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Exclusive

Breastfeeding

Bad Science,

Risky Practice, &

Failed Policy

Photo: Pixabay

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Goodhart’s Law

"When a measure becomes a target, it ceases to be a good measure." - British economist Charles Goodhart

Overall need to (re)focus (policy/medical worlds) on health, not bf metrics, to promote health.

This misplaced focus fits into larger bureaucratization/professionalization patterns whereby reformers have often harmed quality of care/service by trying to standardize and advance it, and these efforts have often been more about power and money than science and ethics.

***

[from book proposal ch 2] -

Goodhart’s law states that, once a measure becomes a policy target, it loses its measurement validity because people respond to incentives to maximize their score. Thus top-down policies often unintentionally create perverse incentives with unintended consequences. That seems to be what happened with exclusive breastfeeding, which is now widely understood to mean withholding formula or even water from most newborns. Baby Friendly explicitly forbids formula-feeding except in cases of medical necessity, for which there is no consensus definition, resulting in documented preventable harm. Yet, widespread prelacteal feeding is practiced in many low- and middle-income countries today. Sugar water or another sweet liquid, animal milk, and formula are all common — and all denounced by medical experts.

***

Also: Erin’s brilliant insight that high initiation rates followed by swift EBF drop-off may reflect social desirability and other response biases, and not actual EBF rates.

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[drawing from https://wildetruth.substack.com/p/old-friends-and-causal-inferences and https://wildetruth.substack.com/p/rabbit-duck-or-moonwalking-bear]

[give people a little time to read it]

There is the same sort of basic interpretive problem in infant feeding research. Not to dichotomize the whole conversation, which has a lot more nuance and diversity of perspectives than that, but purely in terms of interpreting the evidence from peer-reviewed scientific studies.

So [pulling from 2nd SubStack] one way to view PROBIT’s findings is as showing the “rabbit” of newborn starvation periods, a big picture in which

the EBF paradigm probably decreased average starvation period (time after birth until first feeding) as compared to the prior era’s factory-feeding hospital nursery model — but simultaneously worsened three other forms of newborn starvation:
(a) starvation in the two full days before most mothers’ mature milk comes in,
(b) continuing starvation when that milk supply is still not enough, and
(c) starvation when that supply cuts out later or becomes insufficient.

Alternately, another way to interpret PROBIT’s findings is as showing the “duck” of the EBF paradigm, a big picture in which its proponents often claim benefits from a bunch of associated new norms including denying newborns supplementary milk or water, keeping mothers and infants together instead of separating them after birth, and encouraging immediate skin-to-skin contact and breastfeeding initiation. .

Does the evidence from oft-cited breastfeeding studies including PROBIT, and more recently the Scottish study that made the rounds on Twitter – https://twitter.com/vk_wilde/status/1645727411252674562 Adams et al 2023, PLOS MEDICINE, “Infant feeding method and special educational need in 191,745 Scottish schoolchildren: A national, population cohort study”

Do they show the rabbit or the duck? Neither. We have to interpret the evidence. Or — and this is better scientific practice — diagram out the causality in play here, and say what we don’t know from available evidence given the relevant causal logic.

Transition: How do we do this better science?

***

What researchers often interpret as evidence of breastfeeding benefits, may actually instead reflect harm from accidental starvation under the exclusive breastfeeding paradigm. A paramount example because it’s often touted as being a gold-standard study is PROBIT – Promotion of Breastfeeding Intervention Trial (PROBIT) [ “31 Belarussian maternity hospitals and affiliated polyclinics… 13,889 (81.5%) … followed up at 6.5 years.” https://pubmed.ncbi.nlm.nih.gov/17878730/] – [Cureus 1:] a cluster randomized experiment assigning freshly post-Soviet Belarusian hospitals to Baby Friendly-style treatment or control groups - neglected to collect data on relevant post-randomisation events. This is a problem because women who supplemented their infants with formula sooner rather than later may have done so for clinically relevant reasons including delayed and/or insufficient milk. Delayed onset of lactogenesis II predicts excessive neonatal weight loss, formula supplementation, and earlier breastfeeding cessation [36,40], while insufficient milk has long been among the most commonly cited reasons for early weaning worldwide [131-135]. Thus breastfeeding problems likely systematically biased the formula-fed group in this and other studies to contain more babies who had endured longer starvation or deprivation periods, which may have influenced all later outcomes of interest. Subgroup variation in inadequate nutrition/hydration might explain apparent differences between exclusively breastfed and mixed- or formula-fed infants, including reported differences in growth, infections, allergic diseases, and IQ.

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VERY BRIEFLY:

Causal inferences revolution

Science is interpretive

Attn to uncertainty, interests

***

Causal inferences revolution:

The relatively recent revolution in causal inferences was spearheaded by Yuda Pearl, UCLA emeritus professor and Cognitive Systems Laboratory director, and colleagues, and it lets you draw causal logics in a way that makes for better science and statistics, including by being able to see colliders (variables that are influenced by both an intervention and outcome) — something that we’re otherwise not able to do cognitively and that really matters for doing analyses right.

Why bothering modeling causality before running analyses? Why put “science before statistics,” in the words of Richard McElreath, director of the Max Planck Institute for Evolutionary Anthropology in Leipzig and leading science reformer?

Intro stats - correlation alone doesn’t imply causation.

Science is interpretive, and we need a causal model to interpret.

But isn’t that subjective, while science is all about being objective?

No: from research design to statistics, the scientific method in practice is all about making choices that influence your results. About what to analyze, how, and what it means.

Sander Greenland, UCLA professor emeritus in the departments of epidemiology and statistics at UCLA, and a leading statistics reform voice, argues that these choices often privilege the preferred narrative of powerful social networks, and that we should be on the lookout for ways to better recognize and articulate uncertainties and interests in science.

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Infant Feeding Science

Idealized view of experiment:

[assign to EBF] --> [EBF] --> [health outcomes]

What selects for EBF “treatment”?

When does EBF fail?

The main methodological problem in current infant feeding science is that is has an idealized view of the experiment in PROBIT or the quasi-experiment (that’s not really a quasi-experiment) in observational studies.

This is the view in which women get effectively randomly assigned to EBF or not, and health outcomes follow.

But there are many possible contributing factors leading women to try EBF or not, and then EBF itself isn’t one treatment because it can go differently for different mothers and babies, even sibling pairs from subsequent pregnancies. [It was Der et al’s 2006 BMJ sibling comparison analysis of breastfeeding’s effects on IQ: https://www.bmj.com/content/333/7575/945.]

So what leads women to try EBF, and when does it fail?

***

Was previous slide text for 2nd Q:

Lactation failure and breastfeeding insufficiencies from common maternal health problems cause preventable harm to neonates.

When it harms maternal mental health.

***

Was previous presenter nts to go with that (editing 05-19-23):

EBF arguably fails near-universally in the first days of life, but bracketing pre-lacteal feeding…

EBF fails biologically, harming newborns.

Maternal health problems: disordered glucose metabolism, endocrine disorder, exhaustion…

To say nothing of non-biological failures like contributing to postpartum mental health problems, e.g., by increasing pain and decreasing sleep – known contributors to depression.

Maternal mental health: pain, sleep deprivation, excessive infant crying.

