IN DEFENSE OF FORMULA
The ‘Breast Is Best’ Breastfeeding Campaign Is Misguided
Formula in an infant’s diet has been looked down upon in recent years, but the truth is that breastfeeding isn’t necessarily the best choice for all mothers and infants.
The New York Times published a piece earlier this month suggesting that the Trump administration has “[embraced] the interests of infant formula manufacturers” above the well-being of mothers and babies worldwide. That piece came less than two months after stunning opposition to a proposed breastfeeding resolution at the United Nations World Health Assembly in Geneva this spring.
That U.S. delegates’ opposition to the resolution—which called on governments to “protect, promote, and support breastfeeding” and on policymakers to restrict predatory promotion of infant formula—aligns with formula industry interests is undeniable, even though there are no reports that industry lobbyists had a direct hand in the U.S. stance. In theory, any time an infant doesn’t get breastmilk means money in the formula industry’s pocket.
Calling the opposition to the resolution an assault on babies and mothers is a far more loaded assertion, however, one that requires unpacking the “breast is best” adage. A growing number of researchers and medical professionals argue that “breast is best” and its accompanying prescription for nearly all mothers to breastfeed exclusively for at least six months is flawed, and that current worldwide infant feeding goals omit crucial considerations. At the top of that list is sanitation and safe water, both of which are glaringly absent from the resolution that ultimately passed on May 26.
Also absent in this resolution and in broader infant feeding policy is mention of mothers’ right to informed choice and bodily autonomy, the right of infants to be fed irrespective of a mother’s ability or choice to breastfeed, and geographical and political differences around the globe.
In short: “Breast is best” is leaving out many women and children for reasons that are being ignored in this debate.
The breastfeeding resolution specifically affirmed commitment to the WHO-UNICEF Baby Friendly Hospital Initiative (BFHI) launched in 1991 based on the prevailing and seemingly iron-clad “breast is best” mantra. Framed around the internationally accepted code Ten Steps to Successful Breastfeeding, which is designed to “increase breastfeeding initiation and duration,” the initiative urges caregivers to give infants “no food or drink other than breast-milk, unless medically indicated” until introduction of supplementary food at six months of age. Even as controversy brews over whether BFHI is actually helpful and may even cause unintended harm, more than 15,000 facilities in 152 countries and growing have earned the “baby friendly” accreditation.
Despite BFHI’s growth, the data run counter to the prevailing “breast is best” doctrine, which overstates the benefits of breastfeeding and ignores the real world harm of promoting exclusive breastfeeding, and ignores that, in the real world, milk is being withheld from babies who need it in the interest of avoiding formula.
That’s not to say breastfed infants don’t have better lifetime outcomes overall—according to the Centers for Disease Control and Prevention, they have lower rates of asthma, certain types of cancers, diabetes, and obesity.
But when accounting for real world confounding factors, breastfeeding itself isn’t the mechanism by which these improved outcomes are achieved.
So if breast milk isn’t as magical as it’s purported to be, why do breastfed babies fare better? In the developed world, women who breastfeed tend to be more educated, have higher incomes and better access to health care, and are less likely to smoke, among other characteristics that distinguish them from formula-feeding counterparts. Moms who end up using formula are more likely to have had concerns about their infant’s weight gain in the early days of life compared to women who never supplement with breast-milk substitutes.
In other words, by the time these moms realize their babies are being underfed and decide to supplement with or switch to formula, permanent harm may have already occurred.
In the developing world, many caregivers who use breast milk substitutes are forced to prepare them without sanitation and safe water, which together constitute a public health crisis affecting billions of people worldwide. Research on early childhood development and other health outcomes suggests that breast milk doesn’t quite live up to its popular “liquid gold” moniker when accounting for these confounding factors.
In other words, yes, formula-fed babies around the world fare poorly compared to their counterparts, but that’s not because breast milk itself is inherently and significantly superior to responsibly manufactured and safely prepared infant formula. It isn’t easy for researchers to control for these confounders, largely because there are clear ethical barriers to performing randomized controlled infant feeding trials.
This isn’t to say that breastfeeding isn’t beneficial to many mothers and babies—it is. Providing moms who want to breastfeed with adequate resources and support and dismantling barriers to breastfeeding in public spaces and workplaces are noble endeavors. The reality is that billions of people today don’t have access to clean water, and that means breastfeeding can be a matter of life or death for babies where sanitation is a problem.
