There’s a new paper on breastfeeding and IQ.

Is breast feeding associated with offspring IQ at age 5? Findings from prospective cohort: Lifestyle During Pregnancy Study yielded surprising results:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We need to know not merely how long women breastfeed, but why they stop.[/pullquote]

In multivariable linear regression analyses adjusted for potential confounders breast feeding was associated with child IQ at 5 years (categorical χ2 test for overall association p=0.03). Compared with children who were breast fed ≤1 month, children breast fed for 2–3, 4–6, 7–9 and 10 or more months had 3.06 (95% CI 0.39 to 5.72), 2.03 (95% CI −0.38 to 4.44), 3.53 (95% CI 1.18 to 5.87) and 3.28 (95% CI 0.88 to 5.67) points higher IQ after adjustment for core confounders, respectively. There was no dose–response relation and further analyses indicated that the main difference in IQ was between breast feeding ≤1 month versus >1 month.

Here are the results of verbal IQ:

And performance IQ:

The authors concluded:

Breastfeeding duration of 1 month or shorter compared with longer periods was associated with approximately three points lower IQ, but there was no evidence of a dose–response relation in this prospective birth cohort, where we were able to adjust for some of the most critical confounders, including maternal intelligence.

That makes little sense on its face. If breastfeeding truly improves IQ, one would expect a dose response relationship with longer periods of breastfeeding leading to higher IQ. Moreover, one would expect little to no impact from very short periods of breastfeeding.

The authors chose to put a positive spin on a paradoxical result:

Our finding of a three point difference in IQ associated with any duration of breast feeding longer than 1 month is in support of current recommendations, and is even a relaxed message to mothers who struggle with exclusive breast feeding.

But that’s not the only conclusion you could draw. The same data could be used to argue that the babies who breastfed for less than a month were harmed by adverse effects of breastfeeding itself. Instead of increasing IQ, breastfeeding had no impact and breastfeeding complications actually decreased IQ. It’s not a possibility that the authors ever considered since nearly all breastfeeding research starts with the unfounded assumptions that breastfeeding must have benefits and couldn’t have harmful effects.

The study itself has some very real strengths but also some serious weaknesses.

It’s chief weakness is that it reflects secondary findings from a study designed to assess the impact of maternal alcohol intake.

The LPDS (Lifestyle During Pregnancy Study) consists of 3478 mother–child dyads selected from the DNBC with oversampling of pregnant women with moderate weekly alcohol intake, alcohol binge drinkers and women with high versus low fish intake, iron intake and duration of breast feeding, respectively.

Secondary findings are often the result of outcome switching, an issue with serious ramifications for the integrity and reproducibility of the research.

As John Ioannidis and colleagues explain:

Outcome switching refers to the possibility of changing the outcomes of interest in the study depending on the observed results. A researcher may include ten variables that could be considered outcomes of the research, and — once the results are known — intentionally or unintentionally select the subset of outcomes that show statistically significant results as the outcomes of interest. The consequence is an increase in the likelihood that reported results are spurious by leveraging chance, while negative evidence gets ignored. This is one of several related research practices that can inflate spurious findings when analysis decisions are made with knowledge of the observed data, such as selection of models, exclusion rules and covariates. Such data-contingent analysis decisions constitute what has become known as P-hacking …

There’s also the possibility that the variable that was originally studied (in this case alcohol intake) is a confounding factor in any study of the secondary variable (in this case IQ). The authors do acknowledge this problem and attempt to adjust for it.

A major strength of the study is that adjustment for critical confounding variables including, most importantly, maternal IQ. Most studies on breastfeeding and child IQ have failed to take maternal IQ into account, which renders their findings highly suspect.

Only 6 out of 1385 women in the study (0.4%) chose not to attempt breastfeeding.

In our study sample, we categorised the shortest duration as ≤1 month, since very few women reported breastfeeding duration shorter than this, reflecting that by far the majority of mothers in Denmark choose to breast feed their children.

The authors understand that those who don’t even try differ from other Danish women in important ways:

Adding to the difficulty of obtaining an exposure group with shorter duration of breast feeding is the fact, that women who from the beginning choose not to breast feed may be different from those who do breast feed; for example, women who rely on medication for various reasons may choose not to breast feed because of concerns that medication in the breastmilk may harm the infant…

So far, so good, but the authors fail to consider that those who stop breastfeeding after less than a month may also differ from other Danish woman in a critical way. Their infants may have suffered medical complications from breastfeeding like dehydration or jaundice from insufficient milk supply. It seems never to have occurred to the authors that breastfeeding can have risks as well as benefits. Since up to 15% of first time mothers may have insufficient breastmilk, particularly in the early days of birth, a substantial proportion of babies will likely suffer serious consequences of any effort to promote exclusive breastfeeding.

The data the authors provide suggest that may indeed be the case:

Women who breast fed for less than 1 month compared with 7–9 and more than 10 months were generally younger, they were more likely to be nulliparous (had not previously given birth), have higher BMI, to have been smokers during pregnancy or to have their children be exposed to tobacco smoke postnatally, and have lower IQ…

Nulliparity and higher BMI are both risk factors for insufficient breastmilk.