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Health Selection Effects

Positive:

better maternal health → better lactation; more attempted and successful breastfeeding

Negative:

worse maternal health → worse lactation; less attempted and successful breastfeeding
worse neonatal health → more breastfeeding problems

Positive selection effects of maternal health as an unmeasured confound in infant feeding science:

healthier moms have an easier time breastfeeding, may have healthier babies anyway for a range of reasons (genetic, epigenetic, environmental) and then it looks like breastfeeding correlates with better child outcomes — but that’s just because we’ve selected on health. No causal effect of infant feeding needed to explain differences in health outcomes between bf and ff children here.

Negative selection effects:

Maternal level: a number of physical abnormalities correlate with breastfeeding problems. Women know if they have these abnormalities and might logically worry about affecting breastfeeding. They’re things like asymmetrical boobs, boobs not changing normally during puberty or pregnancy, and previous breast surgery. They predict breastfeeding problems because they’re caused by things like endocrine disorder interfering with normal breast tissue formation, or tissue injury interfering with normal lactation duct connection.
Neonatal level: health problems including weakness from accidental starvation from bf can cause bf problems, so exclusivity emphasis may undermine the very goal (bf) it’s intended to promote.

***

Later –

Transition: Why is that? What harms are we really talking about here?

***

Cut –

Research level: moms with breastfeeding problems first accidentally starve their babies trying to exclusively breastfeed them because medical professionals tell them it’s important, and then switch to formula because it doesn’t work. This spikes the “formula-fed” group with (a) infants of less healthy moms who had more breastfeeding problems, and (b) infants who got accidentally starved. Again, not starving babies is a Very Good Idea (TM).

***

[condensed from https://wildetruth.substack.com/p/old-friends-and-causal-inferences]

Selection effects: Health predicts health, and vice-versa

This is another problem. PROBIT didn’t randomize mothers to breastfeed or not, since this was considered unethical. Today it’s increasingly recognized that breastfeeding problems are common. This means that you couldn’t physically randomize women to breastfeed anyway, at least not in the same way that you can randomize patients to take pills or not (terms and restrictions may apply). There is just too much selection on maternal health, and sometimes infant health (related), for this to work; women with all sorts of health problems tend to have more breastfeeding problems — no surprise there, because breastfeeding is really metabolically intensive. But when PROBIT was conducted, no one asked the women how it was going or why they stopped. Women often stop breastfeeding because it doesn’t work. But you have to think that mothers’ experiences matter to bother getting enough anecdata to think about how this might shake out.

In PROBIT, the researchers used a cluster randomized design slating some hospitals to come into the treatment group before others, since supposedly they were all raring to join the American/Western way in the wake of the collapse of the Soviet Union in 1990s Belarus (where the trial took place), and with it the top-down Soviet medical system. Take it from the Westerners heading up the study who didn’t speak their collaborators’ or subjects’ language, because it seems impossible to get a hold of any of the Belarussian collaborators themselves. A top-down medical culture in an authoritarian society transitioning to a global hegemonic paradigm with a language barrier. What could possibly go wrong?

This design likely embedded two main types of selection effects that would tend to bias results in favor of appearing to show benefits from breastfeeding, when one type of them may really show that health predicts health and the other type may really show harms from unsafe breastfeeding practices the trial unwittingly promoted. In the positive universe of the “health predicts health” selection effect, healthier moms have an easier time breastfeeding, may have healthier babies anyway for a range of reasons (genetic, epigenetic, environmental) and then it looks like breastfeeding correlates with better child outcomes — but that’s just because we’ve selected on health. No causal effect of infant feeding here.

It could also be the case, in this positive selection effect universe, that healthier moms tend to be more confident that they’ll be able to breastfeed, and try it at higher rates. After all, a number of physical abnormalities correlate with breastfeeding problems. Women know if they have these abnormalities and might logically worry about affecting breastfeeding. They’re things like asymmetrical boobs, boobs not changing normally during puberty or pregnancy, and previous breast surgery. They predict breastfeeding problems because they’re caused by things like endocrine disorder interfering with normal breast tissue formation, or tissue injury interfering with normal lactation duct connection.

In the negative universe of the “oops, I did it again (I starved the baby)” selection effect, moms with breastfeeding problems first accidentally starve their babies trying to exclusively breastfeed them because medical professionals tell them it’s important, and then switch to formula because it doesn’t work. This spikes the “formula-fed” group with (a) infants of less healthy moms who had more breastfeeding problems, and (b) infants who got accidentally starved. Again, not starving babies is a Very Good Idea (TM).

These two types of selection effects are not mutually exclusive. This means that we could have at least three things going on that explain PROBIT’s results, that are not breastfeeding benefits. In fact, two out of three of these phenomena fit the story of common and preventable harm from exclusive breastfeeding that I’ve argued other evidence may support. And the other is just health predicting health, which we can’t change.

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Better Science: “Science Before Statistics”

Explain causal diagram w disclaimer (below).

Signposting: This kind of confounding is called conditioning on post-treatment variables, post-treatment bias. This critique is an example of something that’s a big problem in epidemiology. Stratifying on post-treatment variables can mess up a lot of designs.

Takeaway: Difficulty in sorting out causality means we should think about infant feeding on a harm prevention model instead of a policy paternalism one.

***

[Pulling from https://wildetruth.substack.com/p/of-milk-and-misery]

Like all my DAGs, possibly like all DAGs? like all research? —this DAG “is of course incomplete and possibly wrong… But an incomplete model is still an improvement over no model at all” (Deffner et al). It’s just a step forward in thinking structurally about causality.

***

[Pulling from https://wildetruth.substack.com/p/rabbit-duck-or-moonwalking-bear]

X - Exclusive Breastfeeding Choice

NS - Neonatal Starvation

EBF - Exclusive Breastfeeding

MH - Maternal Health

CH - Child Health

This DAG expresses the idea that EBF interacts with maternal health (MH) in powerful ways, and then indirect effects of neonatal starvation can be activated by early withholding of formula and/or difficult EBF. Effusive thanks cannot repay Richard McElreath for his kindness and generosity in helping me redraw the DAG, restate the argument, and think more about all this. And for pointing out that it’s a problem that DAGs don’t show moderating effects, but powerful moderating effects are part of the argument.

The DAG shows complex relationships between most of these variables. EBF can affect neonatal starvation (NS), as when colostrum is insufficient and newborns starve. NS can affect EBF, as when newborns are too weakened by days of starvation to successfully breastfeed when mothers’ mature milk comes in. MH can affect EBF, as when exhaustion, disordered glucose metabolism, and/or endocrine disorder contribute to breastfeeding problems. EBF can affect MH, as when it contributes to inflammation and exhaustion directly from the metabolically intensive biological labor of lactation, and/or indirectly from sleep deprivation. NS can affect child health (CH), as when it contributes to jaundice and its progression with possible substantial downstream consequences including permanent neurodevelopmental disorder risk. CH can affect NS, as when poor newborn health impairs feeding. MH can affect can affect CH, as when healthier women produce healthier children. CH can also affect MH, as having a sick child may impact a mother’s physical and mental health. The question in most breastfeeding literature is what the arrow means between EBF and CH. (It just happens to be widely misrepresented as an answer, when we don’t really know.) And it’s well-recognized that CH can also impact EBF, as when newborns are too sick for traditional breastfeeding, and sometimes cup-feeding is considered an alternative (see, e.g., Lang et al 1994, McKinney et al 2016).

