Medical ethicist Susanne Brauer has written:

Obstetrics and midwifery are value-laden, value-producing and value-reproducing practices, values that constitute the social perception of what it means to be a ‘‘good’’ pregnant woman and to be a ‘‘good’’ (future) mother.

Similarly, professional lactation support is also value-laden, value-producing and value-reproducing.

There’s no better example of this behavior than their fraught relationship with maternal autonomy.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Midwives and lactation consultants sugar coat their paternalism by claiming that women who don’t follow their recommendations need more “support.”[/pullquote]

If there is one thing midwives are sure of, it’s that they are committed to maternal autonomy. They believe deeply that women are entitled to choose place of birth, birth attendant, birth support, vaginal birth, refusal of procedures, refusal of pain medication and refusal of hospital policies (e.g. separation of mother and child after birth) that do not serve their needs.

Yet there’s another thing they’re equally sure of: some maternal choices are better than others.

Similarly, lactation consultants are committed to maternal autonomy: women are entitled to choose where, when and for how long they breastfeed. They are entitled to choose public breastfeeding, breastfeeding in Parliament or locations otherwise restricted to professional behavior, breastfeeding on demand and breastfeeding toddlers or older children.

Yet there’s another thing they’re equally sure of: the choice to breastfeeding is better than the choice to formula feed.

How do midwives and lactation consultants square their ostensible commitment to maternal autonomy with promotion of specific maternal choices? Ironically, they rationalize it with paternalism, a practice thoroughly inconsistent with maternal autonomy.

What do we mean by autonomy in a pregnancy/early motherhood setting?

From a legal point of view every medical intervention, including therapeutic, palliative, diagnostic and preventive measures, is potentially an infringement on the bodily and psychological integrity of the patient—regardless of whe- ther the intervention is medically necessary. Each inter- vention is therefore in need of consent from the (competent) patient in order to be legitimate (special cases are emergency cases and medical decisions concerning incompetent or unconscious patients). This is especially true for routine prenatal care where the purpose of medical intervention is diagnostic and preventive in nature, and not the treatment or eradication of disease.

How can we tell if a mother’s autonomy is being respected?

1. She must receive accurate information.

2. She must receive complete information.

3. She must understand the information.

4. She must have a real choice between options.

5. While it is appropriate for a provider to convey what her choice would be in a similar situation, the provider must not exert pressure to produce that choice.

There is a massive professional and lay literature on the many ways in which obstetricians have failed to respect mothers’ autonomy. To their credit, there has been tremendous progress over the years — offering new options that privileged, primarily white women demand — but there is plenty of room for improvement. Obstetricians have replaced their paternalism, the belief that they know best, with greater respect for patient choices.

Midwives have often presented themselves as more respectful of patient autonomy than obstetricians. They spend more time eliciting patient preferences, discussing fears and making plans. They are quite comfortable, often encouraging, in promoting women’s right to refuse conventional medical tests and treatments and have offered novel options — continuous labor support, homebirth, placenta preservation, etc.

In both theory and practice midwives are actually less respectful of maternal autonomy than obstetricians because they feel no compunction about injecting their personal preferences into patient care. An obstetrician might prefer a maternal request C-section for herself, but she has no problem respecting patient preference for vaginal birth; an obstetrician might prefer an epidural for herself but she has no problem respecting patient preference for unmedicated birth; an obstetrician might prefer every possible prenatal test for her baby but she has no problem acknowledging that some women want as few as possible while still being compatible with safety.

Midwives, in contrast, prefer unmedicated vaginal birth for themselves and tout it to their patients. Indeed, they go so far as to label their preferences as “normal birth” and run campaigns to promote it. They argue vociferously against “interventions,” including effective pain relief in labor. For most midwives maternal request C-sections are anathema.

Lactation consultants don’t even pretend to respect patient autonomy. They have created the Baby Friendly Hospital Initiative and promoted public health campaigns, legislation and restrictions of formula, all explicitly designed to privilege exclusive, extended breastfeeding over any other possible choice (formula feeding, combo feeding).

How do midwives and lactation consultants defend their blatant violations of maternal autonomy? The exact same way that obstetricians always justified their violations of maternal autonomy: with paternalism. They believe unmedicated vaginal birth and breastfeeding are better for mothers and babies and that justifies pressuring women into approved choices.

When you point out to them that they are emulating the worst habits of patriarchal medicine, they double down. Instead of reflecting on the irony that they are promoting specific choices instead of maternal choice, they ignore the issue of autonomy altogether. In their account the problem with obstetricians is not that they failed to offer women choices; but that they offered a single choice that was inferior to the single choice that midwives offer.

For example, they applaud obstetricians offering women the choice of VBACs after multiple C-sections or breech vaginal births, because vaginal birth is better. They decry obstetricians offering women maternal request C-sections because C-sections are inferior.

Midwives and lactation consultants have offered one innovation to the practice of ignoring maternal autonomy, however. Obstetricians were quite forthright in asserting that their education and training justified their paternalism. Midwives and lactation consultants sugar coat their paternalism by claiming that women who don’t follow their recommendations need more “support.” But support means helping each mother to achieve HER goals, not the providers goals. We have another word for that: pressure. Midwives pressure women to have vaginal births; they pressure women to refuse epidurals or they sabotage their efforts to get epidurals. Lactation consultants privately and sometimes publicly deride women who can’t or don’t wish to breastfeeding as lazy, ignorant and manipulated by formula companies.

Obstetrics has a long history of paternalism; but to the credit of obstetricians most now recognize this and try to do better. Midwifery and professional lactation support rest firmly on paternalism, the belief that midwives and lactation consultants know best. Sadly they refuse to recognize their own paternalism and therefore continue to impose it.

Last week the Royal College of Midwives took the extraordinary step of reminding its members that every women has the right to bottle feed and that the choice should be suppported and respected. It was an implicit acknowledgement of just how harmful promotion efforts like the Baby Friendly Hospital Initiative have become. Babies’ physical health and women’s mental health are being compromised by the mantra that “breast is best” and, in particular, the risk based language (“artificial baby milk,” “risks of formula feeding”) and tactics (locking up formula, making women sign formula consents) often employed.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The Baby Friendly Hospital Initiatve, as well as the lactivists who promote it, are engaged in unethical violations of women’s autonomy.[/pullquote]

Literally tens of thousands of babies and women are suffering each and every year from these pernicious tactics and it could have been avoided if lactation professionals had considered the ethical dimensions of their language and policies. Indeed, this exact situation — suffering as a result of unethical promotion efforts — was predicted back in 2006 by Rebecca Kukla. Kukla is Professor of Philosophy at Georgetown University and Senior Research Scholar at the Kennedy Institute of Ethics.

In 2006 Kukla published a paper in Hypatia, a journal of feminist philosophy, entitled Ethics and Ideology in Breastfeeding Advocacy Campaigns.