More notable was this:

Both maternal IQ and education were linearly associated with breastfeeding duration EXCEPT for duration less than a month. As the chart above shows, Maternal IQ and education were lowest for those who breastfed 2-3 months, whereas IQ and education for those who breastfed for less than a month were equal to the mean for the group. That’s just what you would expect if breastfeeding for less than a month were not a choice but a necessity due to medical factors.

The authors believe they found this:

We found no clear dose response relation of breastfeeding duration with child cognitive development in our data; rather, our results point to a difference in IQ of approximately three points between children who are breast fed for a short period of 1 month or less compared with those who are breast fed longer.

But they may have found the opposite: breastfeeding has no impact on IQ, but breastfeeding complications lead to a decrease in IQ.

There’s one way to find out. We need to know not merely how long women breastfeed, but why they stop. The IQ of children whose mothers chose not to breastfeed for personal — not medical — reasons may be no different than the IQ of children who were breastfed for more than 1 month. That would upend everything we believe we know about the benefits of breastfeeding.

Deregistered Australian midwife Lisa Barrett was found not guilty in two homebirth deaths.

A former South Australian midwife charged over the deaths of two babies during home births has been found not guilty of two counts of manslaughter.

In the first case of its kind in Australia, Lisa Barrett, 52, pleaded not guilty over the deaths of Tully Kavanagh in 2011 and another baby boy in 2012, who cannot be identified.

In the Supreme Court on Tuesday Justice Ann Vanstone cleared her on both counts…

“Although I find that the accused’s conduct was less than competent, I am not satisfied that her conduct merits criminal sanction.

“My verdict in relation to each count is not guilty.”

I have written about Barrett repeatedly over the past decade. Her involvement in multiple homebirth deaths nearly defies belief.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Who’s responsible when a baby dies at homebirth, mother or midwife?[/pullquote]

Tate Spencer-Koch, Jahli Jean Hobbs, Sam, Tully Kavanaugh and Ian died because Lisa Barrett minimized the risks of homebirth when counseling their mothers, all of whom were at high risk for complications. Of these deaths, 1 was a shoulder dystocia, 2 were second twins, and 2 were breech babies. They died because Lisa Barrett could not handle the complications that were predicted. They died because their mothers did not have the Cesareans that would have saved the babies lives.

The practice of homebirth is notable for its recklessness, but even so Lisa Barrett was in a class by herself. During the Coroner’s inquest into the deaths of Tate and Jahli Jean, Barrett was caught live tweeting the proceedings and offering scathing comments about the prosecution’s case. If that weren’t contemptuous enough, Barrett also managed to find the time to attend Tully’s homebirth death. As a result, the Coroner’s inquest was expanded to include both Tully’s death and Sam’s death.

The report, released in 2012 was scathing in its assessment of Barrett’s conduct. So why wasn’t she found guilty of criminal charges?

I don’t yet have access to the full decision, but I suspect it might have something to do with the argument made by her defense counsel:

In closing submissions, Scott Henchliffe, for Barrett, said there “was no law that made anything that Barrett did, that we have heard about in this case, illegal”.

He said the two mother’s whose babies died had “self-serving memories” of their pregnancies and births and held Barrett responsible for the outcomes.

“The decision to homebirth was their own and in the most general sense it was that decision which, when the risks eventuated, led to both them losing their babies,” he said.

“It’s only human nature for them to seek to put themselves in the light where they carry less guilt or blame or responsibility for what ultimately occurred.”

In other words, these mothers knew the risks, took the gamble and lost.

There’s considerable evidence to support that defense in the case of Tully Kavanaugh. During the inquest into his death:

Expectant mother Sarah Kerr told an obstetrician she was willing to risk the death of one of her twins by having a home birth, a court has heard…

Dr Raman told Deputy State Coroner Anthony Schapel that Ms Kerr, seemed to have “made up her mind” about having a home delivery. That was despite knowing the increased risk of giving birth to twins at home.

“She said she understood either twin could die and she wanted to accept that risk,” Dr Raman said.

And if that weren’t damning enough:

Dr Raman said she asked Ms Kerr about her ante-natal care and who her treating midwife and general practitioner was.

She said Ms Kerr replied that birthing advocate and former midwife Lisa Barrett had been advising her with her pregnancy, but that she didn’t support the couple’s decision to have a home birth.

“She said her midwife didn’t support her twin delivery at home and she wasn’t in favour of it,” Dr Raman said.

Furthermore, Kerr testified at the inquest in defense of Lisa Barrett. Noting that she had attended an earlier hearing about Barrett’s involvement in other homebirth deaths:

In the Coroner’s Court yesterday, Ms Kerr said she was not discouraged from a home delivery despite in August hearing of the adverse outcomes of home births. Ms Kerr told Deputy State Coroner Anthony Schapel she took full responsibility for her actions and was aware of the increased risk of the delivery of twins.

“No one can say I didn’t make an informed choice, I sat through every day of evidence,” she said.

It was only later that Kerr decided she had been misled.

So Lisa Barrett was hardly exonerated and she has paid a high price — legally and financially — for her recklessness. But, at least in Australia, it appears that mothers who choose homebirth in defiance of medical advice bear greater responsibility for the outcome than the midwife who agreed to help them.

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

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

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

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

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Every misogynist healthcare provider “knows” that women lie about their symptoms and suffering.[/pullquote]

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

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

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

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

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

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

Insufficient breastmilk is common, not rare.

