) if the pilot were nursing while going through pre-flight safety checks.

I can’t think of a single professional whose performance would be enhanced by breastfeeding a child while working.

When Australian representatives are in the Parliament chamber, they are working. They are considering legislation, arguing with colleagues, engaged in procedural maneuvers, supposedly giving their full attention to the people’s business. Bringing a baby into the chamber to feed it is unprofessional. It deprives the people of a legislator who is fully engaged with the matter at hand and it deprives babies of mothers who are fully engaged with them.

Don’t tell me that babies need to eat. Adults need to eat, too, but not in the operating room, while court is in session, or in the cockpit in the midst of actively flying the plane. And while it might not be dangerous to eat while examining a patient, or in a client consultation, or during a job interview, it would be disrespectful.

Moreover, breastfeeding at work isn’t a matter of business accommodating mothers, which would be a victory; it’s all about mothers (and babies) accommodating business.

In the past two decades, the line between work and home has been blurred. Sure, in 1996 someone from work could call you at home to consult on a problem, but when you were out of the workplace, you were generally considered unavailable. Computers, smart phones, and email have changed all that. Work has invaded every moment of life. Unless you are out of the range of a satellite phone, you can always be contacted; your coworkers can always send you documents to peruse; your boss can always expect you to finish that report ASAP and send it immediately even if it’s 2 AM. Work has invaded the home and since there are only a limited number of hours each day, it has cut into family interactions. When my father came home from work, I only had to share him with my mother and sports on TV. When today’s parents of young children come home from work, their children often have to continue to share them with work even when they are physically present.

Allowing breastfeeding in the workplace is a cheap substitute for what women and babies really need: generous maternity leave.

In my view, the feminist ideal would be recognition that women are valuable as mothers and valuable as professionals and workers. The feminist ideal is NOT forcing women to bring mothering into the workplace where it will compromise both job performance and mothering.

Allowing women to breastfeed at work and therefore skip maternity leave is like allowing workers to eat at their desks and therefore skip a lunch break. It’s not a victory; it’s a defeat.

When it comes to discrediting lactivism I get lots of help from an unlikely source, lactivists themselves.

For sheer viciousness, it’s hard to top Kathy Dettwyler, Associate Professor, Supplemental Faculty, Dept. of Anthropology, University of Delaware, Newark, who is known for her cultural work on extended breastfeeding and weaning. You may remember the nasty comment she left on a positive Amazon review of the book Lactivism:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactivists can’t identify even a single term baby who suffered brain damage from properly prepared infant formula, yet they’re willing to risk brain damage from insufficient breastmilk.[/pullquote]

… Formula fed children definitely WILL BE INFERIOR to how those same individuals would have turned out if they had been breastfed.

Now she’s spewing drivel that is, if possible, even more offensive.

Ponder: Why so much uproar about the loss of a few IQ points in the children of Flint, Michigan due to lead in the water? The IQ deficit from lead poisoning is about the same as the IQ deficit from infant formula use [rather than breastfeeding]. Yet no one seems to be getting their pantyhose in a twist from infant formula — except those of us who have been doing so for decades. One TV news report tonight was talking about how these kids will have to be followed for years to track their progress, and how $$$$$ will have to be spent on special education services. Uh, why? No one bothers to do that for formula fed children. Serious question.

Note that I am not unsympathetic to the situation in Flint — it’s criminal and immoral and heartbreaking for the families. Just trying to put it in proper perspective…

It’s proper perspective? Yes, let’s put it is its proper perspective.

The effects of lead poisoning on the brain are manifold and include delayed or reversed development, permanent learning disabilities, seizures, coma, and even death.

See? Formula is exactly the same… Oops, guess not. But that doesn’t stop Dettwlyer from exploiting the tiny victims of lead poisoning to further her personal agenda.

Lest you think that the ugliness of lactivism is restricted to clowns like Kathy Dettwyler, consider the actions of Alison Stuebe, MD, a well known professional lactivist.

In a recent piece for the Academy of Breastfeeding Medicine blog, Of Goldilocks and neonatal hyponatremia, Dr. Stuebe felt compelled to address a petition that is circulating highlighting the dangers to babies of inadequate breastmilk.

A heart wrenching story has been circulating on social media about an exclusively breastfed baby who suffered brain damage after 4 days of ineffective feeding. The mother shares how she was reassured that all mothers can make milk, and did not realize until she engaged a lactation consultant at 96 hours postpartum that her child was profoundly dehydrated.

…That warning would directly challenge efforts across the US, and around the world, to emphasize the value of exclusive breastfeeding and the risks of unnecessary supplemental feeding.

Yes, just another random mother complaining about a random event…

Not exactly.

I commented on the post:

Dr. Steube, I notice that you display your own credentials prominently, but you disrespectfully ignored Dr. Christie del Castillo-Heygi’s credentials, referring to her as “the mother.” Dr. Castillo-Heygi is a practicing emergency room physician with degrees from Brown and UCSF medical school.