Writing about breastfeeding promotion in 2006, she makes the following claim:

I argue that the campaign is unlikely to substantially increase breastfeeding rates, unresponsive and even hostile to many women’s actual concerns about breastfeeding, and well positioned to produce shame and compromise agency among the women it targets.

And that’s precisely what has happened.

Kukla’s thesis was that breastfeeding promotion efforts violated women’s autonomy and sense of agency while simultaneously ignoring women’s stated reasons for being unable to or choosing not to breastfeed.

She starts with the often unexamined belief that by controlling women we can control children’s health:

Accordingly, many of our public health initiatives specifically target mothers’ choices, as though these were morally and causally self-contained units of influence; if only we could talk women into making the right choices, these initiatives presume, then children would turn out healthy. However, even if we grant that, given our social division of labor and the natural facts of reproduction, mothers really do have special duties as caretakers of their children’s health, this does not justify the conclusion that mothers’ agential, independent, responsible choices exert primary control over child health outcomes, nor that these choices are straightforward and self-contained sites of moral accountability. We need a more sophisticated ethical analysis in order to avoid an easy individualist politics of blame and a single-minded public health strategy.

By 2006 lactivists had spent more than a decade pressuring to breastfeed yet breastfeeding rates were still considered low:

First, why isn’t the information that “breast is best” — now disseminated in every form, from the bare slogan to detailed scientific information, through hospitals, community health centers, media campaigns, advice books, prenatal classes, Web sites, and parenting magazines, in every language, in Braille and in large font — enough to make women choose to breastfeed? … Second, given that breastfeeding advocates imagine and promote breastfeeding as a joyous natural bonding experience, how can they explain the behavior of the majority of American women, who initiate breastfeeding (presumably with the intention of continuing) but quit early?

They concluded that women needed ever more “education” as well as increased pressure produced by employing risk based language and tactics.

This view is patronizing at best:

We need to think hard about the condescension and even the strategic imprudence involved in throwing our social resources into finding yet more ways of giving women information they already have. Even more fundamentally, we need to question our assumption that improper education is the cause of low breastfeeding rates.

It pathologizes women who can’t or don’t want to breastfeeding:

Rather than looking to the social and symbolic context that might make her feelings explicable and reveal her needs, we pathologize her, casting her as deviant and unmotherly… The emphasis here on personality lays the responsibility for a less-than-joyous breastfeeding experience directly upon the individual character of the mother, while invoking a litany of stereotypical images of gendered virtue.

Hence lactation professionals feel justified in using tactics — like the Baby Friendly Hospital Initiative — that deprive women of autonomy and agency.

I want to end by arguing that the current strategies and imagery used by American breastfeeding advocates … are not only inappropriate, but also constitute unethical assaults on new mothers’ autonomy and agency…

How?

Public health ethics often focuses on analyzing the extent to which restrictions of autonomy that curtail free choice (such as helmet laws, smoking bans, and, to a lesser extent, campaigns designed to change behavior) are justified by their welfare benefits. But I want to suggest that such limitations on negative liberty usually do not cut as deep into people’s intact agency as do violations that undercut our ability to make responsible, agential choices at all. If we have no morally livable options open to us, or if our moral judgments and risk judgments have been seriously distorted by the messages we receive from our culture, then our ability to exercise autonomous agency has been crippled … Autonomy, on any full-bodied account, involves the positive capacity for responsible action, and this capacity is compromised when we are offered only morally distorted representations of reality and self-damaging choices. Contemporary breastfeeding advocacy chips away at the autonomous agency of American mothers …

She concludes:

The breast vs. bottle debate is sometimes framed in terms of the competing interests of mothers and infants … but, overwhelmingly, these interests do not in fact compete. It is in a baby’s interest to have a competent, comfortable mother, and in a mother’s interest for her baby to be healthy and well nourished. Most mothers care deeply about their role as caretakers of their children’s health. Once we begin from this premise, rather than from the assumption that mothers are selfish or stupid until proven otherwise, we need to conclude that since most mothers also already know about the important health benefits of breastfeeding, they would do it if they realistically could.

With respect to breastfeeding, our public health goal should be to make breastfeeding a livable, comfortable, well-informed option for women, and not to cripple women’s ability to find a way of making caring choices for their children.

The Baby Friendly Hospital Initiatve, as well as the lactivists who promote it, are engaged in unethical violations of women’s autonomy in an explicit effort to deprive them of agency in choosing how to feed their children. The result has been injuries and deaths for babies and anguish for mothers. The Royal College of Midwives has acknowledged the harm; sadly, many lactation professionals still can’t bring themselves to do so and continue to write articles and make Facebook and Twitter comments that are both condescending and cruel.

Lactivist Prof. Amy Brown has a new piece on The Conversation this morning. It’s entitled Breastfeeding is not ‘easy’ – stop telling new mothers that it is and it’s a clumsy effort to deny that lactation professionals have spent the last decade pressuring, shaming and blaming women who can’t or don’t breastfeed.

It’s difficult to talk about breastfeeding in a productive way right now…

One of the traps public health promotion can fall into is being so keen to promote breastfeeding that any challenges get glossed over, through fear that it’ll put women off. Instead breastfeeding gets painted as some kind of idyllic, simple, miracle cure for all ills…

Sounds good, right?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It’s the difference between life and death.[/pullquote]

Until you get to this:

Breastfeeding is not easy. It requires women’s time and investment and can be a steep learning curve…

What in life worth doing is easy? We put ourselves through challenges all the time. We work hard for exams. We train for races. We do it because we think it’s worth it, not because it’s easy. And we expect others to support us. Imagine our outrage if we were training for a race and everyone suggested it wasn’t worth it.

Faux empathy with a helping heaping of more pressure, blame and shame. Talk about tone deaf!

It’s difficult for me to understand such a profound lack of empathy for the feeding struggles of new mothers but perhaps it comes from some fundamental differences between lactation professionals like Brown and a feeding safety expert like Christie del Castillo-Hegyi, MD of the Fed is Best Foundation.

1. It’s a difference in personal experience.

I don’t know it for a fact, but I suspect that Amy Brown did not have to watch one of her children struggle with the effects of dehydration induced brain injury.

In contrast, Dr. del Castillo-Hegyi’s eldest son sustained a breastfeeding related brain injury:

My son was born 8 pounds and 11 ounces after a healthy pregnancy and normal uneventful vaginal delivery. He was placed directly on my chest and was nursed immediately. He was nursed on demand for 20-30 minutes every 3 hours. Each day of our stay in the hospital, he was seen by the pediatrician as well as the lactation consultant who noted that he had a perfect latch. He produced the expected number of wet and dirty diapers. He was noted to be jaundiced by the second day of life and had a transcutaneous bilirubin of 8.9. We were discharged at 48 hours at 5% weight loss with next-day follow-up.