In 2010, the Academy of Breastfeeding Medicine acknowledged:

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

There is a biomarker for insufficient breastmilk.

From a 2001 paper:

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

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

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

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

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

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

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

The Academy of Breastfeeding Medicine reported in a 2017 paper:

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

Neonatal hypernatremic dehydration is more common than SIDS.

From 2016 paper :

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

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

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

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

Hypoglycemia also injures and kills babies.

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

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

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

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

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

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

Last week March for Science censored scientific information in an effort to squelch discussion that questioned the benefits of breastfeeding. It was a startling tactic for an organization that claims to promote science.

Referring to Sci Moms, a group that dared to suggest that breastfeeding promotion has risks as well as benefits, the administrators of March for Science Facebook page accused them of:

… a history of denying the well-established science on infant nutrition and criticizing health promotion initiatives of the World Health Organization and other health orgs.

…[W]e want to encourage everyone to treat the SciMoms with some healthy skepticism and remind everyone that there are more reliable resources out there on infant nutrition, such as the World Health Organization, the American Academy of Pediatrics, and the Academy of Breastfeeding Medicine…

This week, Dr. Lori Feldman-Winter, the chair of the American Academy of Pediatrics’ Section on Breastfeeding was quoted in The New Yorker. Dismissing the data of economist Emily Oster, author of the best selling parenting book CribSheet — data that also questions the benefits of breastfeeding — Feldman -Winter had this to say:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Doctors who won’t change their recommendations about breastfeeding in light of new evidence risk harming their patients.[/pullquote]

That’s the really scary part of having a person like Oster, who is not an epidemiologist, distilling this information to the lay public. It’s basically as bad as the anti-vaxxers.

But questioning the benefits of breastfeeding is nothing like questioning the benefits of vaccination. Here’s why: We have copious data on the benefits of vaccination; nearly every prediction made by doctors and scientists about the impact of vaccination has come true. In contrast, though we have nearly two generations worth of data on breastfeeding promotion, almost none of the predictions made by doctors and scientists on its impact have come true.

Over the past generation, breastfeeding organizations, lactation consultants, and advocates of natural mothering assured us that if we increased breastfeeding rates, we would reap the benefits of lower incidence of conditions from allergy to obesity, lower rates of infant hospital readmission and even lower infant death rates. The US invested millions in public health campaigns promoting breastfeeding and the Baby Friendly Hospital Initiative’s “Ten Steps” became integral in many hospitals, accompanied by the hiring of thousands of lactation consultants in hospitals and doctors’ offices.

In the US, the rate of breastfeeding initiation increased from a nadir of 22% in 1972 to over 80% in 2015. In that time, rates of conditions from allergy to obesity have not fallen; indeed, they’ve risen. Hospital admission rates have increased, and there has been no observable effect on infant mortality.

Perhaps more shocking, because it was unanticipated, promoting exclusive breastfeeding has caused serious health problems. It turns out that breastfeeding, like all natural processes, has a failure rate; up to 15% of first time mothers will have difficulty producing enough milk to fully nourish a baby, especially in the early days. There has been a dramatic increase in neonatal dehydration, severe jaundice and related complications. Indeed, exclusive breastfeeding has become the leading risk factor for newborn hospital readmission.

Doctors are trained to expect that half of what we are taught at the beginning of our careers will ultimately shown to be wrong within the next five years; unfortunately, no one knows which half. We read scientific journals each month to learn not only about new discoveries, but new data that overturn old discoveries. The key to providing excellent care to our patients rests on our flexibility to change if the scientific evidence changes. Doctors who can’t or won’t change their recommendations based on new evidence do their patients a terrible disservice and possibly cause them harm.

The March for Science justified its efforts to prevent debate by referring to the recommendations of the World Health Organization, the American Academy of Pediatrics, and the Academy of Breastfeeding Medicine. Anyone with grounding in science will recognize this as the logical fallacy known as the argument from authority:

Insisting that a claim is true simply because a valid authority or expert on the issue said it was true, without any other supporting evidence offered.

It is an especially problematic logical fallacy when discussing new data. For example, I was taught that routine episiotomy in childbirth reduced the risk of vaginal tears. In the 1990’s new data suggested the opposite. It would have been both inappropriate and unprofessional for obstetricians to justify ignoring the new data by claiming that major obstetric textbooks and organizations still recommended episiotomy. It is equally invalid to dismiss new data on the risks and benefits of breastfeeding simply because major textbooks and organizations still strongly recommend breastfeeding.

It seems that Dr. Feldman-Winter of the AAP might have been trying to advance a similar logical fallacy by referencing anti-vaxxers. Anti-vaxxers do indeed disagree with all major health organizations on the safety and efficacy of vaccination. But vaccines aren’t safe and effective because major health organization recommend them; they are safe and effective because the data show them to be safe and effective, dramatically reducing the burdens of disease and death from vaccine preventable illnesses. The predictions that doctors made about the impact of vaccines did indeed come to pass and serious side effects have been rare.

When a fabricated claim was advanced that vaccines cause autism, it wasn’t dismissed out of hand. It was investigated in large studies involving hundreds of thousands of individuals and demonstrated to be untrue.