To her credit, after multiple complaints over 24 hours, including my suggestion to edit the piece, Dr. Stuebe did ultimately identify “the mother” and link to her story, but I wonder why Dr. Stuebe neglected to do so in the first place.

It’s not because Dr. Stuebe denies the deadly reality of neonatal hyponatremia; she doesn’t. It appears she didn’t want to give credence to Dr. del Castillo-Heygi’s experience and the lasting impact on her son.

Dr. Stuebe didn’t want to give attention to the risk of PERMANENT BRAIN DAMAGE and DEATH because she’s more concerned about the “risks” of unnecessary supplemental feeding. And what risks would those be? Not brain damage, not death, but the disruption of the breastfeeding relationship.

I suspect that Dr. Stuebe would be hard pressed to identify even a SINGLE term baby who suffered brain damage from properly prepared infant formula, yet she’s willing to risk brain damage from insufficient breastmilk. I suspect that Dr. Stuebe would be hard pressed to identify even a SINGLE term baby who died from properly prepared infant formula, yet she’s willing to risk infant deaths from insufficient breastmilk.

Dr. Stuebe offers a straw man fallacy to defend her point of view:

What, then, of the tragic stories of brain-damaged babies? Wouldn’t it be easier to supplement all babies, rather than redesign our systems of care to identify dyads at risk and ensure early follow-up for every baby?

No one, least of all Dr. del Castillo-Heygi, has ever suggested supplementing all babies.

Amidst the attempts at obfuscation, Dr. Stuebe admits:

We might start by acknowledging, once and for all, that not all mother-baby dyads are able to breastfeed exclusively. Reproductive physiology is not infallible. 10.9% of women have difficulty getting pregnant or carrying a baby to term. 15 to 20% of pregnancies end in miscarriage, 10% of infants are born preterm, and 1 in 100 infants are stillborn. Similarly, less than 100% of women can exclusively breastfeed.

Which, of course, has been Dr. del Castillo-Heygi’s point all along. Kudos to her for forcing the lactivist establishment to admit it.

Lactivists, both professionals and lay people, seem to have lost their minds over breastfeeding. The truth is that it’s just not that big of a deal. Breastfeeding has benefits, but in first world countries they are trivial, but the moralization of breastfeeding has paralleled the monetization of breastfeeding and an entire industry now believes that it depends on grossly exaggerating the benefits and misrepresenting the risks.

But it’s not all deadly seriousness. Here’s a tweet I received from a lactivist offended that I criticized the recent Lancet breastfeeding studies:

Hard to beat that for eloquence!

On Friday I wrote about the Lancet series on breastfeeding. The authors claim that exclusive breastfeeding around the world could save 800,000 babies each year. I pointed out a paradox that undermines the authors’ contention: the countries with the highest infant mortality rates already have the highest breastfeeding rates.

We shouldn’t be surprised. There once was a time that breastfeeding rates were 100% everywhere and the infant mortality rate was … hideous! If breastfeeding didn’t protect babies for most of human existence, why would it suddenly start protecting infants now?

[pullquote align=”right” cite=”” link=”” color=”#521C4E” class=”” size=””]Increased breastfeeding rates might theoretically decrease infant mortality, but I can’t find any real world evidence that it does.[/pullquote]

In other words, there’s no real world evidence for the purportedly lifesaving benefits of breastmilk. So what are the authors’ basing their claim upon? They base their claims on projections from data gleaned in small studies. Indeed, as far as I know, every assertion that increasing breastfeeding rates will save lives or money is based on projections, never on actual experience. Indeed, as far as I can determine, there is no real world evidence that breastfeeding saves lives or money on the scale estimated by certain researchers.

That’s an important point because there is considerable evidence that other parameters and public health measures do do result in decreased infant mortality.

Here’s the scatter chart of breastfeeding rates vs. infant mortality that I presented on Friday. It is based on data from 121 low and moderate income countries.

As you can see, as the breastfeeding rate rises, the infant mortality rate not only doesn’t fall, it actually rises, too.

Now let’s look at the impact of per capita GDP (gross domestic product), a measure of income, on infant mortality in these same low and middle income countries.

The scatter chart looks very different. It is easy to see that as income rises, infant mortality rates fall. It’s the exact opposite of what we see with breastfeeding rates.

How about the impact of relatively clean water (including public taps, protected wells, and rainwater)? Here’s a scatter chart of access to clean water vs. infant mortality. As access to clean water approaches 100%, infant mortality drops precipitously. That’s also in direct contrast to what we see with breastfeeding.

Finally, let’s look at access to modern contraceptive methods. The scatter chart below plots the proportions of sexually active women using modern contraception vs. infant mortality. Yet again we see that as access to contraception rises, infant mortality falls.

No doubt access to clean water and access to modern contraception are, in part, a function of per capita income, but they are certainly more firmly tied to reducing infant mortality than breastfeeding.

There’s nothing wrong with breastfeeding, of course. But it’s not a magic lifesaving elixir, no matter how much lactivists insist that it is. While increasing breastfeeding might theoretically decrease infant mortality, I can find no real world evidence that it actually does.