… We saw our pediatrician at around 68 hours of life (end of day 3). Despite producing the expected number of wet and dirty diapers, he had lost 1 pound 5 ounces, about 15% of his birth weight… Our pediatrician told us that we had the option of either feeding formula or waiting for my milk to come in …

Wanting badly to succeed in breastfeeding him, we went another day unsuccessfully breastfeeding and went to a lactation consultant the next day who weighed his feeding and discovered that he was getting absolutely no milk… We fed him formula after that visit and he finally fell asleep. Three hours later, we found him unresponsive. We forced milk into his mouth, which made him more alert, but then he seized. We rushed him to the emergency room. He had a barely normal glucose (50 mg/dL), a severe form of dehydration called hypernatremia (157 mEq/L) and severe jaundice (bilirubin 24 mg/dL)…

These numbers put her son at high risk of brain injury and indeed:

At 3 years and 8 months, our son was diagnosed with severe language impairment, autism, ADHD, sensory processing disorder, low IQ, fine and gross motor delays. He was later diagnosed with a seizure disorder associated with injury to the language area of the brain…

2. It’s a difference in professional training

Amy Brown is a professor of psychology. To my knowledge she has no medical training. Dr. del Castillo-Hegyi, in contrast, studied the effects of glucose on neonatal ischemic brain injury at Brown University and is a practicing, Board Certified Emergency Room physician.

It’s not really surprising then that Dr. del Castillo-Hegyi has much more experience with the medical aspects of breastfeeding and its complications.

3. It’s the difference between having no responsibility for patient care and having ethical and legal responsibility for the care of the vulnerable.

Amy Brown never has to see the results of her “advice.” She just gives it and assumes it works. Dr. del Castillo-Hegyi takes responsibility for providing medical advice and sees the effect of her recommendations every time she steps into the ER.

4. It’s the difference between “easy vs. easier” and “possible vs. impossible.”

Breastfeeding, like pregnancy, has a substantial failure rate. Current best estimates are that as many as 15% of first time mothers cannot produce enough breastmilk to fully nourish a baby, particularly in the early days. That’s significant but not as high as the natural miscarriage rate of 20%.

Imagine if lactation professionals like Prof. Brown treated women who miscarried like they treat women who can’t breastfeed because they don’t produce enough milk. Would insisting that pregnancies could be divided into easy or easier address their problems? Would efforts to make their pregnancies “easier” prevent miscarriage? Would refusing to acknowledge the biological basis of miscarriage reduce the suffering of these women? No, no and no.

The situation is the same when it comes to breastfeeding. For the 15% of women who are biologically unable to produce enough breastmilk particularly in the early days after birth, would making breastfeeding “easier” increase milk output? Would ignoring the consequences of infants screaming frantic from hunger and mothers weeping desperate to soothe their babies increase milk output? Would refusing to acknowledge the biological basis of insufficient lactation reduce the suffering of these women? Of course not, yet that is precisely what lactation professionals continue to offer instead of being honest about medical reality.

5. It’s the difference between process and outcome.

Prof. Brown promotes breastfeeding (a process); Dr. del Castillo-Hegyi promote healthy babies and healthy mothers (an outcome). That might involve exclusive breastfeeding, combo feeding or exclusive formula feeding. I suspect that Prof. Brown imagines that breastfeeding guarantees a healthy outcome, but that’s because she’s ignoring the latest scientific evidence and not listening to what struggling mothers are telling her. Breastfeeding has a high failure rate that leads to suffering, injury and death. That’s why breastfed babies are readmitted to the hospital at double the rate of bottle fed babies. That’s why there is a growing problem with infants presenting with profound dehydration. That’s why 95% of cases of kernicterus (jaundice induced brain damage) can be traced back to breastfeeding.

6. It’s the difference between an echo chamber and an uphill battle.

As we speak Prof. Brown is currently enjoying the atta-girls from dozens of lactivist colleagues on Twitter. She never appears in a setting where her ideas and claims can be subjected to probing questioning from other medical professionals. In contrast, Dr. del Castillo-Hegyi occupies the same place in the breastfeeding world that Ignaz Semmelweis purportedly occupied in the world of puerperal fever. Her knowledge, her integrity and her sanity are repeatedly called into question. Lactation professionals ignore the data she presents and the warnings she issues, demeaning and insulting her.

7. It’s the difference between life and death.

Dr. del Castillo-Hegyi is desperately trying to prevent agonizing infant hunger, prevent neonatal brain injuries and deaths and prevent the maternal suffering that results from all three. Prof. Brown ignores those outcomes, refuses to acknowledge the frequency with which they occur and refuses to listen to what women are telling her. Tragically, that can be the difference between life and death.

What’s the ethical response when a provider learns that a course of action she recommended has caused unintended harm?

Lactation consultants believe (because they teach and tell each other) that breastfeeding is best for every baby. As a result, they have harmed tens of thousands of babies and mothers for whom breastfeeding will never and can never be best. The Royal College of Midwives obliquely acknowledged that harm by reminding midwives that bottle feeding is a valid choice and that women who choose it merit respect and support.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Milli Hill, Amy Brown and Sheena Byrom among others are on Twittter right now engaged in this unethical behavior even as we speak.[/pullquote]

Midwives in general and UK/Australian midwives in particular believe (because they teach and tell each other) that unmedicated vaginal birth, so called normal birth, is best for nearly every mother and baby. As a result they have harmed untold numbers of mothers and babies who have sustained birth injuries, brain damage or even died when complications were ignored in the pursuit of vaginal birth. The Royal College of Midwives obliquely acknowledged that harm by shuttering their Campaign for Normal Birth.

Those are nice first steps, but sadly the RCM did not go far enough. As a result the bullying of mothers continues and many of the rank and file feel free to ignore the admonitions. Medical ethics requires more of providers who issue a recommendation that causes unintended harm than simply stopping the harmful recommendations. Ethics requires acknowledgement of the harm, support of those who have been harmed and reevaluation of the scientific evidence that undergird the harmful recommendation.

Instead, lactivists, like UK/Australian midwives before them have done the opposite.

• They’ve denied the harms.
• They’ve derided the parents of babies who have been harmed and called them liars.
• They’ve impugned the integrity of safety advocates.
• They’ve dismissed the scientific evidence of harm.
• And they’ve invoked their good intentions to absolve themselves of responsibility.

Milli Hill, Amy Brown and Sheena Byrom among others are on Twittter right now engaged in this unethical behavior even as we speak.

Imagine for a moment if the doctors who prescribed DES (diethylstilbestrol) had behaved like Hill, Brown and Bryom.

Diethylstilbestrol (DES) was first synthesized in 1938 and was the first orally active nonsteroidal estrogen that could be used for human therapy. At that time, endocrinology was in its infancy and this discovery was a unique and great advance. Recurrent pregnancy loss was a serious medical problem then as it is now. It was believed the problems were due to a faulty hormonal environment of the fetal-placental unit, rather than primarily to genetic causes, as we have subsequently learned.

The result was unforeseen disaster.