New evidence about the benefits and risks of breastfeeding has been published and actual experience — including tens of thousands of hospitalizations each year for insufficient breastmilk — adds urgency to the need to reassess current recommendations. Dismissing new evidence out of hand, attempting to silence discussion of that evidence, and demeaning anyone who dares question the conventional wisdom in light of the new evidence isn’t science; it’s defensiveness.

We face a crisis; tens of thousands of newborns are suffering preventable complications each year because their mothers have been convinced that breastfeeding will provide benefits that have failed to materialize. We need immediate action from pediatricians and lactation professionals to prevent ongoing harm. Instead we are getting disparagement of those who use new data to question old certainties. Babies and mothers deserve better.

We are in the midst of a dramatic resurgence of vaccine preventable diseases sickening hundreds of children at the cost of millions of dollars. It’s time to take a page from the lactivist playbook and start a Baby Friendly Vaccine Initiative.

The central premise of breastfeeding promotion effort is that no mother would refuse to breastfeed if she only understood the benefits and got the proper support. Adapting to vaccine refusal means no mother would refuse to vaccinate if she only understood the benefits and got the proper support.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Those who vaccinate are better mothers than those who don’t.[/pullquote]

Considering that vaccines save millions more lives in practice than breastfeeding ever could, increasing vaccination rates should take priority over increasing breastfeeding rates. That’s why I propose an immediate overhaul of the Baby Friendly Hospital Initiative to promote vaccination instead of breastfeeding.

The Ten Steps to Successful Vaccination are:

1. Have a written vaccination policy that is routinely communicated to all health care staff.
2. Train all health care staff in the skills necessary to implement this policy.
3. Inform all pregnant women about the benefits of vaccination.
4. Insist that every mother sign a vaccine contract that emphasizes that anything other than full vaccination on the CDC schedule threatens baby’s health.
5. Mandate frequent visits by a vaccination consultant to provide constant support for vaccination.
6. Help mothers initiate all recommended injections within one hour of birth.
7. Show mothers how to obtain vaccinations even if they are separated from their infants.
8. Accept no refusal to vaccinate unless medically indicated.
9. Encourage vaccination on demand by the pediatrician.
10. Foster the establishment of vaccination support groups and refer mothers to them on discharge from the hospital or birth center.

Wait, what? Some mothers think there are legitimate reasons not to vaccinate their babies? There are no legitimate reasons; it’s just a sign that they haven’t received enough vaccination support from hospital personnel, their peers and society at large.

Wait, what? Some mothers think that vaccination harms their infants? Who cares what they think? Public health officials have spoken on the issue of vaccination and mother’s observations of their own infants are irrelevant.

Wait, what? Some mothers think this is an issue of personal freedom? It most certainly is not. Vaccinating a child does not simply protect that child, but it provides a measurable benefit to society.

Lack of peer support for vaccination is a serious problem in and of itself. There are webpages and Facebook groups that encourage parents not to vaccinate or to diverge from the CDC schedule. Such webpages and Facebook groups must be ruthlessly suppressed along with public shaming of anyone who doesn’t support routine childhood vaccination.

Let’s face it: those who vaccinate according to the CDC schedule love their children more than those who do not. Only a lazy, selfish mother would listen to anti-vaccine quacks instead of the CDC.

I even have a motto for the new Baby Friendly Vaccine Initiative:

Breastfed Is Good,
Fed Is Better, but
Vaccinated is BEST!

Why waste time promoting breastfeeding when we could be promoting vaccination and saving far more lives?

Breastfeeding professional Kathleen Kendall-Tackett PhD, IBCLC wrote an editorial for the latest issue of Clinical Lactation entitled Concerns About the 10 Steps.

She’s attempting to respond to growing criticism of breastfeeding promotion initiatives by the Fed Is Best Foundation. The second paragraph sounds quite reasonable.

While I frequently do not agree with Fed Is Best’s recommendations or approach, I feel that it’s important to hear what they are saying. Mothers do fall through the cracks, and tragically some mothers and babies have been harmed. In response to these stories, we have two options. We can ignore them and keep doing what we are doing. Or we can view this as an opportunity to continue to improve our models of care.

Unfortunately it was preceded by the first paragraph, which makes accusations about the Foundation.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Will breastfeeding professionals answer these questions if mothers ask them?[/pullquote]

For the past several weeks, I’ve been working on a talk about what we can learn from Fed Is Best. I spent days going through their Website and reading the stories they have posted—a pretty tough assignment. Some of the breastfeeding information on their site is completely wrong — or wrong enough. And the mothers’ stories are heartbreaking. This organization has been a vocal and divisive presence on social media, and they have garnered international attention to their cause.

It’s difficult to be more vague and unsubstantiated than “wrong – or wrong enough.”

I know better than to believe that Kendall-Tackett would agree to engage publicly with me, but I’ve decided to imagine what I would ask her if she agreed. I would not press her to detail her concerns, but rather I’d pose a series of yes or no questions to clarify her position. Since the Fed Is Best Foundation bases its recommendations on the scientific evidence, I’d question her about that.

1. Is the claim that exclusive breastfeeding is now the leading risk factor for newborn readmission wrong? Yes or no?

2. Does the scientific evidence show that the risk of a breastfed baby being readmitted to the hospital is 1 in 71? Yes or no?

