Lactation sanity

My friend and occasional fellow poster Elizabeth brought this article from The Atlantic to my attention today, and I have a lot to say about it. It's a level-headed and refreshingly skeptical look at the hype, over-selling and judgmental posturing that attaches to contemporary breast-feeding. I want to photocopy it and wallpaper my office with it.

It's worth reading in its entirety, at least if you're interested in the subject (or, frankly, in getting a good idea about how medical findings get distorted in the general media). Some choice excerpts:
[T]he medical literature looks nothing like the popular literature. It shows that breast-feeding is probably, maybe, a little better; but it is far from the stampede of evidence that Sears describes. More like tiny, unsure baby steps: two forward, two back, with much meandering and bumping into walls. A couple of studies will show fewer allergies, and then the next one will turn up no difference. Same with mother-infant bonding, IQ, leukemia, cholesterol, diabetes. Even where consensus is mounting, the meta studies—reviews of existing studies—consistently complain about biases, missing evidence, and other major flaws in study design. “The studies do not demonstrate a universal phenomenon, in which one method is superior to another in all instances,” concluded one of the first, and still one of the broadest, meta studies, in a 1984 issue of Pediatrics, “and they do not support making a mother feel that she is doing psychological harm to her child if she is unable or unwilling to breastfeed.” [emphasis mine]
One of the greatest mercies (and I do not use that word lightly or flippantly) I have been able to confer is telling new mothers that they are not failures if they cannot breast feed. I have had these experiences with the mothers of patients, with family members and with friends. They have happened with new mothers and mothers who have nursed successfully in the past. For whatever reason, and despite a sincere desire to do the very best for their baby, they have been unable to breastfeed. And they feel like failures. Not merely frustrated or disappointed, but like failures. And many have been reduced to tears when I (for all intents and purposes) offer absolution and tell them that they are not failures, that their babies will thrive and bond just fine, and that their guilt and stress and anxiety are not warranted. A culture that makes new mothers, already stressed and tired in the best of times, feel like failures if they can't breastfeed is unhelpful and unhealthy.

What does all the evidence add up to? We have clear indications that breast-feeding helps prevent an extra incident of gastrointestinal illness in some kids—an unpleasant few days of diarrhea or vomiting, but rarely life-threatening in developed countries. We have murky correlations with a whole bunch of long-term conditions. The evidence on IQs is intriguing but not all that compelling, and at best suggests a small advantage, perhaps five points; an individual kid’s IQ score can vary that much from test to test or day to day. If a child is disadvantaged in other ways, this bump might make a difference. But for the kids in my playground set, the ones whose mothers obsess about breast-feeding, it gets lost in a wash of Baby Einstein videos, piano lessons, and the rest.
I am going to generalize a bit, so forgive the excluded nuances and exceptions to what I say. By and large, the new mothers that choose to bottle-feed at the outset are less educated, less financially stable, and have less access to all of the various benefits that accrue to being well-educated and affluent. Elizabeth has expressed curiosity about a comparison between women who choose to bottle-feed at the outset to those who would nurse but can't, and I think a study of this would be illuminating (if one could ever be designed). I suspect that the small IQ benefits attributed to breast-feeding would diminish even further, and are more accurately attributable to aspects of the mothers and parenting choices than nursing per se.

Further, it's important to remember that a difference that is "statistically significant" in a clinical study may mean next to nothing in the real world. A difference of a few IQ points between the two groups that cannot be explained by random chance is considered "statistically significant," but has no real bearing on whether or not little Taylor will get into Princeton.
In the early ’90s, a group of researchers got together to revise the American Academy of Pediatrics’ policy statement on breast-feeding. They were of the generation that had fought the formula wars, and had lived through the days when maternity wards automatically gave women hormone shots to stop the flow of breast milk. The academy had long encouraged mothers to make “every effort” to nurse their newborns, but the researchers felt the medical evidence justified a stronger statement. Released in 1997, the new policy recommended exclusive breast-feeding for six months, followed by six more months of partial breast-feeding, supplemented with other foods. The National Organization for Women complained that this would tax working mothers, but to no avail. “The fact that the major pediatric group in the country was taking a definitive stance made all the difference,” recalls Lawrence Gartner, a pediatrician and neonatologist at the University of Chicago, and the head of the committee that made the change. “After that, every major organization turned the corner, and the popular media changed radically.”
There is much about contemporary medical practice that sticks in my craw, but little makes me angrier or more tendentious than the so-called "Baby Friendly Hospital Initiative," intended to promote and support breast-feeding. It consists primarily of purging member hospitals of all mention of formula (or bottles, period) and treating a decision not to nurse as roughly on par with giving your infant a pack of unfiltered Camels. Even its name implies that formula-feeding is, by definition, baby-unfriendly. I find the whole thing self-congratulatory, doctrinaire, and unyielding. One of the most insufferable martinets I have ever encountered was a lactation consultant that confronted me for having the audacity to tell a nursing mother that she could start solids before six months, contra the AAP recommendation about nursing exclusively for six months. Apparently, giving her the option had "confused" her. (I have been told by many, many frustrated mothers that the intervention of a lactation consultant has often been a mixed blessing.)