Then, in the late 1960s, eight extraordinarily rare cases of clear cell adenocarcinoma (CCA) of the vagina were diagnosed and treated in women in their teens and early 20s in the Boston area. No such cluster of cases in young patients had ever been seen previously. CCA of the vagina was known to be a cancer that rarely occurred even in older women. In an effort to understand the cause of this cluster, a case-control study was conducted at the Massachusetts General Hospital in 1971 that linked the appearance of these cancers to the patients’ mothers having been treated with DES …

Subsequently, DES use during pregnancy was associated with other adverse health effects in the exposed female offspring, including an increased frequency of anatomic problems in the female genital tract … all of which led to pregnancy complications including premature birth of offspring of the DES-exposed daughters…

How did the medical profession respond?

They acknowledged the harms, indeed they publicized the harms in an effort to inform any woman who might be affected.

They validated the harms that had befallen the affected women. They did not accuse them of lying about the harms; they did not impugn their integrity; they did not ignore the scientific evidence.

They did not invoke their unquestionably good intentions to avoid responsibility.

They reassessed the scientific evidence and the faulty conclusions they had drawn from it.

In contrast, lactivists and many midwives are still in deep denial despite both scientific evidence and testimonials of harm on both social and mainstream media.

Dr. Miriam Stoppard rightly takes them to task over their denial in regard to breastfeeding.

I don’t know which I feel more, anger or relief, at the announcement from the Royal College of Midwives (RCM) that mothers who choose to bottle feed their babies must be respected.

What took them so long to realise their rigid adherence to a policy of pressuring women to breastfeed was cruel and heartless?

Legions of bottle-feeding mothers have been humiliated and made to feel failures, guilt and shame by hard core midwives and health visitors who toed the party line and used “breast is best” as a whip to subjugate new mums.

I couldn’t have said it better myself!

The RCM is now all appeasement. “We know every woman wants the best for her baby and we want to be able to empower our members to support women to be the best they can be and enable them to make decisions that are right for themselves and their babies.”

But what about all those terrified mothers who were bullied and harassed by health care professionals making their lives a misery?

An apology would seem appropriate.

An apology would be nice, but a good first step would be to reprimand the Milli Hills, Amy Browns, and Sheena Byrons for their unethical behavior and publicly tell them to stop.

Lactivists are spluttering on Twitter.

They’ve been apprised over and over again about the harm that they’ve caused:

• The epidemic of neonatal hospital readmissions (tens of thousands per year) for dehydration, hypoglycemia and jaundice.
• The permanent brain injuries and deaths that result.
• The heartless closing of well baby nurseries to force women to undertake full care of their babies the moment the placenta has been delivered.
• The babies who’ve been injured and died because of smothering in or falling from their mothers hospital beds.
• The mental anguish of mothers who have been encouraged to let their babies scream in hunger because “breast is best.”
• The guilt and suffering of women who want to breastfeed but are physically unable to do so.
• The thousands of testimonials, Facebook posts and tweets from women who are angry that lactivists lied to them, pressured them, and shamed them.

How dare anyone mention the babies who have suffered as a result of their propaganda? How dare any mother share her own anguish at breastfeeding pressure? How dare anyone fail to recognize that lactation professionals are the “good guys”?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]If lactation professionals acknowledge the suffering they’ve caused maybe they aren’t the good guys after all.[/pullquote]

It’s this last issue that’s most important.

As I written repeatedly over the years, breastfeeding activism is not about babies; it’s about mothers and how they wish to view themselves: as better, more loving, more educated, more committed to self-sacrifice than women who bottlefeed. And what goes for breastfeeding mothers goes double for lactation professionals since they “support” mothers into becoming better, more loving, more educated, more committed to self-sacrifice than the lazy, stupid, selfish women who bottle feed.

Lactivists can’t apologize for the harm they’ve caused because they can’t bear to acknowledge suffering they’ve caused. Because if they acknowledge the suffering they’ve caused maybe they aren’t the good guys after all and that is simply intolerable.

How intolerable?

They are incredible snowflakes. Most lactation professionals have blocked me on Twitter because they can’t bear to have their beliefs called into question.

They are furious at the charges I have leveled against them for the above mentioned suffering, as well as their sexist invocation of biological norms and their mind boggling hypocrisy, yet they can’t seem to respond in a measured way with facts and scientific citations.

They are so indignant at the possibility that they have harmed anyone that they have endlessly tried to smear the Fed Is Best Foundation and Christie del Castillo-Hegyi and Jody Segrave Daly who run it.

They prefer to tell each other that the formula industry is behind every woman who cries out in anguish rather believe their cries.

They have the temerity to insist that breastfeeding is not supported when there is an entire profession, an army of providers and government policy supporting it.

They cling fiercely to the notion that they are the victims, while assiduously ignoring the babies and women who are the real victims. They must be the victims when they are the good guys, right?

But here’s the problem, lactivists:

When someone shows you evidence that you’ve hurt them, you don’t get to decide you haven’t. If you want to hold yourself blameless you must provide evidence that those harms did not occur or that aggressive breastfeeding pressure wasn’t responsible for those harms.

When someone tells you that they felt anguished, pressured and shamed by lactation professionals, you don’t get to decide that they misunderstood or it’s all in their head.

When women whose babies have been harmed or have seen the harm that has befallen other women’s babies set up a Foundation to promote safety in infant feeding, you don’t get to impugn their motives, imply they are taking bribes from the formula industry, or declare that they hate breastfeeding.

When you have hurt as many infants and mothers as you have, you don’t get to claim that you are the good guys. It doesn’t matter how pure your motivations, if you hurt babies and women — and there is no doubt that you have done so — you aren’t the good guys.

I don’t expect apologies from the Amy Browns and Kimberly Seals Allers of the world, but is it too much to hope for personal reflection? The Fed Is Best Foundation currently has over 560,000 supporters on Facebook; that’s a lot of women and babies who have suffered and continued to suffer because of aggressive breastfeeding promotion. Are they all lying? Are they all misunderstanding? Are they all in the employ or under the sway of formula companies? Or is the real problem that lactation professionals have been lying to themselves about being the good guys?

When thousands of women tell you they are hurting because of your actions, you aren’t entitled to call yourselves the good guys.

The lactivist whining continues!

This week the Royal College of Midwives reminded its members that women have an absolute right to choose bottle feeding and are entitled to respect for that choice.

Why did they do that? I’d like to think it’s because they recognized that the benefits of breastfeeding in industrialized countries are trivial, that pressuring women to breastfeed is deeply sexist — violating a women’s right to bodily autonomy — and because they recognized the suffering and anguish they were causing.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactivists imagine themselves as motivated by love for babies and fealty to science and imagine women who don’t breastfeed as lazy, selfish, under the sway of formula companies or lacking support.[/pullquote]

But I’m a cynical person and I suspect that the real reason was that aggressive breastfeeding promotion is starting to cost the National Health Service serious money. Breastfed babies are readmitted at double the rate of bottle fed babies. Massive financial judgments are being paid out to compensate parents whose babies were brain injured or died. And that’s on top of the millions of dollars wasted to aggressively promote breastfeeding. Moreover, none of the promised benefits in lives or healthcare dollars saved has materialized.