This is my favorite part, because I got it wrong at first: The DAG also shows X, exclusive breastfeeding choice. In the PROBIT dataverse, this would include randomized treatment assignment to a hospital promoting EBF. In another dataverse, it would still include whether the hospital/healthcare practitioners promote EBF. It may be influenced by whether a woman’s mother or other female kin or intimates breastfed, or what social networks told her about it otherwise. It may be influenced by other unmeasured aspects of the healthcare setting (usually a hospital) or the woman. For example, multiple researchers and clinicians have noted that it tends to be first children of upper/middle class parents who really want to do things right, whose “exclusively breastfed” newborns wind up rehospitalized with horrific complications of starvation. It’s also widely noted that African-American women tend to formula-feed instead at much higher rates than other racial groups. So there’s a broad range of factors, many unmeasured, that may influence whether a mother chooses to try EBF in the first place.

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Infant Feeding Choice

	Risks	Benefits
Infant feeding method…
Exclusive breastfeeding		X
Other	X

[transition]: The reason we need to focus away from measures and targets, and on promoting health and well-being by caring about and listening to individual mothers and babies instead, is that the current choice structure is a fiction that causes common and preventable harm.

***

[benefits from book proposal]:

The way we do infant feeding today is a very recent invention. Counterculture era reformers misinterpreted a rich tapestry of diverse safety infrastructures in previous infant feeding practices as a Garden of Eden where every woman could safely feed her baby nothing but breastmilk before formula came along, and any other method risked harm. That origin myth accorded with confirmation bias in favor of the supposedly magical powers of “exclusive breastfeeding” — giving babies only the breast for food and water. The breastfeeding myth in that sense is the story that exclusive breastfeeding saves the most vulnerable newborns from malnutrition and fatal infections; makes smarter kids and higher-earning adults; prevents autism, obesity, cancer, MS, and allergic diseases; and protects against HIV transmission — but only in poor countries. All while lowering mothers’ risks of postpartum depression and breast cancer, reducing environmentally wasteful dairy production, and sticking it to the big corporations prioritizing profit over public health. Experts frame all these benefits as coming with no risks, because breastfeeding is “natural.” This myth is comforting and wrong.

***

[Ellie’s text]

Current policy thinking about early infant feeding assumes exclusive breastfeeding benefits infant health without incurring meaningful risks….

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Informed Consent

	Possible risks	Possible benefits
Infant feeding method…
Prelacteal feeding	X	X
Exclusive breastfeeding - no delay, sufficient	X	X
EBF – delay, insufficiency	X	X
Mixed – limited or not…	X	X

But that thinking packs a number of assumptions.

Among them: It sets up a false opposition between EBF and mixed and FF that ignores other possibilities: prelacteal feeding, EBF with and without delay and insufficiency, and mixed feeding with and without strict limits.

Serious ethical problems in current choice structure: Flaherman et al’s ELF-TELC trials – The Effect of Early Limited Formula on Breastfeeding, Readmission, and Intestinal Microbiota: A Randomized Clinical Trial – used 10 mL of formula per bf session, resulted in preventable hospitalizations among neonates who had already lost excessive weight but below a threshold that excluded them from the trial.

FOIA results - investigators didn’t inform their IRB of associated risks, or their funder, probably parents either but wasn’t able to get the full IRB protocol to see what they did tell parents exactly – still appealing with HHS.

[Flaherman 2018: https://pubmed.ncbi.nlm.nih.gov/29550235/; 2019: https://pubmed.ncbi.nlm.nih.gov/31157878/]

All cells, no safety: In addition to framing feeding mode in binary terms of breast v formula, the normal infant feeding choice conversation also privileges the binary frame of risks of formula v benefits of breastfeeding, when all options have possible risks and benefits. There is no world with complete safety no matter what you do, we are all balancing different risks and benefits using different values and goals as well as often different facts, all the time.

Informed consent, not paternalism: One of the central contributions of Ellie and her colleagues here at the the Centre for Parenting Studies to discourses like this one is the emphasis on meaningfully informed consent as opposed to policy paternalism, which fits nicely with Lina and her co-authors’ emphasis on autonomy and equitable distribution of burdens, and is also consistent with my message here.

My main point of emphasis in this talk is that the categories in the usual early infant feeding conversation are empirically wrong in ways that needlessly and sometimes quite seriously endanger neonates and their mothers. When I talk about this conversation, I don’t just mean the way the broader culture talks about infant feeding, and the way parents and their healthcare practitioners talk about it, although that’s part of it. But also at the highest levels of public health and medical authority, [Ellie’s text:] Current protocols and their implementation, such as the WHO/UNICEF Ten Steps to Successful Breastfeeding codified by the Baby-Friendly Hospital Initiative, emphasize exclusivity in breastfeeding, [when] that paradigm is based on flawed [logic and] science. Widely recognized potential confounds for exclusive breastfeeding’s purported infant health benefits include breastfeeding insufficiencies as well as maternal health and socio-economic status. So this contribution considers the problems of the rise of the focus on exclusivity, and what the alternative should be.]

In addition to the fact that the usual framings are partial and the categories are wrong, because the magic of exclusivity is a modern myth, a key criticism from research methodology is that these cells contain myriad uncertainties. There often seems to be a conflation of expertise with certainty and even sometimes dominance, and this is a cultural pathology that scientific methods not only don’t require but actively conflict with. Part of doing better science is saying what we don’t know.

But falsely opposing “EBF” (which typically starves neonates for the first days of life at least) with not doing what’s “best” sets mothers up to fail no matter what they choose.

So we want to replace this choice structure.

In order to replace it with something better, what do we know about infant feeding?

***

[Marc’s book proposal comments, maybe hit as three main points I’m making here up-front before clicking on?]

Intro paragraph should summarize argument. Is it that you’re arguing for mixed feeding? Then say that.

Is it normal to starve babies for 48 hours under EBF? Then say that.

Didn’t used to be/myth of universality of exclusivity? Maybe that up. (Maybe, I”m not even surewhat he’s suggesting and thait is fresh.)

***

We need to set the terms of the infant feeding discourse so that women have more meaningful choices, and a big part of that is saying how modern infant feeding science tends to get it wrong because EBF is not a treatment, but a post-treatment variable that gets confounded by health.

***

Feeding methods - EBF with NO delay and sufficient milk vs delay/insufficient milk, with and without prelacteal feeding. Mixed feeding with limited formula versus to satiety. Formula feeding with different types. So much more heterogeneity than binary variables capture.

Mixed/to satiety

Formula feeding - different methods (cup v bottle, scheduled v on demand, measured v to satiety, different formulations of formula, probiotics)...

Deaths, disabilities.

Risks/benefits: NN starvation complications, pediatric infections, ND disorders, IQ

Imagining this is in the West, in poorer settings FF also assoc w possible NN starvation risk, due to diarrheal disease from dirty water, dilution from poverty/corruption/insecure formula access. Then you really need some empirics to compare related deaths and hospitalizations between feeding methods. EBF proponents assume EBF’s cell is way smaller than FF’s, but this is unestablished empirically.

Uncertainty.

Precautionary principle invocation (preventing starvation harm paramount).

Listening to ordinary people’s experiences.

Risk literacy and informed consent.

Photo: Leelo the First.

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Safety Infrastructure

What is it?