Look. I am totally in favor of breast-feeding. It clearly has many benefits for the babies and mothers that can do it without undue stress and anxiety. But it is only one benefit among many, and one that is serially overstated. The judgement that women feel when, for whatever reason, they don't nurse is ridiculous. I was thrilled to read this article, and I hope it sparks a renewed degree of both skepticism and relief among mothers.


  1. Although I'm a lousy athlete, I once belonged to La Leche League. (Bad joke.)

    Seriously, in retrospect, I think some of LLL's views were fanatical. Especially since I was not able to nurse Baby #2 nearly as successfully as Baby #1, I became a lot less smug about the subject.


  2. Dan, thanks for your thoughts on this. I know so many moms who really struggle with enormous feelings of guilt and end up depressed and resenting their children. Good intentions gone horribly awry.

  3. Wait second. me baby #2.

  4. Dan, I dare say, I think I love you. Thanks for posting this. I was just having a conversation with my (non-mom) friend yesterday about my quest to inventory the parenting thoughts in my head and sort them into either a) commercially seeded hyper-parentingisms or b) good maternal common sense. And a good portion of category "a" has to do with breastfeeding. Even though it has been SO easy for me (and I don't intend to stop breastfeeding anytime soon simply because I hate doing dishes), I have recognized how much pressure there is out there. And it seems if there's that much commercial pressure, that it's got to be somewhat of a fad. I loved hearing the medically founded "other side" of the story. I wish this article was handed out with every hospital's take-home packet; I will certainly be sharing it with friends. Thanks again!!!

  5. From her article: In my playground set, the urban moms in their tight jeans and oversize sunglasses size each other up using a whole range of signifiers: organic content of snacks, sleekness of stroller, ratio of tasteful wooden toys to plastic.

    Based on that description it is a wonder that there were men hard up enough to want to impregnate these women. Sleekness of strollers? Good lord what status obsessed brain dead women.

    My wife breast fed all of our children, being that the first two were born and nursed in China (and due to the recent horrors of the melanine poisoning thank God she did). And our third breast feeds as well. All of them prefer to be nursed and none of them have taken to the bottle well.

    I certainly would not hold it against any women if due to considerations such as work she didn't breast feed. Anyone who presumes to know anything about such an intimate matter is an idiot. My sister in law could not breast feed due to a medical condition. In the end it is a personal decision, which is none of my business. However, our society is right to encourage breast feeding. One can encourage without condemnation.

    This is a weak article, and pretty vapid. Formula is expensive and in too large parts of the third world it literally kills. Like it or not much of America's cultural expressions gain life overseas. Breast is best has probably saved the lives of untold children. But I suppose such a thought would never cross the mind of a pampered upper class woman who chooses to write about the importance of her every little feeling.


  6. While I appreciate your point about women needing to know that, if they are unable or unwilling to breastfeed, their children will do fine; and the disgust at the idea that there is only one right way to do things and any variance is utter failure, we also need to talk about a culture that proclaims breast is best and then does nothing to educate and support women who choose to do what is, unequivocally best for baby's immune system. (I agree that the IQ data is flimsy and rather unscientific in that it's correlational and could be argued as socioeconomic IQ difference, not breastfeeding difference; and that the bonding argument is tenuous at best).

    Why do women still have to fight employers just to get time to pump in a dirty bathroom stall? Why don't pediatricians and OBs know more about lactation problems and where to send patients who are struggling? Why do new moms, nursing or not, not have better work leave available, often scurrying back to the income they need only weeks after giving birth, knowing that baby and mom are much healthier if given six months to breastfeed? Why *do* hospitals give formula and formula-sponsored gifts as part of the pre-delivery tour as though the expectation is that we should all use formula and the hospital promotes formula over breastfeeding? Why are lactation support groups generally pay-for-service meetings instead of hospital-sponsored public health service? Why do we allow a culture to persist that has strangers yelling insults at mothers nursing discreetly? Why don't more people know a woman can successfully nurse an adopted child? Why does all of society feel it can judge parents' every decision but not support them with child care and parental education? Why are we more outraged as a nation at seeing Janet Jackson's nipple than at the fact that a shocking number of mothers try breastfeeding but give up quickly because they don't have the resources and information to fix inevitable problems? Why don't we *tell* women that breastfeeding can be difficult for both mom and baby to learn, that it will hurt, that pumping, even when done correctly, does not drain the breast like a baby can and will slowly diminish supply if not undertaken more often than baby feeds?

    I believe that a lot (but not all) of lactation issues can be solved with easy and free access to a good lactation consultant. That learning a skill that previous generations learned by watching other mothers breastfeed is really tough and demands education and support before during and after birth. That other mammals do not have the rate of inability to breastfeed that American women do.

    AND I feel that demonizing parents who feed with formula misses the much bigger picture about how far this country has to go in promoting loving families who feed their children well their whole lives and raise them to be responsible, caring citizens. Formula is not child abuse. Not even close. Fostering eating disorders and childhood obesity are. Emotional abuse, physical abuse, sexual abuse are WAY bigger problems than deciding not to breastfeed.

    I like that the article opens a dialogue and reveals a belief-and-judgment chasm that need not exist. I like that it's honest about one woman's ambivalence about breastfeeding after years of doing it. I don't like that this article minimizes the efforts of women to overcome the sociopolitical efforts that still keep us from breastfeeding if we choose to.

    And I agree with blackton that pushing the pendulum back toward the 1950s formula-only culture can really do longterm damage around the world.