It’s hardly a coincidence that the RCM was also forced to shutter their Campaign for Normal Birth. It, too, had become too costly in lives and money and failed to provide the promised benefits.

In response, lactivists have continued doing what they do best — lying, shaming, and asserting victimhood.

Consider this tweet from Kimberly Seals Allers:

As #breastfeeding is under attack, we need ALL WOMEN to see the right for women to choose & if so, be properly supported to use their bodies for their biological norm as a Women’s issue. Instead of falling prey to ways of dividing us.

As I noted on my Facebook page, claiming that respecting bottle feeding means breastfeeding is under attack is like claiming “black lives matter” means white people are under attack. Seals Allers dropped in to chastise me.

… Dear NonPracticing OB, I see that you are very consistent with your lack of context and rabble rowsing, while the rest of us are actually at work in the community. But I won’t address your collapsing methaphors and logic gaps — I am used to those but I will address the lack of facts: I never said supporting bottle feeding was attacking breastfeeding –YOU SAID THAT. I support bottle-feeding all the time. Have you been to where I work in Detroit???? And Philadelphia??? I have invited you and Christine on many occasions… Women must use bottles. Women also use formula!! And I support them!!! …. So please get your facts straight. When I say breastfeeding is under attack (And thank you asking instead of making blatant ASSumptions), I mean the commercial interests– the multi-million infant formula contracts, the multi-billion lobbying against WHO Code guidelines and the multi-billion dollar drug industry, the sensational headlines that pit mothers against mothers (your MO) and don’t get to the policy gaps that can save lives (including more training for physicians on lactation failures as I’ve also said many times) –so I don’t know who said I don’t respect bottle feeding because I do. PLEASE GET YOUR FACTS STRAIGHT!!! …

So many words, so little substance! And so much attribution bias.

In psychology, an attribution bias or attributional bias is a cognitive bias that refers to the systematic errors made when people evaluate or try to find reasons for their own and others’ behaviors. People constantly make attributions regarding the cause of their own and others’ behaviors; however, attributions do not always accurately reflect reality. Rather than operating as objective perceivers, people are prone to perceptual errors that lead to biased interpretations of their social world.

Simply put, attribution bias or error is the tendency to ascribe one’s own mistakes to lofty motives and other people’s behavior to malice.

Attribution error is fundamental to contemporary lactivist theory which imagines all lactation professionals motivated by love for babies and fealty to science and imagines all women who don’t breastfeed as lazy, selfish, under the sway of formula companies or lacking “support.”

Seals Allers demonstrates attribution bias by assuring us of her pristine motivations and attributing base motivations to me.

But the facts are indisputable: Babies are dying because lactivists are lying about the instrinsic failure rates of breastfeeding. Healthcare costs are rising because breastfed babies are being readmitted at twice the rate of formula fed babies, suffering from dehydration, hypoglycemia and jaundice. Liability payments are soaring as babies sustain permanent brain injuries or even die as a result of aggressive breastfeeding promotion. The promised saving from breastfeeding promotion have utterly failed to appear.

Seals Allers excuses herself and her colleagues for culpability in these injuries and deaths because their motives were pure.

She apparently can’t imagine that my motives are pure, too. I want to stop the neonatal brain injuries and maternal anguish at inability to breastfeed. And I have no connection to the evil formula industry, which in any case, has nothing to do with the intrinsic failure rate of breastfeeding.

I’m not so sure the motives of Seals Allers and other lactivists are entirely pure; they make money from lactivism and they feel superior for having breastfed. But that doesn’t really matter; if we want to stop these easily preventable injuries and deaths, and well as maternal anguish, lactivists must take responsibility for the fact that they lied and babies died as a result. Most importantly, they need to stop lying!

They may have had the best of motives, but that does not absolve them. Trying to deflect attention by questioning others’ motives doesn’t absolve them, either.

The road to hell is paved with good intentions.

Moral certainty can be used to justify the harm done by failing policies and actions. Those with good intentions believe their practices are good for the group; it is self-evident to them. They justify collateral damage in the belief they do a greater good.

I don’t doubt that your intentions were good, Ms. Seals Allers, despite the harm that has occurred as a result. Please give feeding safety advocates like me the credit for the same pure motivations you give to yourself.

Let the lactivist whining begin!

I wrote yesterday that the Royal College of Midwives issued a statement of what should have been obvious all along:

Bottle feeding is a woman’s right

New mothers ‘should not be shamed into breastfeeding’

Bottle feeding mothers’ ‘choice must be respected’ midwives advised

Prof. Amy Brown, like most professional lactivists, is upset that her unfettered ability to mentally torture new mothers by locking up formula, making women sign formula consents and refusing to provide information about bottle feeding has been curtailed.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Should women believe their own feelings of midwife induced pressure, shame and guilt, Amy Brown, or you?[/pullquote]

She expresses her frustration in a new piece What are women’s ‘rights’ when it comes to infant feeding? I notice that Prof. Brown puts the word rights in quotes implying from the start that women don’t really have any rights to control their own breasts.

But even worse, Prof. Brown appears to believe that women have no right to tell their own stories of mental torture to the press.

The right for the media to not sensationalise women’s experiences to make money.

…[W]omen do not deserve those headlines. Many a woman in my research has talked about how they hate and blame themselves, feeling like failures. Equally, many a woman has struggled on breastfeeding, through pain, confusion, exhaustion… because she couldn’t get the support she needs.

And the media thinks this is news? Heartbreak is not news. It is not there to sell papers. The only thing it is there for is to learn from and to move forward. And no one does that by stirring up layers and layers of deep hurt.

That would be hilarious if it weren’t so hypocritical. Brown has spent that last years using the media to publicly bewail the “lack of support” for breastfeeding, including:

Low UK breastfeeding rates down to social pressures over routine and sleep sensationalizing the selfishness of new mothers who want to get sleep to recover from childbirth.

Why Fed Will Never Be Best: The FIB Letting Our New Mothers Down sensationalizing the purported lack of support for breastfeeding and bitterly mocking women who have insufficient breastmilk by obnoxiously and falsely asserted that insufficient breastmilk is rare when it is quite common (up to 15% of first time mothers in the first few days after birth).

The breathtakingly hypocritical Don’t We Deserve Fairer Priced Formula Milks? arguing in direct opposition to basic economics that the Thewlis Bill, further restricting formula advertising in the UK, would lower the cost of formula. That’s like the anti-abortion crowd claiming that restrictive abortion laws are designed to improve the safety of pregnancy termination.

But when it comes to sensationalization, it’s hard to top Brown’s March 2018 piece Baby bottle propping isn’t just dangerous – it’s a sign of a broken society

Should women believe their own feelings of midwife induced pressure, shame and guilt, Amy Brown, or you?