Not just physical, but also social structures and practices.

For whom?

Everyone, but disproportionately benefits the most vulnerable.

When, why, and how did modern Western societies accidentally destroy infant feeding safety infrastructure?

[Cureus 1 abstract topic sentences]

Previous advanced civilizations recognized this problem of breastfeeding insufficiencies and had an infrastructure to solve it: Wetnursing, shared nursing, and prelacteal feeding traditions used to be well-organized and widespread.

Modern societies accidentally destroyed that infrastructure. Then, modern reformers missing a few generations of direct knowledge transmission about safe breastfeeding invented a new, historically anomalous conception of breastfeeding defined in terms of exclusivity

***

This happened through a unique confluence of historical forces having to do with modern social shifts, and reimaginings on the part of modern reformers bringing bf back in the late 20th c that were unintentionally imbued with cognitive bias and a lack of thinking structurally about causality.

Chief among the crucial social shifts were the accidental destruction of wetnursing as a well-organized profession – which was unprecedented among advanced civilizations – and the demographic shift to childbearing later and less that meant new mothers no longer typically had built-in social support network of lactating kin.

And chief among the reimagining mistakes was the idea that breastfeeding meant this particular idea of EBF that was also historically unprecedented in the context of the collapse of safety infrastructure protecting infants from starvation.

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Exclusivity Myth: The Fall

Mythological origin story.

Surprisingly recent change.

False oppositions.
Without evidentiary basis.
May undermine breastfeeding.

Photo: Cottonbro Studio.

This particular conception of bf is centered on a myth of the magic of exclusivity.

In this story, before the advent of formula, there was an infant feeding garden of Eden where exclusivity was universal.

But in reality, there was never one way of feeding babies, certainly never a failsafe one. Yale’s Human Relations Area Files (HRAF) World Cultures database shows a rich tapestry of worldwide traditions that challenge modern assumptions about exactly what traditional wisdom was lost before modern reformers lacking intergenerational knowledge about breastfeeding brought it back. Many dairy herding cultures have long fed their babies other animal milks early and often. Some hunter-gatherer tribes (Efe and Aka per SH/from HRAF) get another lactating woman to feed a newborn before its own mother’s milk comes in. Many practice other kinds of prelacteal feeding during that period.

Bf vs formula isn’t the only false opposition (exclusivity of the milk itself); prelacteal feeding vs bf (vs beginning delineation cos insuff universal); the idea that supplementing necessarily undermines instead of supporting bf is another. Another exclusivity myth component: exclusivity of the mom doing the bf (universalizing)...

Recency/Swedish case [Cureus 1]: This change was very recent. Baby Friendly recommends breastfeeding initiation as soon as possible after birth, which is compatible with nursing followed by formula supplementation until breastfeeding is established. Hofvander [104] found that among Swedish Baby Friendly hospitals, some routinely supplemented less than 10% of healthy neonates until breastmilk came in, while in others up to 90% were supplemented. There seems to be little available evidence on such hospital-level variation in interpreting and applying Baby Friendly-style exclusive breastfeeding promotion. It appears the change was top-down, without safety consideration, and part of the modern bureaucratic focus on metrics. But existing evidence is insufficient to support the idea of a forced choice between supporting breastfeeding and formula. To the contrary, starvation weakens muscle strength neonates need to nurse.

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Exclusivity Reality

Particularly dangerous in the first days.

Near-universal insufficiency.
Worse in first-time mothers.
Colostrum taboo as a “Chesterton’s fence.”
Fit into waiting to initiate, another denounced traditional practice.

1st days/universality: The breastfeeding myth normalizes newborns’ plaintive hunger cries when mothers’ breasts are mostly empty in the full 48 hours before milk typically comes in. Never before in the history of human society did experts teach women to starve newborns during this time regardless of hunger cues, without recourse to supplementary feeding of any kind. By contrast, previous advanced civilizations recognized this near-universal problem of breastfeeding insufficiencies, and had an infrastructure to solve it: Wetnursing, shared nursing, and prelacteal feeding traditions used to be well-organized and widespread. Modern societies accidentally destroyed that infrastructure. Then, modern reformers missing a few generations of direct knowledge transmission about safe breastfeeding invented a new, historically anomalous conception of breastfeeding defined in terms of exclusivity.

Primaparas: [from Cureus 1] A sizeable minority of breastfed neonates receives inadequate nutrition/hydration [36-39], risking serious injury or death, because breastfeeding insufficiencies including delayed and insufficient milk affect double-digit percentages of mothers. According to some estimates, delayed onset of full milk production (lactogenesis II), defined as mothers perceiving milk coming in beyond 72 hours postpartum, occurs in 33-44% of first-time mothers [39, 40]. In one study of “unusually compliant and well educated” first-time mother volunteers, 15% had persistent insufficient milk after three weeks despite intensive professional lactation support [36]. In that study, minimal prenatal breast enlargement and minimal postpartum breast engorgement as well as prior breast surgery significantly predicted insufficient lactation - suggesting biological root causes. Such insufficiencies put a substantial minority of breastfed babies at risk of suffering insufficient nutrition/hydration for days, weeks, or longer. Such a lengthy deprivation or frank starvation period would normally be considered medically dangerous and legally as well as ethically unacceptable to impose on any human. It overlaps with the riskiest period for neonates, who are most likely to die within their first week of life [41,42].

Colostrum [ch 2 book proposal]:

In addition, many cultures consider colostrum (the thin first milk) to be taboo. Anthropologists used to think this was an example of maladaptive culture, but emerging research suggests it may be a “Chesterton’s fence” — something we should have made sure we understood the purpose of, before bulldozing it. Immediate breastfeeding, especially among first-time mothers, is associated with rare but potentially lethal newborn collapse. Waiting to start breastfeeding until milk comes in may protect babies from this harm. It may also support lactation and overall maternal health by giving mothers time to rest after giving birth.

Colostrum’s makeover from taboo to treasure was quite recent. And newborn care experts did not always believe that it was enough to feed babies only colostrum before mothers’ milk came in.

(as the Swedish case shows)

***

Short:

Waiting days to initiate breastfeeding as another/part of the same older traditions. → Risk of falls, smothering from exhaustion.

Long:

Other dangers beyond SUPC [from ch 6:]

There is also a growing body of research on Sudden Unexpected Postnatal Collapse (SUPC) events in Sweden, in which previously healthy newborns experience life-threatening collapse events. Some involve a newborn face-down on a first-time mother’s breast, struggling to breathe while trying to drink milk that won’t come in for days. Again, with prompt, appropriate medical intervention, most survive. The breastfeeding myth says newborns should be in this position, as mothers should initiate breastfeeding as soon as possible after birth; the long history of colostrum taboos suggests maybe they shouldn’t be there in the first place.

The same insistence on immediate breastfeeding initiation despite most mothers’ lack of milk for days also contributes to serious risks from maternal exhaustion. In January 2023, an Italian mother accidentally suffocated her newborn after falling asleep breastfeeding. The father claims he requested nursery care for the newborn so his partner could rest, and that his request was refused. Many women say they were denied nursery care like this by hospitals promoting exclusive breastfeeding under policies including Baby Friendly. The breastfeeding myth says that keeping mothers and babies together supports breastfeeding. But the reality is that pressuring exhausted mothers to attempt round-the-clock nursing, in spite of most of them predictably having no milk yet for days, carries serious risks for no proven benefits.