3. Has there been a recent surge in cases of hypernatremic neonatal dehydration sometimes correctable, but sometimes leading to seizures, permanent brain injury or death? Yes or no?

4. Are approximately 90% of cases of kernicterus (severe jaundice) the result of insufficient breastmilk intake? Yes or no?

5. In the wake mandated of hours of skin to skin and mandated rooming in has there been a rise in the incidence of newborns smothering in and falling from maternal hospital beds? Yes or no?

6. Breastfeeding professionals promised that an increase in breastfeeding rates would lead to decreased incidence of conditions like allergy and childhood obesity. Isn’t it true that while rates of breastfeeding initiation have shot up from 22% in 1972 to over 80% in 2015, incidence of those conditions has continued to rise? Yes or no?

7. Breastfeeding professionals predicted that breastfeeding would reduce infant hospitalizations. That didn’t happen, did it? Yes or no?

8. Breastfeeding professionals insisted that increasing breastfeeding would save infant lives. With the exception of a decreased incidence of necrotizing enterocolitis in premature babies, that has not happen either, has it? Yes or no?

9. Isn’t it true that infant stomach capacity is not 5-7 cc as claimed by lactation professionals with reference to a paper published in 1921, but actually much higher, 20 cc or more as demonstrated by more recent scientific evidence? Yes or no?

10. Isn’t it the case that nearly all the benefits for breastfeeding claimed by lactation professionals have been debunked by newer, more comprehensive research that corrects for confounding variables like maternal education and socioeconomic status? Yes or no?

These are not hard questions to answer. Hopefully breastfeeding professionals like Kathleen Kendall-Tackett will answer them — perhaps if mothers ask her.

What’s the most important tool of any science denialist? It’s the delete button, of course!

From anti-vaxxers to homebirth advocates, from creationists to climate deniers, advocates of pseudoscience sharply distinguish themselves from advocates of science by aggressively deleting any comments that question received wisdom and banning those who persist in inserting actual scientific evidence into a discussion. Deleting and banning is the quickest way to squander scientific credibility.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The hill they chose to die on? Breastfeeding.[/pullquote]

Therefore, I was surprised to see March for Science squander its hard earned credibility to promote an ideology ahead of scientific evidence. The hill they chose to die on? Breastfeeding.

We have had some come to us about this post promoting an organization (Sci Moms) with a history of denying the well-established science on infant nutrition and criticizing health promotion initiatives of the World Health Organization and other health orgs.

We don’t dispute the science of this particular post, so we’re going to leave it up, but we want to encourage everyone to treat the SciMoms with some healthy skepticism and remind everyone that there are more reliable resources out there on infant nutrition, such as the World Health Organization, the American Academy of Pediatrics, and the Academy of Breastfeeding Medicine…

Someone came to them?
Denying the well-established science?
Criticizing health promotion initiatives?

Orwell couldn’t have done a better job.

This isn’t a science; it’s the logical fallacy “argument from authority.” But the worst part is the deleting and banning of anyone who tried to reason with the folks at March for Science.

Let’s take a look at what the LATEST scientific evidence about breastfeeding shows.

The most recent, most comprehensive review of the entire breastfeeding literature is Greenville, N. C. “Is the” breast is best” mantra an oversimplification?.” THE JOURNAL OF FAMILY PRACTICE 67.6 (2018). Here’s what the authors found:

The evidence for infant breastfeeding status and its association with health outcomes faces significant limitations; the great majority of those limitations tend to overestimate the benefits of breastfeeding. Nearly all evidence is based on observational studies, in which causality cannot be determined and self-selection bias, recall bias, and residual confounding limit the value or strength of the findings.

Moreover, breastfeeding has risks as well as benefits:

…[E]xclusive breastfeeding at discharge from the hospital is likely the single greatest risk factor for hospital readmission in newborns. Term infants who are exclusively breastfed are more likely to be hospitalized compared to formula-fed or mixed-fed infants, due to hyperbilirubinemia, dehydration, hyper- natremia, and weight loss (number needed to harm (NNH)=71). For weight loss >10% of birth weight with or without hospitalization, the NNH for breastfed infants is 13.

That translates to tens of thousands of preventable hospital readmissions each year.

According to Sarin, Arjun, Andrew Thill, and Clay W. Yaklin. “Neonatal Hypernatremic Dehydration.” Pediatric annals 48.5 (2019): e197-e200:

Dehydration/excessive weight loss is defined as a loss of more than 10% of birth weight prior to the end of the first week of life, and is thought to occur in up to 15% of exclusively breast-fed infants.

And the consequences are devastating:

Serum sodium level greater than 160 mEq/L is a risk factor for morbidity and mortality. The most commonly cited complications include seizures, bradycardia, vascular thrombosis, disseminated intravascular coagulation, renal failure, intracranial hemorrhage, pontine myelinosis, cerebral edema, and death. Seizure is the most common complication and usually occurs during correction of the hypernatremia, as do the other common complications.

Aggressive, unreflective breastfeeding promotion (like the breastfeeding promotion by the March for Science) has been responsible, particularly the poorly named Baby Friendly Hospital Initiative:

Flaherman, Valerie, and Isabelle Von Kohorn. “Interventions intended to support breastfeeding: Updated assessment of benefits and harms.” Jama 316.16 (2016): 1685-1687.

