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.