These exhausted mothers are also more prone to dropping their newborns, usually while falling asleep. These falls often fracture babies’ delicate newborn skulls. At the hospital level, policies promoting exclusive breastfeeding have been associated with increased risk of these falls and fractures.

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Exclusivity Reality

Danger continues.

Disparate harms: Race, development.
Deaths, wasting, possible lower IQ.
No proven trade-off of benefit for substantial possible risks.

Danger continues: especially for the most vulnerable.

Starvation danger from exclusive breastfeeding goes beyond just the first few days of life. Going back to Mike Muller’s 1974 investigative report “The Baby Killer” that sparked the Nestlé boycott and eventual Senate hearings, substantial minorities of women have long reported insufficient milk. So the promotion of exclusive breastfeeding as a policy and a medical intervention has always been predicated on ignoring starving newborns’ hunger cries as well as women’s experiences in the first few days and beyond.

Disparat: [Cureus 1] For jaundice, a lower threshold of concern is appropriate in the context of: prematurity [158]; low birthweight; systemic infection such as sepsis; birth trauma [113]; C-section; male gender [159]; Asian race due to increased incidence of UGT1A1 [160-162]; African, Sephardic Jewish, Greek, Turkish, Chinese, and Italian race due to increased risk of glucose-6-phosphate dehydrogenase (G-6-PD) deficiency [163]; and darker skin due to melanin reducing visible skin yellowing [164].

Data from the PROMISE-EBF trial (Promoting Infant Health and Nutrition in Sub-Saharan Africa: Safety and Efficacy of Exclusive Breastfeeding Promotion in the Era of HIV), conducted from 2006-2011 in Burkina Faso, Uganda, South Africa, and Zambia show evidence of possible increased deaths and other harm from the intervention.

Deaths; : Highest-ever measured perinatal mortality rate in Burkina Faso, with maternal nulliparity significantly predictive; proven “success” decreasing prelacteal feeding, doubling EBF rates.
Hunger: more wasting in Uganda and lower ponderal growth in Uganda and Burkina Faso.
Neurodevelopment: possible decrease in general cognition scores.
No proven benefits, including on diarrheal disease rates in SSA in PROMISE.

[more details PROMISE from Cureus 1]:

Additional evidence suggests that exclusive breastfeeding promotion in the absence of safety infrastructure addressing common breastfeeding insufficiencies may be associated with increased infant morbidity and mortality in less well-resourced settings. For instance, the PROMISE-EBF trial (Promoting Infant Health and Nutrition in Sub-Saharan Africa: Safety and Efficacy of Exclusive Breastfeeding Promotion in the Era of HIV), conducted from 2006-2011 in Burkina Faso, Uganda, South Africa, and Zambia reported some findings suggestive of possible increased neonatal mortality risks associated with breastfeeding insufficiencies in the context of heightened emphasis on exclusivity in the intervention arm of the trial: Diallo et al [115] reported the highest-ever measured perinatal mortality rate in Burkina Faso. Diallo et al [116] reported maternal nulliparity significantly predicted neonatal death (95% CI 1.5 to 12.1), consistent with a possible link with breastfeeding insufficiencies.

One alternative, not mutually exclusive explanation is that lack of medical care contributed to prolonged labor generating birth trauma resulting in stillbirths and neonatal deaths on days 0-2 of life (T. Tylleskär, personal communication, September 16, 2021). But it is not clear why obstetric neglect would have increased during the trial. Trial data cannot be used to test either hypothesis, because information on causes of death, possible complications resulting from insufficient milk intake, or maternal perceptions of breastfeeding problems were not collected.

Engebretsen et al [117] reported the PROMISE study intervention successfully decreased prelacteal feeding in Burkina Faso. Engebretsen et al [118] reported this intervention was associated with more wasting in Uganda and lower ponderal growth in Uganda and Burkina Faso. Investigators hypothesized these apparent adverse effects may have resulted from misguided public health and medical (including PROMISE) encouragement to mothers to continue exclusively breastfeeding for six months, when infants may need supplementary foods beginning around four to six months to ensure appropriate nutrient and caloric intake. This is consistent with Forsyth’s criticisms [119] that prolonged exclusive breastfeeding leads to later child mortality and morbidity, a six-month recommendation is too rigid, and context-specific interdependence of breastmilk, complementary foods, and infant formulas if required should be central to early infant feeding research and policymaking. It is worth noting that the PROMISE team’s possibilities were constrained in this context by the current exclusive breastfeeding promotion regime, which since the World Health Assembly’s 1981 adoption of the routinely amended International Code of Marketing of Breast-milk Substitutes (the WHO Code) [120] has increasingly discouraged donations of free or low-cost formula and other supplies to healthcare facilities, even in settings with endemic poverty and communicable diseases like HIV that are transmissible through breastfeeding. Thus formula is unavailable in many low-resource settings even when it is medically necessary.

Reported PROMISE results showed no possible infant health benefits to balance the potential risks of lengthening neonatal starvation and later infant under-nutrition periods through the study’s exclusive breastfeeding promotion. Tylleskar et al [121] reported the intervention did not significantly affect the prevalence of diarrheal disease. Tumwine et al [122] reported a possible decrease in general cognition scores (95% CI -0.40 to 0.05). Investigators interpreted these findings as null, and hypothesized that they might be explained by the high prevalence of exclusive breastfeeding across treatment and control groups. They might also be partly explained by different subgroup effects; for instance, some infants might have become more vulnerable to diarrheal disease when they received insufficient nutrition/hydration due to breastfeeding insufficiencies, while others might have become less vulnerable when breastfeeding worked early and well.

Unaffiliated with PROMISE, Bhattacharjee et al reported the estimated national exclusive breastfeeding prevalence in Burkina Faso nearly doubled between 2000 and 2017 [123]; this increase coincided with the country’s highest-ever measured perinatal mortality rate during PROMISE. Overall, the evidence suggests that exclusive breastfeeding promotion, in the absence of safety infrastructure protecting infants from common breastfeeding insufficiencies, may have contributed to preventable infant mortality associated with lengthier neonatal starvation periods in sub-Saharan Africa, as well as to worse developmental outcomes including growth and cognition. But researchers neither collected data on breastfeeding insufficiencies that would enable relevant analysis, nor mentioned related risks in the study protocol, instead describing breastfeeding unequivocally as safe - a typical representation in current research and policy. That representation ignores evidence that a sizeable minority of mothers will experience breastfeeding insufficiencies likely to cause serious clinical problems in some of their exclusively breastfed infants; in less well-resourced settings such as these, those infants are relatively highly likely to die or suffer permanent disability as a result.

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What harms?

Short-term neonatal risks: starvation, SUPC, falls, smothering.
Long-term child risks: permanent neurodevelopmental, metabolic damage.
Short-term maternal risks: mental health.
Long-term maternal risks: PPBC.

[Cureus 1]: Early insufficient nutrition/hydration has possible long-term effects including neurodevelopmental consequences such as attention deficit hyperactivity disorder, autism, cerebral palsy, cognitive and developmental delay, epilepsy, hearing impairment, kernicterus, language disorder, mood disorders, lower IQ, and specific learning disorder.