Importantly, midwives do not deserve these headlines either. I have never met a midwife who has judged or criticised a woman for not breastfeeding. I have met plenty a midwife who has worked through breaks and past end of shifts to sit with a woman in pain and distress.

Brown is nothing if not an expert in gaslighting:

Those headlines are designed to do one thing – to turn women against each other, to cause arguments, to distract. They are designed to push women towards formula companies and away from each other. They are designed to divide and cause people to spend time debating a non-debate. They are designed to turn women against midwives, to turn midwives against their organisation. In other words, to cause havoc that privileges one group only – the formula industry.

Really? All those women who are telling their stories of mental distress over breastfeeding are attempting to turn women against each other and push women toward formula companies? You can’t be serious, Prof. Brown.

Gill Walton the head of the RCM wants only to turn women against midwives and to turn midwives against their organization? Are you for real, Prof. Brown?

Brown’s reveals her true obsession with this statement:

Every time we fight with each other. Every time we get distracted. Every time we fall into a trap of having to endlessly defend – they win.

While Brown may view everything through the prism of a battle to the death between lactivists and formula companies, the rest of us are concerned about BABIES.

That’s right, Prof. Brown, babies; you remember them? I can’t be sure since you didn’t bother to mention their needs at all. And that just proves the point I have been making for years: lactivism is not about babies and what they need; it’s about lactivists and how they wish to see themselves. They imagine themselves as superior mothers battling the forces of the formula industry and emerging victorious when the reality is that they are women who were lucky enough to face fewer breastfeeding problems than others and are battling for personal self-esteem, professional marketing share, and economic enrichment through greater employment opportunities.

Brown finishes with a flourish of lactivist sanctimony:

Enough of the stirring. There are no ‘sides’. We’re all fighting for the same things. More investment, more support, more value. Let’s stop the media from trying to pretend otherwise.

Sorry, Prof. Brown, there are sides and you’ve placed yourself squarely on the wrong one:

There are women on one side and lactation professionals who think they know better on the other.

There are hungry babies, babies suffering from hypoglycemia, kernicterus, and hypernatremic neonatal dehydration on one side and lactation professionals denying their suffering on the other.

There are mothers who want only to do what is best for their babies on one side and lactation professionals who refuse to listen to them, who lie about the natural failure rate of breastfeeding and who promote a process — breastfeeding — above the physical health of babies and the mental health of mothers on the other.

Fed Is Best. Fed Is Feminist. Offering lactivist “support” that women don’t want is neither.

Hallelujah!

According to The Independent, Midwives told they must respect mothers who decide not to breastfeed:

Mothers who decide not to breastfeed their child must be respected for their choice, midwives are being told.

New advice from the Royal College of Midwives (RCM) stresses new mothers should be given appropriate support if they make an informed decision to bottle feed…

[T]he RCM acknowledges some mothers struggle to start or carry on breastfeeding, breastfeeding, and says the decision is a woman’s right.

Think about that for a minute:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The RCM has just publicly acknowledged what Joan Wolf, Courtney Jung, Suzanne Barston, Christie del Castillo-Hegyi, Jody Segrave Daly, and I have been writing for the past decade.[/pullquote]

• The physiology of breastfeeding has not changed. A significant proportion of women have ALWAYS struggled to breastfeed.

• Women’s right to control their own bodies has not changed. Bottle feeding has ALWAYS been a women’s right.

• Midwives’ ethical obligations have not changed. Midwives were ALWAYS ethically required to respect women’s feeding choices.

This is an admission that they and the rest of the breastfeeding lobby — La Leche League, the Baby Friendly Hospital Initiative, professional lactivists in the World Health Organization — have spent the past decade IGNORING and DENYING women’s struggles and babies’ suffering, IGNORING and DENYING women’s rights, IGNORING and DENYING their ethical obligation to respect women’s choices.

Gill Walton, new head of the RCM essentially acknowledges their woeful behavior:

“…[S]ome women cannot or do not wish to breastfeed”.

“They must be given all the advice and support they need on safe preparation of bottles and responsive feeding to develop a close and loving bond with their baby,” Ms Walton added.

We know that every woman wants the best for her baby, and we want to be able to empower our members to support women to be the best they can be and enable them to make decisions that are right for themselves and their babies.”

This is EXACTLY what Joan Wolf, Courtney Jung, Suzanne Barston, Christie del Castillo-Hegyi, Jody Segrave Daly, and I have been writing for the past decade.

Why is the RCM suddenly acknowleding what everyone has known for years? I suspect it’s because the power of the breastfeeding lobby has come up against the tremendous suffering and massive amount of healthcare spending their unethical behavior has caused. Babies are injured and dying from dehydration, jaundice and falling from or being smothered in their mothers’ hospital beds. Breastfed babies are being admitted to the hospital at twice the rate of their formula fed peers, costing hundreds of millions of healthcare dollars per year. Moreover, women are vocally opposing both the scientific claims and the unethical tactics of the breastfeeding lobby.

As I have noted in the past, the unethical behavior of the breastfeeding lobby can be traced to a seminal 1996 paper by lactation consultant Diane Weissinger who set out a roadmap of lactivist behavior. She proposed the use of shaming language to pressure women into breastfeeding.

Why?

She couldn’t have made it clearer:

All of us within the profession want breastfeeding to be our biological reference point. We want it to be the cultural norm; we want human milk to be made available to all human babies, REGARDLESS OF OTHER CIRCUMSTANCES. (my emphasis)

Regardless of the fact that up to 15% of first time mothers cannot produce enough breastmilk; regardless of the fact that many women don’t want to breastfeed; regardless of women’s right to control their own bodies and midwives’ ethical obligation to support women’s choices.

The breastfeeding lobby — despite endlessly whining of victimhood — has controlled the infant feeding discourse with an iron fist for the past decade and more.

Sociologists Sunna Símonardóttir and Ingólfur V. Gíslason explain that women have been challenging the power of the breastfeeding lobby.

How?

Mothers pointed out that formula fed children are healthy.

The most uncontested and culturally accepted type of medical discourse on breastfeeding is the long list of the assumed benefits on the health and wellbeing of children…

Even though the women do not directly challenge this overall assumption, or make claims that breastmilk has no health benefits over formula, some of them do contest certain aspects of the hegemony of the medical breastfeeding discourse. The women who challenge the medical discourse on breastfeeding do so from a personal standpoint, contrasting their own happy and healthy children with the image of formula fed children as deprived and less healthy.

Their formula fed children are smart:

For some of the women, the worst aspect of this medical discourse on the benefits of breastfeeding is the notion that breastfeeding has a positive effect on a child’s intelligence. The women stress the academic achievements of their children and how in fact their formula fed child is ‘top of the class’.