But data also show that in the real world, the pressure to breastfeed exclusively and offer no other food or drink in the first few months of life, and especially in the first few days of life, can cause real harm that’s “happening before our eyes,” Christie del Castillo-Hegyi said. Del Castillo-Hegyi is an emergency physician who researches newborn brain injury and breastfeeding, and is the co-founder of the Fed is Best Foundation (FIBF), a nonprofit organization of health professionals and moms who educate on the safest methods for breastfeeding, mixed feeding, and formula feeding.
“Doctors are reporting it, and it’s showing up in medical literature, and the WHO is literally choosing to ignore it,” she added.
Del Castillo-Hegyi isn’t alone in raising the alarm—she pointed to a Change.org petition with more than 6,000 signatures (hundreds of them from health professionals) calling for U.S. officials to protect newborns from the risks of insufficient milk intake.
Consider that sudden unexpected postnatal collapse (SUPC) and sudden unexpected infant death (SUID) among otherwise healthy newborns, while rare overall, are strongly associated with rooming-in and skin-to-skin care. BFHI promotes both practices in the interest of helping mothers initiate breastfeeding within the first hours of birth and establish exclusive breastfeeding.
Or consider complications of insufficient breastmilk supply, especially in the days immediately following birth, before milk “comes in” (which is more common in first-time mothers). Leading breastfeeding advocacy organizations and BFHI tell new mothers that newborns who nurse frequently will get enough milk, and that a newborn doesn’t need much milk in the first few days of life.
But an estimated 15 percent of moms don’t produce enough milk, which can lead to dehydration, low blood pressure, hypoglycemia (low blood sugar), and hypernatremia (too much sodium in the blood), which can result in brain injury and, in rare cases, death.
It’s also important to note that the pressure to breastfeed exclusively can take a toll on some mothers’ mental and physical health. Women worldwide (including me) have objected to the WHO/BFHI expectation to care for and exclusively feed their newborns around the clock immediately following childbirth, which is the most grueling physical and medical ordeal many new mothers have experienced. It’s also a full-time job—in the first few weeks of life, an exclusively breastfed infant can nurse eight to 12 times a day or more in long stretches.
Breastfeeding exclusively from birth isn’t natural either, contrary to the WHO’s spurious assertion that exclusive breastfeeding is “normal” and “optimal” for “virtually all mothers,” which was established in large part after studies of milk volumes of 13 women in the 1980s— studies that are hardly generalizable. Throughout history and around the world, babies have been fed milk from wet nurses, animals, and other substitutes to their own mothers’ milk for myriad reasons, including insufficient milk in the days following birth. Exclusive breastfeeding “is being promoted in a way that is supplanting what was previously done” to prevent the harm of insufficient breast milk, said del Castillo-Hegyi. “We have no history of letting babies cry and starve.”
Providing mothers with an accurate picture of the unique pros and cons of her infant feeding options and ensuring she has a safe means to feed her infant by whichever method makes the most sense for her should be part of any responsible infant feeding resolution.
“Mothers ought to be given the opportunity to decide what kind of feeding is suitable to them, definitely pointing out the disadvantages and advantages of each feeding decision they take,” said Hannah Awadzi, executive director of the Special Mothers Project, which advocates for children with cerebral palsy in Ghana, and whose first-born daughter suffered from severe starvation-related jaundice and hypoglycemia while exclusively breastfeeding with insufficient milk. Her daughter subsequently developed cerebral palsy, known to be caused by bilirubin toxicity and hypoglycemia.
All of this doesn’t negate that formula industry oversight is vital. So far, there are no reports that formula industry lobbyists had a direct hand in the U.S. opposing parts of the resolution as written, but the history of formula manufacturers’ predatory marketing practices is known. Lucy M. Sullivan, executive director of 1,000 Days, an organization that works in the U.S. and globally to improve nutrition for women and children, detailed in a Twitter thread that the resolution that finally passed removed mention of the WHO Guidance on Ending the Inappropriate Promotion of Foods for Infants and Young Children, which she says the formula industry “despises.”
Given how infant feeding plays out in the real world, it’s clear that there are public health reasons to oppose the WHO’s aggressive promotion of exclusive breastfeeding aside from formula industry influence. To truly provide infants “the best start to life” requires facing the complexity of achieving that goal. The resolution that passed, and its blatant exclusion of safe water and sanitation measures that are surely crucial to infant and child well-being, exposes the WHO’s commitment to exclusive breastfeeding ideology at the expense of real world outcomes for mothers and children all over the world.