[from book proposal]

Mothers deserve the truth about infant feeding: The alternative to formula, for many babies, isn’t breastmilk. It’s nothing. Breastfed babies typically don’t get enough milk in the beginning, and for some this deprivation goes all the way on the continuum to acute starvation, with documented effects of severe malnutrition in breastfed infants reported in the medical literature since the late 1970s: profound cardiovascular collapse, severe hypernatremia, perforated duodenal ulcer, and transient renal failure. The #1 cause of newborn rehospitalization in the U.S. is complications of starvation from breastfeeding, chiefly hyperbilirubinemia (jaundice), hypoglycemia, and hypernatremic dehydration. These complications may ultimately risk death or permanent neurodevelopmental harm. They don’t have established safe thresholds, and there is absolutely no proven benefit for which parents (usually unknowingly) exchange these risks. Nor is there any test to diagnose or medication to effectively treat common breastfeeding problems. Breastfeeding medicine is a mess.

Transition: better practice can prevent these possible harms. What does that look like?

***

[from book TOC]

PART TWO “Best” Fails the Test: Evidence of Harm

CHAPTER FOUR Of Brains and Bellies: Starvation and Lifelong Health

CHAPTER FIVE Bad Crud, Good Crud: Pollution and Probiotics

CHAPTER SIX Killing Black Babies: The Dirty Secret of Infant Mortality

CHAPTER SEVEN Burning Down the House: Crisis, the Code, and Future-Proofing

Transition: What kind of permanent neurodevelopmental harm are we talking about?

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Better Practice: Science Before Belief

Prelacteal and supplemental feeding.
Evidence-based screening for breastfeeding problems.
Evidence-based prenatal education.
Education and support for safer infant feeding.
Listen to people.

Correct the historical mistake - renormalize supplemental feeding in the first days and beyond as necessary.

Ev-based… → Part knowing and applying existing evidence, part listening to women and babies.

Support includes financial support for feeding infants appropriate supplemental milk. The Soviet norm was formula in the hospital, supplemental milk access out of it. Why no global milk? Why not industry partnerships?

The car risk analogy doesn’t work - a car demonstrably gets you somewhere, while bf doesn’t have any proven causal benefits. Infant feeding as a microcosm of modern Western societies that give individuals imperfect information, bad choice sets, personal responsibility for structurally influenced or determined outcomes, and tells them how lucky they are for living in this here and now (ignorant of alternatives present and past).

Evidence-based foci (birth control failure, postpartum breast cancer).

All about more caring care: baby the baby, mother the mother.

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Better Policy: Ethics Before Metrics

Systematic local and state-level support for mixed and formula-feeding.
New international legal regime structuring formula donations.
Constraint of and cooperation with industry.
Public milk provision alternatives?
Diverse, context-dependent safety infrastructures.

No more single points of failure in infant feeding.

***

[Cureus 1]: Current early infant feeding guidelines conflict with the available evidence. Recent reform efforts have tended to focus on using more technology and measurement to harm fewer neonates instead of proposing the indicated paradigm shift in early infant feeding to prevent more harm. The scientific evidence is already sufficient to mandate application of the precautionary principle to feed neonates early, adequate, and often milk before mothers’ milk comes in and whenever signs of hunger persist, mitigating possible risks including death or disability. In most contexts, the formula is the best supplementary milk for infants at risk from breastfeeding insufficiencies. National-level reviews of scientific evidence, health policy, and research methods and ethics are needed to initiate the early infant feeding paradigm shift that the data already support. Policy experiments and related legislative initiatives might also contribute to the shift, as insurers might decline or be required by law to decline reimbursing hospitals for costs of this type of preventable hospitalization, which otherwise generates profit.

***

[1st draft talk nts 04-03-23 – ]

The what is pretty easy: Feeding neonates milk early, enough, and often would prevent a lot of harm, some of it quite serious. In settings where formula access, literacy, and clean water aren’t a problem, that means formula. In settings where these things are a problem, the solution probably involves restructuring the global legal regime surrounding formula donations. The WHO’s 1981 International Code of Marketing of Breast-milk Substitutes — “the Code” — effectively prohibits free or low-cost formula donations, even in impoverished, HIV-endemic, and crisis contexts. The Code has got to go.

Even at this simple logistics level, not talking about problems of misinformation and social pressure, ensuring neonates don’t starve given breastfeeding’s common insufficiency will likely get more complicated in the medium-term. As destabilization continues, more crises will cause more supply chain disruptions — causing more formula shortages like the recent U.S. and Australian ones. All this while epidemics like COVID-19 will continue to be stoked by climate change, political conflict, and urbanization. These forces may make it important to consider a return to shared nursing and wetnursing practices as part of restoring what used to be a diverse infant feeding safety infrastructure. Alternately, we may decide animal milk is a more ethical option, and build better societal knowledge about diluting it with water and sugar to make it more similar to breastmilk while fortifying it with essential vitamins like vitamin D and folate, which breastmilk is also missing. Some commentators, like George Monbiot, believe precision fermentation will scale and that we should end dairy production to combat climate change, but I think that remains to be seen, and we can’t dismantle an industry that ensures our babies don’t starve.

The takeaway point — myth-based medicine pervades modern life, do not adjust your sets, this is actively crazy, dangerous pseudoscience hurting newborns and new mothers. Burn it down to the ground and start over.

***

[from book proposal ch 7 – ]

***

CHAPTER SEVEN Burning Down the House: Crisis, the Code, and Future-Proofing

What’s the future of infant feeding in an increasingly unstable world? Criticizing the aid world’s Kafka-esque stimatization — and sometimes outright prohibition — of formula donations as worsening crises and amplifying destabilization, this chapter envisions a diverse array of possible solutions to keep more babies fed.

As climate emergency increases health risks from extreme weather, food insecurity, and disease, more mothers and babies will need emergency food aid and medical care including formula. This highlights a conflict in the aid world: International NGOs pressure healthcare professionals to promote exclusive breastfeeding, prohibit formula donation even in emergencies, and treat women seeking formula as ignorant patients to be educated about the virtues of exclusive breastfeeding. This results in preventable infant hospitalizations, and public outcry from healthcare professionals and humanitarians who want to prevent them. Some NGOs even require a prescription for formula, a policy Doctors Without Borders criticizes. Aid organizations need more formula to supply in crises, but breastfeeding activists lobby for ever more restricted access, instead. Stress and malnutrition may impair or stop lactation, so this conflict risks harming those who need help most.

It’s time for a new legal and policy framework to structure formula donation and distribution so that all mothers (ideally) can access this common medical necessity for their infants. “The Code” —which bans donations of free or low-cost formula even in impoverished, HIV-endemic, and crisis contexts — has got to go. And the needed shift is truly worldwide.

Food banks in wealthy, Western countries like the U.S. and the UK have to stop banning or discouraging formula donations. Social services have to stop penalizing formula-feeding moms. Researchers and doctors should stop discounting or psychologizing the experiences of mothers who report common breastfeeding problems like insufficient milk, and start listening to women’s experiences and hungry babies’ cries. No mother should have to watch her child go hungry because she’s not able to breastfeed and not believed.

At the same time, formula is not a simple, one-size-fits-all solution. Safe drinking water is unavailable in much of the world. The shame of 20th century global public health that we couldn’t fix that. Now our civilization is in decline. Going forward, more crises will cause more supply chain disruptions — causing more formula shortages like the recent U.S. and Australian ones. All this while epidemics like COVID-19 will continue to be stoked by climate change, political destabilization and conflict, and urbanization. These forces may make it important to consider a return to shared nursing and wetnursing practices as part of restoring what used to be a diverse infant feeding safety infrastructure.