They and their children have bonded fiercely to each other:

Breastfeeding … has been constructed as a vital aspect of mother–child bonding, reflecting the ideology of intensive mothering and ‘the need for mothers to manage risk by heeding expert warnings and advice.’ A number of women reject this idea that bonding takes place through breastfeeding by discussing the effects that breastfeeding (or trying to breastfeed) had on their mental and psychological wellbeing. Those women had usually been trying to establish breastfeeding with a lot of difficulty and severe pain, and they describe trying to breastfeed as an ‘emotional roller-coaster’ that has had serious consequences and often made them feel depressed and anxious. Breastfeeding is therefore not constructed as helpful when it comes to bonding, but directly harmful to the bonding process.

Women found that most of the ostensibly scientific claims made about breastfeeding were not true in their circumstances. That’s hardly surprising since, as I and others have detailed repeatedly, most of the scientific claims made about breastfeeding were made as part of the Panglossian paradigm beloved of both lactivists and anti-vaxxers that nature is perfect and technology cannot improve upon it.

The scientific evidence about breastfeeding has always been weak, conflicting and riddled with confounding variables. Early claims about the benefits of breastfeeding have not been borne out by later, larger studies. Most importantly, none of the predicted public health benefits of breastfeeding (based on mathematical modeling) have occurred; there have been no measurable changes in the mortality and morbidity rates of term infants and no healthcare dollars saved. To the contrary, the results of the power of the lactivist lobby are best measured in infant deaths and disabilities, maternal anguish, and hundreds of millions of dollars spent each year treating breastfeeding complications.

What the findings of this study do is to make visible certain discursive constructions and power relations that have remained hidden or simply taken for granted. Once they have been identified, we are much better equipped to disrupt and untangle these constructions and power relations and critically engage with the normalizing discourses on infant feeding …

Is this, as Guardian columnist Zoe Williams asks, the end of the breastfeeding wars?

I doubt it for the reason that Williams herself details: privilege.

The underlying issue was class-based: breastfeeding, the middle-class choice, gave middle-class parenting a superior status that would otherwise have been difficult to assert… [T]he First Three Years became a key policy area, with improbable and unpleasant assertions about what non-U parents were like. They fed their babies formula, then they left them all day strapped into a buggy, pointed at a wall; they didn’t give them the right vocabulary because they weren’t interested in talking to them. Bottles became a key signifier of parental neglect …

It’s was never about babies, but always about mothers:

This has been a culture war, and quite an exhausting one, where nothing meant exactly what it said: the pro-breastfeeding line originated with second-wave feminism, asserting a woman’s choice to feed with her baby as she saw fit, without medical or corporate interference. That liberation became an oppression; if it’s the only thing you’re allowed to choose, that’s not a choice. It fed into a set of ideas that located the source of childhood disadvantage not in hardship but in their parents’ sub-optimal behaviour, so that poverty would indicate, literally, that if you weren’t a bad person then probably your mother was. And this political notion was mediated not just through women’s bodies but through our actual tits. It was faintly chilling for all women, mothers or not. It would be wonderful if the RCM’s humane, good sense intervention marked the end of it.

It would be wonderful, but I predict that the breastfeeding lobby is not going down without a fight. There will be wailing and gnashing of teeth: about Nestle, about victimhood and about “The Science.” There will be no mention of the fact that breastfeeding is a big business, bringing in billions of dollars of revenue in breastfeeding products, and probably much more in lactation consultant fees and salaries.

Winston Churchill’s words about actual war may apply to the breastfeeding wars.

Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.

“Unvaccinated is the biological norm for human beings.

Natural immunity, the sole source of infant/child immunological protection in nature, has evolved as a result of 200 million years of Darwinian pressure to become the perfect defense against disease.

When we move away from this biological norm, it is up to us to research the effects of this, and this puts the onus on vaccines to show there is no risk associated with its use. Just as we examine the risks of other changes to our biology, like a diet filled with fast food (again, we don’t speak of the “benefits” of avoiding McDonalds), the same holds for vaccination. Or rather, should hold. The fact that it doesn’t speaks to the power of Big Pharma and the societal push for vaccines to be seen as the norm.

The vast majority of vaccines research has treated vaccines as something that can be done outside this biological norm and still confer “benefits”. That can’t possibly be true.”

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Lactivists treat breastfeeding like antivaxxers treat natural immunity.[/pullquote]

Typical anti-vax nonsense, right?

While unvaccinated is indeed the biological norm, we can do better than nature. Limited to only natural immunity, infants and children become ill and die in droves.

As this impressive graphic shows, both cases and deaths from vaccine preventable diseases have dropped dramatically with the introduction of vaccines.

There has been literally a 100% drop in deaths from diphtheria, a 100% drop in deaths from polio, a 100% drop in deaths from rubella and smallpox, previous a dreaded disease, was eliminated altogether.

Unvaccinated may be the biological norm for infants and children but deaths from vaccine preventable diseases are also the biological norm. Natural immunity is indeed the product of hundreds of millions of years of evolution, but that didn’t make it perfect or even close to perfect. While there are certainly benefits to natural immunity (it can be longer lasting than vaccine induced immunity), there are also considerable risks. In order to acquire natural immunity, you have to survive the disease and many don’t.

In the case of vaccine preventable disease, nature is good, but technology is better, safer and far more convenient. You’d have to be kidding yourself to pretend otherwise.

Now I have a confession to make:

The above quotes, while typical of antivax beliefs, do not come from antivaxxers. They come from lactivists. I merely substituted vaccine rejection for breastfeeding.

It was easy to do because the claims lactivists make about breastfeeding mirror the claims antivaxxers make about natural immunity. In both cases they represent wishful thinking, not reality and are based on the belief that natural selection creates the best possible outcome.

This view was derided by evolutionary biologist Stephen J. Gould as the Panglossian paradigm. The paradigm references Pangloss, a character in Voltaire’s Candide who believes that “all is for the best in this best of all worlds.” In the context of evolution the Panglossian paradigm imagines that everything that exists in nature today is the product of intense natural selection and represents the perfect solution to a particular evolutionary problem.

In the case of immunity the Panglossian paradigm insists that natural immunity represents the perfect solution to the evolutionary problem of disease. In the case of breastfeeding the Panglossian paradigm insists that breastfeeding represents the perfect solution to the problem of infant nutrition.

Science blogger Josh Rosenau explains Gould’s seminal paper written with Richard Lewontin, “The Spandrels of San Marcos and the Panglossian Paradigm: A Critique of the Adaptationist Program.”

The point was that biologists were too quick to insist that every feature was adaptive and a result of natural selection. Spandrels are triangular structures produced when two round arches meet. They are necessary byproducts of joining rounded and flat surfaces. Nonetheless, in many churches they are richly decorated and the entire artistic vision for a space can be shaped by the spandrels. One might, Gould points out, be lead to think that the spandrels are there in order to be used for paintings, and not that they are necessary by-products nicely dressed up. The worldview he criticizes treats anything, whether spandrels or five fingers, as the product of intense selection, a perfect solution to the problems it faces.