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.

Aggressive breastfeeding promotion HARMS babies:

Other harms were noted in the 2016 paper 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.

So the benefits of breastfeeding have been massively exaggerated and the risks ignored. That’s precisely what feeding safety advocates have been saying for years. It is deeply unfortunate that the March for Science chose to elevate ideology over science, and ideological conformity over scientific debate.

They would do well to keep the following aphorism in mind.

Science:
If you don’t make mistakes, you’re doing it wrong.
If you don’t correct those mistakes, you’re doing it really wrong.
If you can’t accept that you’re mistaken, you’re not doing it at all.

I propose that we add the following line just for March for Science:

If you delete and ban those who question you and hide the evidence that you were mistaken, you have spectacularly destroyed your credibility.

The media loves a heartwarming story, but calling Baby Boy Accurso a “miracle baby” isn’t merely misguided; it’s grotesque.

People Magazine claims ‘Miracle’ Baby Dies Just 18 Days After His 37-Year-Old Mom Suddenly Died During Childbirth:

Just 18 days after his mother suddenly died during childbirth, a newborn died on Friday after his family had to make the unbearable decision to take him off life support, the family’s pastor confirmed…

Matthew Sr. continued, noting that while it was an agonizing decision, he still considered his son a “living miracle,” as he managed to defeat the odds and open his eyes, breathe on his own and pump blood through his heart.

But the death of a baby and mother isn’t a heartwarming miracle story; it’s a tragedy possibly precipitated by the mother’s choice to give birth outside the hospital.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The death of a baby and mother isn’t a heartwarming miracle story; it’s a tragedy possibly caused by the choice to give birth outside the hospital.[/pullquote]

What People Magazine fails to appreciate is that Baby Accurso’s death was almost certainly preventable and his mother’s death may have been preventable, too.

Chiropractor Matt Accurso Sr. has eagerly, repeatedly and at great length shared his “miracle” spin on what is possibly a preventable double tragedy that did not have to happen, but he’s been surprisingly short on the details of the birth itself.

…Matthew is a living miracle…

Without an ounce of oxygen he made it in an ambulance to an emergency room, through an emergency c-section and into a NICU. Matthew then defied all odds and opened his eyes, breathed on his own, pumped blood through his strong heart …

I cannot be sure, but it sounds like a home or birth center birth gone wrong. There was another detail that strongly suggested to me that this was possibly a homebirth. According to the local TV station’s first report of the story:

Though the CDC report [on maternal mortality] said more than half of those deaths are preventable, Accurso’s family said it was a very rare and unpreventable medical emergency that took her life.

Before an autopsy, it is almost impossible to know the definitive cause of a maternal death and whether or not it was preventable. Final results from an autopsy can take weeks to firmly establish the details. Yet this father insisted he already knew, though he provided no evidence from medical personnel or tests. In my experience, that is often a sign of defensiveness over choosing an out of hospital birth that results in death.

What kind of unpreventable medical emergencies result in the death of the mother?

These include a ruptured uterus as a result of a previous C-section, amniotic fluid embolus, stroke or heart attack. All can be unpreventable and deadly, but there’s an important caveat: death is NOT inevitable; most can be treated in hospitals with varying degrees of success. Even amniotic fluid embolus, the most deadly among these events, has a 40% survival rate in a hospital. Moreover, the baby’s life can typically be saved by immediate C-section.

In other words, it’s not clear that the death of this mother and her baby was either unpreventable or inevitable. In fact, the details of the story suggest that the baby almost certainly could have been saved.

Lauren Accurso stopped breathing at home. Had she been in the hospital, she could have been intubated immediately and possibly there would have been minimal disruption of oxygen to her brain and her baby’s brain. A C-section could have been performed quickly and the baby might not have sustained any brain injury, in contrast to the devastating brain damage that occurred during the time it took to reach the hospital.

Lauren Accurso died because she reached the emergency room AFTER her life might have been saved. Had the same precipitating event taken place in the hospital, there was a very real chance of saving her life.

There is nothing “miraculous” about the fact that the baby survived as long as he did. It was entirely due to medical professionals. It was the result of tremendous, ongoing efforts of ambulance personnel, emergency room physicians and nurses, obstetricians, neonatologists and a massive amount of high tech medical care. The fact that it didn’t succeed wasn’t their fault. That lies in the choice to give birth far away from lifesaving medical professionals and their technology.

Hospitals are like infant car seats. Most of the time they aren’t needed because most driving trips do not involve an accident. But when an accident occurs they are invaluable.

Would anyone call it a miracle if a mother fails to put a baby in a car seat and that baby is subsequently ejected through the windshield onto the pavement? I doubt it. Would anyone call it a miracle if the baby survives to arrive at the hospital profoundly brain damaged? I doubt it. Would anyone call it a miracle if the baby eventually dies from the brain damage sustained by not being in a car seat? I doubt it.

So why are we pretending that this very likely preventable death is anything other than a horrific tragedy?

Natural mothering advocates have a serious philosophical problem and infants and children have become the collateral damage.