Every option has risks. These risks vary by individual, time, and place. Our best bet to keep the most babies fed is to support diverse infrastructure including formula aid access, safety infrastructure for shared nursing and wetnursing (including infectious disease screening and breastmilk pasteurization education and equipment), animal milk safety support, and, potentially, emerging lab-grown breastmilk substitutes made using “precision fermentation” (new lab-grown breastmilk).

It’s not clear whether precision fermentation will scale. Some environmental activists like George Monbiot have called for the end of dairy production despite its medical necessity in infant feeding, appealing to the promise of precision fermentation. But if debunking the breastfeeding myth [maybe ditch that term idk] teaches us anything, it should be to not put all our eggs in one basket. Single points of failure are dumb. Diverse crises will require diverse solutions. We won’t save humanity by letting our babies starve.

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Infant Feeding

… would be an excellent idea.
Harm prevention model.
Better science.
Better ethics.

Infant feeding … Would be an excellent idea.

Exclusive breastfeeding accidentally introduced a single point of failure into infant feeding for no established benefit.

Safer breastfeeding is possible.

Why not give more caring care?

***

Not anti-bf; pro-informed consent, better science, and better safety infrastructure including more evidence-based education and support for safer breastfeeding.

We don’t know a lot about how to do that, should cautiously base policy recommendations and medicine on better science instead of myth.

Not going to look like proclaiming any one-size-fits-all model as “best.” (Even in Aka and Efe examples of prelacteal shared nursing, practice is offering the baby the breast 2-3x/day from another lactating woman – the baby sets the feeding terms in the context of availability.)

Gets back also to informed consent not policy paternalism.

As cultural participants, observers, and critics, I think we have to ask ourselves some hard questions about the role of Puritanism in creating current infant feeding norms that are causing not just measurable medical harm, but also a world of preventable pain and suffering.

Why is the burden of proof on reformers to push the culture to try to make babies and mothers have better lives by listening to them about their needs?

Facets of Calvinism (hard work, tho saved by faith alone); social Darwinism (Erin’s insight on antipathy toward the poor possibly playing a role in formula access barriers amidst the wasteland of neoliberal austerity policies and the cost of living crisis; there’s an analogous application of that to less healthy paying health prices).

This is culture, not science, and there’s insufficient evidence establishing that the current approach is “best.”

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Extra slides

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Collective Action Problem

Who benefits from a new paradigm?

Aggregate gains.
Especially vulnerable subgroups.

Who pays a cost, and so resists change?

Special interests (e.g., experts in the currently dominant paradigm risk financial costs).
Ideologues risk psychological costs.

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Increasing Breastfeeding Problems?

Pollution exposures.
Diseases.
Changing norms around pregnancy/motherhood and work: Fatigue.
Misguided modern breastfeeding practices ironically undermining lactation.

***

[from chapter 5 book proposal – ]

CHAPTER FIVE Keeping It Clean? Pollution and Probiotics

This chapter debunks two facets of the breastfeeding myth that stem from the fallacy that natural means better, presenting scientific evidence on the risks of environmental pollution and the benefits of probiotics that show other infant feeding options are better in some contexts.

Part of the breastfeeding myth is the idea that it keeps infant feeding clean by avoiding the threat of possible contamination (bad crud) while providing healthful probiotics (good crud) for free. But the evidence on both fronts actually points to more uncertainty and possible preventable harm from breastfeeding and the way experts currently promote it. Summarizing scientific and medical research on pollution in breastmilk on one hand, and the evidence on breastmilk versus probiotics on the other, I show that — just like in the preceding chapter’s case of brains and bellies — experts underestimate breastfeeding’s risks and overestimate its benefits. The available evidence supports very different conclusions from current practice about how best to protect the most vulnerable infants from some of the worst risks they face.

Milk is risky. Formula manufacturing and preparation risk mistakes and contamination, and sometimes babies die from them. The same is true of supplemental dairy milk production, distribution, storage, and infant feeding preparation (i.e., heating and dilution with water and sugar to make it more similar to breastmilk). Human breastmilk, straight from the breast, at first seems to avoid these problems, since it can’t go bad. But scientists have long recognized that breastmilk can still be contaminated. One source of such contamination is environmental pollution. And pollution’s effects on breastfeeding may start before the first drop of milk is drunk: Pollution can short-circuit lactation.

Insufficient milk is the most commonly cited reason that mothers add or switch to formula. But there’s been so little research that takes women’s experiences seriously, that we don’t know if breastfeeding problems have increased over recent generations. What if more and more women have been less and less able to produce enough milk to keep their increasingly breastfed babies from suffering starvation harm?

Some red flags come from animal studies. For instance, exposing mice to the toxin dioxin during pregnancy blocks lactation by keeping mammary glands from differentiating — the maturation process that human mammary glands, too, normally undergo during pregnancy in preparation for breastfeeding. As Swan and Colino show, increasing exposure to environmental pollutants is linked with increasing incidence of numerous fertility and other health problems in animals including humans. Some of these problems, in turn, are associated with breastfeeding problems — such as PCOS (Polycystic Ovarian Syndrome), overweight/obesity, and diabetes, which are all metabolic disorders. No surprise there: Lactation is incredibly metabolically intensive. Metabolic ill health in one form may also manifest in another.

So breastfeeding problems may be a symptom of pollution exposure. But what about women exposed to pollution and for whom breastfeeding still biologically works, after milk comes in and notwithstanding common experiences like pain and mastitis (breast infection/inflammation) — i.e., most women? Grandjean and others show that particularly toxic, “forever” chemicals get stored indefinitely in fatty tissue, released in breastmilk, and may account for stunted growth and attenuated vaccine responses in breastfed children. Brody and Rudel suggest that maternal elimination of carcinogenic substances through breastfeeding could contribute to an apparent inverse association between lactation and breast cancer risk — although we should be skeptical of that association in the first place for reasons I’ll explore later. Brody and Rudel’s point, though, is that women may lower their own breast cancer risk by transferring carcinogens to their babies through breastmilk. How does this all translate?

It may make sense to avoid breastfeeding if you’re particularly concerned about past pollution exposure, to test (your hair, blood, breastmilk) to find out more if you’re curious and capable, and especially to not force it if breastfeeding isn’t working for you. Breastfeeding problems could be your body’s way of telling you that you don’t really want to feed your baby what your breast tissue has stored up. The alternative is probably safer. What’s the logic there?

Milk from animals lower on the food chain, like cows and goats, tend to have less stored pollutants to transfer, just like smaller fish tend to have less heavy metal and other pollutants. Most pregnant women are familiar with warnings to avoid bigger fish like tuna and opt for smaller fish like sardines due to mercury concerns. It would be nice to have more data on this, but the same logic may apply to milk.

Where the breastfeeding myth ignores or minimizes the impacts that environmental contamination may have on lactation abilities and breastmilk safety, on one hand, it trumpets breastfeeding’s benefits for babies’ guts and especially microbiomes, on the other. Experts tout breastmilk as especially evidence-based in protecting some of the most vulnerable babies, like low birthweights (LBWs) and premies, from some of the worst outcomes, like necrotizing enterocolitis and sepsis. Responding in part to such claims, many hospitals pay huge sums for special human breastmilk-based fortifiers for these infants; others collect donor milk in HIV-endemic settings to pasteurize for them. This is lucrative and risky business.

