Primum non nocere – breastfeeding edition


Could lactation professionals possibly get more self-absorbed and clueless?

Every time I think they’ve reached the nadir, they show they are perfectly capable of a sinking lower. That’s my reaction after reading an editorial in this month’s issue of Breastfeeding Medicine, Primum Non Nocere Breastfeeding.

Primum non nocere is translated as “first do no harm” or “above all, do no harm”. It’s an elliptical sentence in that the last few words are implied but missing: Above all, do no harm to PATIENTS!

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The Academy of Breastfeeding Medicine seems to think that the only part of mothers worth protecting is their breasts, not their lives.[/pullquote]

Primum non nocere is closely related to two of the four cardinal principles of medical ethics: beneficence and non-maleficience (the other two being autonomy and justice).

The primary ethical principle that forms the foundation for medical care (and the foundation of every society throughout history) is the concept of beneficence — the obligation to do good for others. The ability to do good is also the obligation to do good.


The desire to do good often compels health care practitioners to perform some action in virtually any clinical situation, regardless of its effectiveness or even lack thereof. It is a reflection of our training, if not our DNA… [C]ountless studies around the world have demonstrated that physicians and the public perceive the benefits of almost every treatment to be far greater and the risks substantially lower than they really are. There is a biased belief in the good that will be done…

That’s why it is so important to give priority to doing no harm. It acts as a brake on our impulse to do something.

This is especially critical in preventive medicine when patients are healthy and all but a small subset are likely to remain healthy.

Preventing illness and screening for disease (or potential disease) in asymptomatic people is now considered an imperative. The benefit of various preventive measures, and the perceived absence of risk of testing and treatment (e.g., from screening tests such as prostate-specific antigen and mammography, or from statin therapy) are likewise far from reality.

When I saw that the editorial included “primum non nocere” in the title, I assumed that the author would be addressing the harms caused by aggressive breastfeeding promotion in general and the Baby Friendly Hospital Initiative in particular. I couldn’t have been more wrong. The author Timothy J. Tobolic, MD, President of the Academy of Breastfeeding Medicine, is concerned with preventing harm to breastfeeding, NOT preventing harm to babies and mothers.

In my view, it is a fundamental violation of medical ethics to place protecting a process above protecting patients. NOTHING comes before the wellbeing of our patients.

Wait, I hear you say. By promoting breastfeeding, which is good for babies and mothers, we are promoting the wellbeing of our patients.

That attitude is typical of the paternalism and egotism so beloved of physicians — Doctor knows best! — and so despised by patients. The history of medicine is littered with examples of doctors causing harm by believing in the tests, medications and treatments they promoted. Diethylstilbestrol (DES) was prescribed by doctors who believed they were doing good, episiotomies became routine because doctors were sure they were doing good. You would think we would have learned some humility by now, but apparently not.

But, wait, I hear you say. Breastfeeding is natural; it must be better than any technological alternative.

Wrong! Natural immunity, so beloved of anti-vaxxers, is far inferior to vaccine induced preventive immunity. Just because something is natural doesn’t mean we should reflexively support it. We should apply the same ethical principles to the natural as to any other medical recommendation.

I naively thought Primum Non Nocere Breastfeeding would be about reducing the rising rate of newborn dehydration, addressing the fact that 90% of cases of kernicterus (jaundice induced brain damage) are caused by breastfeeding, the reacting to the fact that exclusive breastfeeding is the leading risk factor for newborn hospital readmissions accounting for literally tens of thousands of newborn readmissions each year at a cost of hundreds of millions of dollars.

Silly me! The brain injuries, suffering, deaths and massive expenditure of healthcare dollars both to promote breastfeeding and to treat the complications caused by promoting breastfeeding don’t even rate a mention by Dr. Tobolic. He doesn’t seem particularly interested in protecting patients; he wants to protect breastfeeding!

I find some of his recommendations nauseating, as well as deeply unethical.

He seems to think epidurals pose a risk to breastfeeding:

Epidural anesthesia has revolutionized pain control during labor. However, there remains inadequate information and education of mothers on the potential harms that epidurals can have on breastfeeding. As recommended by ABM Clinical Protocol #15, Analgesia and Anesthesia for the Breastfeeding Mother, Revised 2017, more studies need to be done on safety of analgesics used in deliveries and their impact on breastfeeding. Reliable safety information must be developed for the education of mothers.

There is NO EVIDENCE that epidurals interfere with breastfeeding in any way, but no matter. Apparently the theoretical risk of epidurals to breastfeeding is more important than the REAL risks of breastfeeding promotion like newborn readmissions, brain injuries and deaths.

The amount of nonsense in his piece is truly mind boggling. This is what he writes about the “Golden Hour.”

I had many opportunities to have a student or resident present at a delivery. I would challenge them to observe, both during and after the delivery, the activities that disrupt or encourage breastfeeding and watch the magic of newborn self-attachment. Few took me up on this valuable education and I believe must be promoted as a necessary part of medical education.

Newborn attachment does NOT take place at birth; it is a SPONTANEOUS process that occurs over time and has NOTHING to do with breastfeeding. Successful extended breastfeeding is NOT dependent on that first hour. There are indigenous cultures in which mothers do not offer the breast for the first few days and substitute prelacteal feeds instead. And what about an opportunity for the mother to recover from the exhaustion and agony of childbirth in the first hour? Who cares about the mother?

Some of the nonsense is deadly:

The automated blood pressure monitor continuously attached to the mother especially after delivery can be disruptive to trying to get the baby latched. I personally have removed them to allow the mother to get in a better position to hold the baby. It is an annoyance that could be done intermittently and not for staff convenience.

Perhaps Dr. Tobolic has failed to notice that the US is experiencing a crisis in maternal mortality. Pehaps he fails to understand that one of the factors responsible for the crisis is failure to recognize and treat hypertensive disease of pregnancy PARTICULARLY after birth. Blood pressure monitoring is crucial to protecting mothers, but Dr. Tobolic and the Academy of Breastfeeding Medicine seem to think that the only part of mothers worth protecting is their breasts, not their lives.

Dr. Tobolic’s opinion piece is an ethical travesty. The fact that he could write it and publish it is symptomatic of the unethical nature of contemporary breastfeeding promotion. Women are more than their breasts. Their pain counts; their suffering counts; their lives matter more than whether or not they breastfeeding! Babies are more than mouths. Their pain counts; their suffering counts; their lives matter more than whether or not they breastfeed!

The American Academy of Breastfeeding should be ashamed that they have lost the plot so thoroughly that they actually think promoting breastfeeding is more important than whether mothers and babies live or die. But in their supreme self-absorption and cluelessness, they are probably patting themselves on the back instead.