On breastfeeding: don’t listen to what pediatricians say, watch what they do


It’s an oft stated and remarkably valuable aphorism: “Don’t listen to what people say; watch what they do.”

In other words, though people may give lip service to a variety of morally elevating thoughts, their personal beliefs are reflected not in their words, but in their behavior.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Don’t listen to what Dr. Klass says about the importance of breastfeeding, follow what she did.[/pullquote]

Perri Klass has a piece about breastfeeding in today’s New York Times and it is an excellent illustration of the aphorism.

In Practicing What I Preached About Breast-Feeding, Klass acknowledges that she didn’t always do what she counseled the mothers in her practice to do.

I had not managed [exclusive breastfeeding] with my first two children, one born while I was in medical school, the second right at the end of my residency. I had breast-fed them both, but relied on formula to get through day care days, and the breast-feeding had ended altogether by seven or eight months.

But with my third, since I was a full-fledged practicing pediatrician, I felt a moral obligation to follow the recommendations that I had been earnestly dispensing…

Like most pediatricians, I am a true believer in the benefits of breast-feeding, though I myself was bottle-fed, along with many in my cohort (what can I say, I was born in the 1950s)…

In other words, Klass felt obliged to follow the recommendations of the WHO and AAP though she doesn’t think not following them harmed her two older children. After all, she herself was bottle fed, and it didn’t seem to harm her.

But my own decision was mostly about that feeling that I had to un-hypocrite myself.

Though Klass proclaims herself a true believer in the benefits of breast-feeding, she does not present her decision to follow the standard recommendations as an effort to keep her baby healthier than her older children, or because she thinks she will thereby be a better mother. She does it so she won’t feel so guilty about being a hypocrite.

I appreciate her honesty, but it might have been better for her patients if she resolved her cognitive dissonance in the opposite way. Instead of attempting to follow recommendations that she apparently doesn’t believe to be truly necessary, she could have acknowledged that she doesn’t think that following the WHO and AAP recommendations makes for better mothers or healthier babies.

Klass doesn’t mention most of the (spurious) benefits of breastfeeding quoted by professional lactivists and she does highlight the fact that the benefits of breastfeeding in industrialized countries are far less than in countries without access to clean water.

She quotes Dr. Michael Kramer, the lead investigator in the Probit Studies that found that the benefits of breastfeeding are limited to approximately 8% fewer ear infections and 8% fewer episodes of diarrheal illness across the entire population in infants in the first year. To put that into perspective: the vast majority of breastfed infants will experience no discernible health benefit from breastfeeding.

But Dr. Kramer thinks there is a neurocognitive benefit.

For parents in a developed country, one of the main motivators is neurocognitive development, accelerated brain development,” he said.

“We really don’t know what it is about breast-feeding, whether it’s something in the milk, whether it has to do with increased physical contact between lactating mother and nursing baby, or if just the time it takes to breast-feed means increased opportunities for verbal exchange between mother and baby,” Dr. Kramer said. “I think that is an interesting topic for future research.”

The truth is that we really don’t know IF the association between breastfeeding and neurocognitive development even exists. Curiously neither Dr. Klass nor Dr. Kramer discuss the more recent and more comprehensive Colen study that found NO association between breastfeeding and neurocognitive development. That study, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons compared the association between breastfeeding and a variety of purported benefits between babies, between families, and between babies within families.

There were differences between breastfed and bottle fed children in 10 of the 11 measured variables when looking at the overall group. Those differences persisted when comparing families in which all the children were breastfed to families where all the children were bottlefed. But when the authors looked within families, there was no significant difference between breastfed and bottle fed children. That indicates that most of the purported benefits of breastfeeding are the result of socio-economic status, maternal education level, and access to healthcare, NOT due to breastfeeding.

Perri Klass is hardly alone among female physicians:

Dr. Maryam Sattari, an associate professor of medicine at the University of Florida, was the lead author of a 2016 study on the breast-feeding intentions and practices of 72 internal medicine physicians. The study found that 78 percent of the babies were exclusively breast-fed at birth and 40 percent of them at 12 months, though 63 percent of the mothers had planned to go to a year…

Nearly a quarter of the female internists in the study didn’t even bother with exclusive breastfeeding and the majority did not follow the WHO and AAP recommendations. That’s hardly more than the general population.

While breast-feeding overall is on the rise, the numbers show that many mothers in this country are not following the A.A.P. recommendations. Compared to 2003, more women in 2013 were initiating breast-feeding (81 percent, up from 73 percent), and still breast-feeding at a year (31 percent, up from 20 percent).

That suggests to me that they didn’t believe the purported benefits were worth the inconvenience. The truth, which physicians know better than anyone else, is that the benefits of breastfeeding in industrialized countries are trivial and almost certainly don’t involve improvements in neurocognitive development.

Klass reports:

With my own third child, I made it to six months exclusively, me and my trusty electric breast pump. At times I felt I had gone a little off the deep end in my intense curation of those bags of frozen breast milk, carefully ferried to the day care center every day. It was a great relief when my son began avidly eating other foods, and it was then easier to go on breast-feeding him, evenings and weekends and whenever it made sense. We kept going till he was a little over a year old.

But at no point does she indicate that she thinks her third child is healthier or smarter or that her first two children suffered in any way from not being exclusively breastfed.

The shameful truth is that the WHO and AAP recommendations of exclusive breastfeeding for 6 months and continued breastfeeding for one to two years are based on little more than ‘white hat bias,’ the misrepresentation of evidence for what are believed to be righteous ends.

As Cope and Allison who first defined white hat bias note:

Certain postulated causes have come to be demonized (… formula feeding of infants) and certain postulated palliatives seem to have been sanctified. Such demonization and sanctification may come at a cost …

That cost is the mental health of mothers who have been shamed and bullied into believing that breastfeeding is far superior to formula feeding as a result of righteous indignation against the immoral activities of formula manufacturers in underdeveloped countries during the 1970’s. Yes, Nestle and other companies have blood on their hands for convincing women to switch to formula even though they did not have access to clean water. But that doesn’t mean that there is anything wrong with formula itself.

Though Klass dutifully gives lip service to the WHO and AAP recommendations, she only followed them when it was finally convenient to do so. She, like many female physicians, doesn’t really believe that bottle feeding is harmful. Therefore, my advice to new mothers is this:

Don’t listen to what Dr. Klass says about the importance of breastfeeding, follow what she did.