On one hand natural mothering ideologues are wedded to one size fits all precepts as the foundational “evidence based” recommendations around childbirth, infancy and childhood:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The victims of the conflict are our babies and children.[/pullquote]

• Unmedicated vaginal birth is “best” for all mothers and all babies
• Breastfeeding is “best” for all mothers and all babies
• Natural immunity is “best” for all children and all diseases

But that inevitably leads to problems when the scientific evidence shows something quite different:

• A minimal C-section rate of 19% is needed to achieve low perinatal and maternal mortality
• Insufficient breastmilk affects up to 15% of first time mothers in the days after birth
• Natural immunity can only be achieved with astronomical child mortality rates

That means that relentlessly promoting unmedicated vaginal birth puts newborns at risk of brain injuries and deaths. Aggressive promotion of breastfeeding is leading to the iatrogenic hospitalization of tens of thousands of newborns each year. And anti-vaccination ideology has led to the resurgence of deadly diseases that threaten the most vulnerable among us: infants, immunocompromised and elderly.

That’s when natural mothering advocates fall back on the claim of “radical individuality” to justify ignoring mainstream medical recommendations.

• Studies that show homebirth to have a higher death rate than hospital birth can’t be applied to individuals
• Studies that show that insufficient breastmilk has an incidence of 15% can’t be applied to individuals
• Studies that lead to an optimal vaccination can’t tell us the vaccination schedule that an individual child might need

Why not?

As natural childbirth advocates Henci Goer and Amy Romano wrote in their book Optimal Care in Childbirth:

… [Scientific studies] aggregate populations and include and exclude participants based on predetermined criteria. This means that, however valid the results may be for the study population, they cannot be generalized with certainty to populations with different characteristics under different circumstances, or even to individuals within the study population.

Or as Romano wrote on the Lamaze International blog Science and Sensibility:

…[T]here is no such thing as a good or bad healthcare decision. There’s only such a thing as a good or bad healthcare decision for a certain person. Evidence cannot guide practice without the other piece of the equation – the person to which the evidence is to be applied.

So how do natural mothering advocates justify one size fits all recommendations purportedly based on scientific evidence while simultaneously insisting that no scientific study can yield recommendations for individuals? The simultaneous use of incompatible strategies falls squarely into the category of “motivated reasoning.”

As Wikipedia explains:

When people form and cling to false beliefs despite overwhelming evidence, the phenomenon is labeled “motivated reasoning”. In other words, “rather than search rationally for information that either confirms or disconfirms a particular belief, people actually seek out information that confirms what they already believe”. This is “a form of implicit emotion regulation in which the brain converges on judgments that minimize negative and maximize positive affect states associated with threat to or attainment of motives”.

But there’s more here than an evidence double standard. Natural mothering advocates square the circle with a specific kind of motivated reasoning: the conspiracy theory.

When you stop and think about it, it is clear that the philosophy of natural mothering is based on conspiracy theories:

• Natural childbirth ideology routinely invokes an economic conspiracy among obstetricians who have marginalized midwives in an effort to increase market share.
• Lactivism routinely invokes an economic conspiracy among formula companies to profit by increasing market share
• Anti-vax ideology routinely invokes a massive world-wide conspiracy that seeks to increase Big Pharma profits by mandating vaccines and indemnifying manufacturers

The paper Conspiracy Endorsement as Motivated Reasoning: The Moderating Roles of Political Knowledge and Trust investigates political conspiracies, but it has a lot to tell us about medical/mothering conspiracies.

The authors start by defining conspiracy theories:

[C]onspiracies compose the belief that actors, usually more powerful than the average citizen, are engaging in wide-ranging, “black-boxed” activities to which individuals can attribute an insidious explanation to a confusing event.

The economic conspiracies at the heart of natural mothering ideology firmly fit within this definition. The confusing event is that the scientific evidence does NOT support the claims of ideologues.

How can that be? According to the ideologues, this is the result of deliberate actions on the part of the conspirators.

[E]ndorsing [conspiracy theories] that attribute nefarious intent to political opponents can serve an ideological worldview-confirming function by reinforcing one’s political views through impugning opposing viewpoints…

It may look like the scientific evidence supports a high C-section rate but the doctors who produce the scientific evidence have a financial conflict of interest that leads them to promote the use of technology in birth.

It may look like the scientific evidence support the principle that Fed not Breast is best, but the research is secretly funded by formula companies to promote the use of formula.

It may look like the scientific evidence shows beyond any reasonable doubt that vaccines are safe, effective and do NOT cause autism, but the researchers are secretly in the employ of Big Pharma; they are paid to produce these results.

Theories of radical individuality in this view are not merely self-dealing on the part of ideologues —midwives, doulas, lactation consultants and anti-vax advocates. They are the only way open to those brave enough to confront the conspirators.

There’s one serious problem with this view, however. There’s no empirical evidence to support it.

There is simply no empirical evidence that scientists and physicians are engaged in any effort to promote the economic fortunes of obstetricians. Conflict of interest disclosure mean that breastfeeding researchers who receive formula industry funding must disclose it and most researchers on the risks and complications of breastfeeding have no such relationships. And while there is all too much evidence of Big Pharma take immoral and sometimes illegal steps to produce research that bolsters particular products (for example, Merck and Vioxx), there is no empirical evidence that Big Pharma had any need to pay anyone to prove that vaccines are safe and effective because they are safe and effective.