That’s not what I thought prior to reading the Lancet papers, but that’s actually what the data shows. Increasing breastfeeding rates are actually associated with INCREASED infant mortality.

It’s not because breastfeeding causes infant deaths; it doesn’t. It’s because babies die due to malnutrition (of themselves or their mothers), vaccine preventable illnesses, lack of medical care and war. Breastfeeding can’t fix those things and it is foolish (or worse) to pretend that for women living in abject poverty, their babies’ survival depends on breastfeeding.

It sounds spectacular. The headlines in The Guardian are typical, Breastfeeding could prevent 800,000 child deaths, Lancet says:

If almost every mother breastfed her children it could prevent more than 800,000 child deaths a year, yet governments are failing to promote and support breastfeeding, with rates remaining far below international targets, new research has found.

Poor government policies, lack of community support and an aggressive formula milk industry mean breastfeeding is not as widespread as it could be, according to a two-part Lancet breastfeeding series published on Thursday.

[pullquote align=”right” cite=”” link=”” color=”#F90207″ class=”” size=””]Countries with the highest infant mortality rates have the highest breastfeeding rates.[/pullquote]

It certainly seems plausible since breastfeeding is known to prevent diarrheal illnesses and colds and since formula prepared with contaminated water can be deadly. I had no reason to doubt the claim when I started reading the main paper Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect.

According to the authors:

Our meta-analyses indicate protection against child infections and malocclusion, increases in intelligence, and probable reductions in overweight and diabetes. We did not find associations with allergic disorders such as asthma or with blood pressure or cholesterol, and we noted an increase in tooth decay with longer periods of breastfeeding. For nursing women, breastfeeding gave protection against breast cancer and it improved birth spacing, and it might also protect against ovarian cancer and type 2 diabetes. The scaling up of breastfeeding to a near universal level could prevent 823 000 annual deaths in children younger than 5 years …

But the more I read, the less convinced I became.

Why?

Countries with the highest infant mortality rates have the highest breastfeeding rates.

I created this scatter plot of 121 low and middle income countries by comparing breastfeeding rates at one year (found in the supplementary material) and infant mortality rates (deaths from birth to 1 year, UN data).

As you can see, there’s no relationship between breastfeeding rates and infant mortality rates. Indeed, the countries with the highest rates of infant mortality often have the highest breastfeeding rates.

Why doesn’t breastfeeding have an impact on observed infant mortality?

Part of the reason is that the benefits of breastfeeding are quite small. Over 800,000 deaths prevented is a great thing, but when you consider that over 135,000,000 babies are born around the world each year, the deaths prevented present 6 babies per 1000. That’s too small to be reflected in country wide infant mortality.

So if infant mortality rates don’t change with breastfeeding rates, how did the authors reach the conclusion that 800,000 lives could be saved if all mothers breastfed? They extropolated from small studies and made a myriad of assumptions in doing so. It seems to me that many of these assumptions are simply wrong, rendering the authors’ conclusions unlikely to be true.

I’m no statistician and I haven’t read all the studies that the authors rely upon, so if I’m making mistakes with my analysis please let me know, but here are my concerns.

1. The authors assumed that findings of small studies could be extrapolated to entire nations. But each study had its own parameters and confounding variables and therefore might not be generalizable.

2. The authors assumed that substantial numbers of babies are dying from formula or contaminated formula itself. But the scatter plot suggests that there are other factors responsible for the bulk of infant deaths. These could be malnutrition (of mother and/or baby), infectious diseases that cannot be prevented by breastfeeding, civil unrest, etc. For example, promoting breastfeeding is not going to save a baby whose mother dies of malnutrition leaving him without any source of food.

3. The authors assumed that the lifesaving benefits of increasing the breastfeeding rate would be evenly distributed over populations, but that can’t possibly be true. When a country has a high infant mortality rate and also has a breastfeeding rate of 97% of 1 year olds, there’s no room to raise the breastfeeding rate.

4. The authors ignore history. There was a time when 100% of infants were breastfed … and the infant mortality rate was astronomical because the benefits of breastfeeding are really limited.

There’s nothing wrong with promoting breastfeeding. But there is something wrong with making spectacular statements about breastfeeding saving hundreds of thousands of lives in the absence of population data to support it. Small scale studies can provide valuable insights, but they can’t replace real world experience. In the real world, breastfeeding rates don’t seem to have much impact on infant mortality rates at all.

It would be interesting to model how many lives could be saved by other measures such as water filtration and food donations; those have the added benefit of being able to save lives of older children and adults, not just infants. I suspect that something like water filtration could save far more lives than promoting breastfeeding. It’s much cheaper to promote breastfeeding though than to provide, run and maintain water filtration technology.

Where does that leave us? It leaves us telling poor women that they could solve their own problems by breastfeeding, and patting ourselves on the back for our insights. Meanwhile babies continue to die in droves from causes that have nothing to do with breastfeeding at all.