In other words, an existing natural feature, whether immunity or breastfeeding, may not be the result of evolutionary pressure, it may be an incidental feature of a solution to an entirely different problem or it may represent the limits of genetic adapatation. For example, it would undoubtedly be evolutionarily advantageous to have eyes in the back of our heads yet we never developed them. Instead technology gave us mirrors, which we can use to escape our biological limitations and see behind us. Two eyes don’t represent the best of all possible outcomes, merely the outcome that we have.

Nature is NOT perfect and therefore technology can improve upon nature.

It’s easy to see the limits of the Panglossian paradigm in immunity. Natural immunity is clearly deficient and involves a massive amount of disease and death. Just as rear view mirrors allow drivers to escape the limitations of only two forward facing eyes, vaccines allow us to escape the limitations of an immune system that requires us to be exposed to a deadly pathogen (and possibly die) in order to become immune.

It’s harder to see the limits of the Panglossian paradigm in breastfeeding because lactivists and their organizations have spent dozens of years and millions of dollars explicitly denying the limitations of breastfeeding. They’ve resorted to lying in order to do so: lying about the high failure rate of breastfeeding due to insufficient breastmilk, lying about the high complication rate from dehydration or jaundice and lying to exaggerate the benefits of breastfeeding. They lie not out of malice but out of a deeply held belief in the erroneous Panglossian paradigm that evolution produces the “best of all possible world” when it merely produces survival of the fittest. They assert that formula cannot possibly be as good as breastmilk when the reality is that it, like vaccines, could ultimately be better, safer and more convenient because we can often improve upon nature.

Breastfeeding may represent the result of hundreds of years of evolution but evolution does not produce perfection. Lactivists who refuse to recognize their error are no different from antivaxxers who refuse to recognize the same error.

What do lactivists and antivaxxers have in common? Neither truly understands the limitations of evolution, and lacking that understanding make extravagant and false claims about the virtues of the biological norm.

The headline, Infant formula could change gut bacteria, contribute to childhood obesity, is alarming.

The findings are worrisome:
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]If they had used a growth chart of how all infants grow, not merely breastfed infants, the title might easily be ‘Exclusive Breastfeeding and the Risk of Underweight in the First Year of Life.’[/pullquote]

A new study shows that babies who were breastfed had different bacteria environments, or microbiomes, in their guts –- and lower obesity levels as they grew -– than babies who were primarily fed formula…

For the study, published in the Journal of Pediatrics [sic], researchers in Canada looked at data from the Canadian Healthy Infant Longitudinal Development, or CHILD, focusing on the first year of life for more than 1,000 infants from four different sites.

Researchers in this study wanted to know if only breastfeeding, breastfeeding plus some early foods, or formula feeding alone affected the type of bacteria found in the infants’ guts at two ages: 3 to 4 months and 12 months.

What did they find?

Of the formula-fed babies, 33 percent were overweight or at risk of being overweight, while 19 percent of exclusively breastfed babies were overweight or at risk.

There’s a serious problem with the study, however. It uses a flawed and arbitrary measure of infant obesity.

The paper is Association of Exposure to Formula in the Hospital and Subsequent Infant Feeding Practices With Gut Microbiota and Risk of Overweight in the First Year of Life.

The authors report:

There were 1087 infants in the study (507 girls and 580 boys); at 3 months, 579 of 1077 (53.8%) were exclusively breastfed according to maternal report. Infants who were exclusively formula fed at 3 months had an increased risk of overweight in covariate-adjusted models (53 of 159 [33.3%] vs 74 of 386 [19.2%]; adjusted odds ratio, 2.04; 95% CI, 1.25-3.32). This association was attenuated (adjusted odds ratio, 1.33; 95% CI, 0.79-2.24) after further adjustment for microbiota features characteristic of formula feeding at 3 to 4 months …

Here is a chart of the results.

How did they determine which babies were “obese”?

At 12 months of age (mean [SD] age, 12.4 [1.3] months), infants were weighed and measured by CHILD Study staff. Age- and sex-specific weight for length z (WFLz) scores were calculated according to World Health Organization standards. A WFLz score greater than the 97th percentile was considered overweight, and a WFLz score greater than the 85th percentile was considered at risk for overweight …

But breastfed babies and formula fed babies grow differently. The CDC acknowledges:

The WHO growth charts reflect growth patterns among children who were predominantly breastfed for at least 4 months and still breastfeeding at 12 months. These charts describe the growth of healthy children living in well-supported environments in sites in six countries throughout the world including the United States. The WHO growth charts show how infants and children should grow rather than simply how they do grow …

The WHO growth charts establish the growth of the breastfed infant as the norm for growth. Healthy breastfed infants typically put on weight more slowly than formula fed infants in the first year of life. Formula fed infants gain weight more rapidly after about 3 months of age. Differences in weight patterns continue even after complementary foods are introduced

Wait, what? Formula fed infants are being evaluated on a scale designed for breastfed infants?

To understand why that’s a serious problem it’s instructive to consider the genesis of the current WHO standards. Previous standards evaluated growth based predominantly on formula fed infants since most infants were formula fed at the time they were developed. Many breastfed infants were diagnosed as underweight using these charts. Breastfeeding advocates claimed that it was wrong to evaluate breastfed infants using formula fed infants as the standard.

They had a point, but it’s not clear that it was a valid one. It’s based on the assumption that every breastfed infant is fully fed when the reality is that breastfeeding has a significant failure rate and some breastfed babies are actually underfed. Far fewer babies receiving formula are underfed since they can eat until satiety instead of merely until the milk runs out.

The WHO charts purportedly show “how infants and children should grow rather than simply how they do grow.” But they don’t measure how infants “should” grow, they measure how breastfed infants, including underfed infants, grow. It’s a classic example of the naturalistic fallacy: if something is a certain way in nature, that’s how it ought to be. But that’s makes as much sense as constructing a child growth chart including those with rickets to evaluate contemporary children who have easy access to calcium and vitamin D.

It’s not clear at all that any of the purportedly obese infants in this study would be considered obese if the authors used a growth chart of how all infants grow, not merely breastfed infants. In that case, the title of the study might be ‘Exclusive Breastfeeding and the Risk of Underweight in the First Year of Life.’

This paper is yet another example of white hat bias.

‘White hat bias’ (WHB) [is] bias leading to distortion of information in the service of what may be perceived to be righteous ends… WHB bias may be conjectured to be fuelled by feelings of righteous zeal, indignation toward certain aspects of industry, or other factors. Readers should beware of WHB and … should seek methods to minimize it.

Breastfeeding researchers are so sure that breastfeeding is beneficial, and are so hostile to the infant formula industry that they arrange their data in ways that promote breastfeeding and demonize formula. Creating and employing infant growth charts that assume that breastfeeding is always best for every baby is bias in the service of what are perceived to be righteous ends. But it’s bias nonetheless and it’s wrong.

And that makes the conclusion of this study entirely arbitrary.