The bottom line is that there is an irreducible conflict between the scientific evidence about childbirth, breastfeeding and vaccines and the claim that the evidence can’t be applied because of radical individuality. Natural mothering ideologues are fighting a losing battle, invoking fantastical conspiracy theories as a form of motivated reasoning. In the meantime, the collateral damage to infants and children has been enormous.

Is contemporary midwifery the ugly stepsister of obstetrics?

Everyone knows the story of Cinderella. Enslaved by her stepmother, bullied by her stepsisters, Cinderella manages (courtesy of her Fairy Godmother) to attend a ball where she meets the Prince. Rushing to leave, she loses her petite glass slipper. The bereft Prince vows to find her again by searching for the woman who can wear the shoe.

Cinderella’s stepsisters know the shoe is not theirs; no matter. When the Prince’s aide attempts to put the shoe on Drizella, she jams her much bigger foot into it and announces, to obvious disbelief, that it fits. She is so desperate to claim the reward, that she will say whatever it takes, even if it is obviously nonsense.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Claiming personal experience is a form of scientific evidence is the rhetorical equivalent of jamming a big foot into a tiny shoe, and declaring, “It fits!”[/pullquote]

Similarly, contemporary midwives are so desperate to claim the reward of financial compensation and professional autonomy that they will say whatever it takes, even if it is obviously quackery. To wit, the new medical anthropology paper by Andrea Ford, Advocating for evidence in birth: Proving cause, effecting outcomes, and the case for ‘curers’ that I wrote about on Friday. Ford attempted to rebut my longstanding critique that midwifery is not based on scientific evidence by insisting that personal experience is scientific evidence. It’s the rhetorical equivalent of jamming a big foot into a tiny shoe, and declaring, “It fits!”

For example, according to Ford it doesn’t matter whether spicy food can be proven to induce labor so long as the midwife and patient believe it can. In this way, midwifery theorists assert with a straight face that what the patient believes has happened is “scientific evidence” on the same footing with objective evidence of what actually happened.

Though Ford imagines she is rebutting my criticism of modern midwifery, she is both corroborating and bolstering it. She is demonstrating that contemporary midwifery theory is quackery because the foundational principle of quackery is that personal experience is evidence.

I first explained this exactly ten years ago. I quoted the paper The Persuasive Appeal of Alternative Medicine:

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 …

In other words:

• You don’t have to listen to experts; everyone is an expert in her own body.
• It doesn’t matter what studies show; the only thing that matters is how you feel about scientific claims.
• Your personal experience isn’t irrelevant to determining causation or cure; it is the central, perhaps the only, thing you need to know to make a determination.

These are the guiding principles of quackery, whether it is homeopathy, anti-vaccine advocacy or bogus cancer cures. The goal is to undermine the standard of reasoning so that rational debate is impossible.

As this paper on pseudoscience notes:

…[I]n discussions about alternative medicine one often hears the claim that each person or patient is “radically unique”, thus frustrating any form of systematic knowledge about diseases and treatments. Of course, advocates of unproven medical treatments use this argument as a way to deflect the demand for randomized and double-blind trials to substantiate their therapeutic claims. If each patient is radically unique, there is no point in lumping patients together in one treatment group and statistically comparing them with a control group… The argument is so convenient that it has been borrowed as a … strategy by countless alternative therapists …

It is offered as a way of making pseudoscientific claims invulnerable against both empirical evidence and rational argument. That is precisely what Ford is doing in her paper.

Again referencing philosopher Isabelle Stengers, Ford writes:

…[W]hat if evidentiary practice were expanded to include the non-rational? Stengers also has a category into which midwives who do not seek belonging via rationality might fall, a third category of ‘curers’ who ‘are not haunted by the idea of being able to disqualify others, but rather who have cultivated an “influencing practice”’ Such curers are not concerned with being rational (as a charlatan is), much less with proving (as a doctor-scientist is); Stengers asks if modern medicine does not indeed have something to learn from them.

One of the older midwives I spoke with during fieldwork, who was a pillar of the local birth community and the natural birth movement in the 1970s, explained to me that ‘pre-stats’ she and her cohort just had a feeling that home birth was ok, they didn’t feel the need to prove it, nor to consolidate a best practice, as ‘the nature of midwifery appeals to independent minds, and there will be diverse opinions… We practice from our own innate wisdom, not protocols’…

You know you’re in a bad place when you insist that charlatans are more concerned with being rational than midwives are! Ford seems oblivious that she is situating midwifery securely within quackery.

The sad reality is that midwifery theorists from Soo Downe, to Sheena Byrom, to Hannah Dahlen are the basest form of quacks. That’s doesn’t mean they don’t believe what they say; many quacks believe they are making people healthier when they are actually making them sicker, as well as making themselves wealthier and more influential. But they are quacks nonetheless and they are harming women and babies.

Why have we allowed this to happen?

Because midwifery, like most forms of quackery, is cheaper than evidence based medicine and saving money is more important to government and hospital bean counters than saving lives. It’s as if the Prince determined that searching for Cinderella was too expensive and it was cheaper to settle for the ugly stepsister instead.

That’s not a happy ending … but there can never be a happy ending when you insist quackery is deserving of the same respect as science.