Yet again, the science underpinning these practices is weak and leads to uncertain conclusions. In contrast, evidence strongly supports the efficacy of probiotic supplementation in protecting vulnerable newborns from lethal infections. Unlike exclusive breastfeeding, probiotic supplelmentation carries no known risks. There are also indications that probiotics may improve gut health, mood, and immunity more broadly. Data show that many babies are born with altered gut microbiomes after their mothers took antibiotics during pregnancy. So there are many reasons to try adding probiotics to breastmilk or formula, and no apparent reasons not to — other than cost and access.

As usual, there’s no forced choice here — breastfeeding doesn’t exclude probiotic supplementation, or vice-versa. But widespread emphasis on communicating breastmilk benefits (misrepresented as certain), rather than on communicating better-established benefits of probiotics, does babies and mothers alike a disservice. It adds possible risk for premies and LBW by discouraging formula-feeding, when formula yields more nutritional and caloric bang per gulp. That’s why, although practices vary widely, some hospital units specializing in vulnerable babies actively discourage breastfeeding; some use those special human breastmilk-based fortifiers in part to concentrate the supposed magic of breastmilk into a formula (if you will) that better meets LBWs and premies’ needs. When healthcare professionals pressure mothers of LBWs and premies to express or pump milk, it adds pain, work, and stress to an already stressful time — for no proven benefit. Mothers of premies are especially likely to have low breastmilk supply, and their babies are at all sorts of heightened risks. These are the mothers who least need extra pressure in their lives.

When it comes to contamination, there are no easy answers in our messy world. Environmental pollution is pervasive, under-studied, and can have wide-ranging health effects from sabotaging lactation to causing cancer; there is, sadly, no infant feeding option that avoids it. Our bodies, at the same time, are “contaminated” by microorganisms that are not us, that make up 1-3% of our mass, their cells outnumbering ours 10 to 1. When they’re good — e.g., when they include diverse strains of lacto and bifido bacteria in our intestines — they’re very, very good for us; and when they’re bad — e.g., E. coli or C. diff — they can kill us. All sorts of contamination can be passed through breastmilk — from killer chemicals to healthful probiotics.

Confronting complex social problems, like the uncertain effects of corporate corruption in the form of rampant pollution on women’s and children’s bodies, is far less appealing than pretending we know that “breast is best.” Part of the power of the breastfeeding myth comes from its comforting reassurance that everyone, all over the world, regardless of class or race, can access the best infant nutrition known to man. Otherwise, problems like pollution, poverty, lack of sanitation, and infectious diseases would make global infant feeding policy a study in inequality brutalizing blameless children from the start. What if it still is?

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Breastfeeding Promotion

Universal
Binary
Framing
Certainty
Natural = safe
One-size-fits-all

Photo: Jonathan Borba

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Starvation

Science:�Unmeasured confounds

Practice: �Common/preventable

harm to neonates/moms

Ethics: �Listening to people

There are three lenses through which to look at the problem of starvation from breastfeeding as it’s currently promoted by leading health authorities including the WHO and AAP (American Academy of Pediatrics).

***

[from book proposal draft ch 3]

… journalist Mike Muller in 1974 published “The Baby Killer.” This widely-read War on Want (UK anti-poverty NGO) investigative report accused Nestlé and other Western formula manufacturers of unethical marketing practices in poor countries, where experts believed formula-feeding contributed to large numbers of infant deaths, mainly through use of dirty bottles, unclean water, and over-dilution due to poverty. They unintentionally left the babies saved by formula out of the story.

The villain in “The Baby Killer” is formula-feeding, personified in the cover image of an emaciated black baby in a bottle. Ironically, the report cited multiple studies showing that double-digit percentages of women reported not making enough milk. But Muller and his contemporaries apparently never made the connection between starving babies and breastfeeding problems.

At the time, doctors, researchers, Muller, and the public agreed: the vast majority of these mothers were either mistaken, or had psychosomatic problems. If they just relaxed and believed they could do it, then breastfeeding would work fine for them, just like it supposedly did for women in traditional societies. This gaslighting sparked a political firestorm.

Activists mistakenly believed that breastfeeding posed a universally available, free, and safe infant feeding alternative — one that predatory companies had intentionally sabotaged by getting new mothers hooked on their product until their supply dried up. Worldwide Nestlé boycott, protests, and a 1978 U.S. Senate hearing ensued, with healthcare professionals from around the world starring as expert witnesses. In a projection of the new technology of formula onto the old experts including female friends and family, doctors dismissed prelacteal and supplemental feeding as folk tradition.

In blockbuster testimony, Manila Dr. Natividad Relucio-Clavano claimed her research showed that switching from formula to breastfeeding dramatically decreased infant deaths in her hospital in the Philippines. But Clavano didn’t submit any documentation into the Congressional record. Years later, she published the study, which shows that her testimony was misleading. Because what changed was not only how babies got fed (bottle or breast), but also how soon. Before the shift, the “starvation period” (her term) was 8-12 hours for normal babies and 16-24 hours for preterms. Hospital workers gradually shortened it to 8, then 6, then 4, and finally 2 hours — suggesting they, themselves, may have realized that not starving babies is a really good idea (TM). But, as in much other infant feeding research, flawed study design makes it impossible to tell what cause generated what effect here.

Transition: this is that unmeasured confounds story…

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The Gospel of Boob

Old and New Testaments.
New: Late 20th c. invention.
Natural = safe.
Emphasizes exclusivity.
Claims myriad benefits.
Lacks informed consent.
Put pseudoscientific spin

on old preferred stories.

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Rising Autism Incidence

[from Cureus 2]

This marked rise in autism [29,30] and other neurodevelopmental disorders [31] coincides with the introduction and rise of the exclusive breastfeeding paradigm [32-36]. There are many reasons to suspect the relationship is causal. Its modern Western creators imagined this new early infant feeding paradigm was natural. Ignorant of its historical novelty, they did not collect safety data on the intervention. Now, increasingly well-established possible mechanisms of harm include brain damage from hyperbilirubinemia caused or exacerbated by starvation/deprivation due to insufficient milk intake associated with exclusive breastfeeding.

…

… data on autism risk appear consistent with the hypothesis that breastfeeding problems can cause insufficient nutrition/hydration, and exposure to such conditions of deprivation/starvation can [permanently] harm neurodevelopment.

… [of particular concern is the link between jaundice and bilirubin-induced brain injuries with possible long-term neurodevelopmental consequences consistent with disorders including autism and ADHD]

… the jaundice-autism effect may be quite large and the statistically significant correlation seems real [p-curve testing for publication bias], but where does the risk come from? The evidence suggests that severity matters; however, there is no safe level of hyperbilirubinemia with respect to neurodevelopmental harm. Both findings indicate that the precautionary principle is particularly relevant to preventing associated harm.

…

The evidence supports applying the precautionary principle by feeding hungry neonates formula to prevent and treat jaundice and other common complications of insufficient milk intake, which may risk neurodevelopmental harm [26]. Supplementation with water or sugar water does not reduce hyperbilirubinemia [130,131]. Formula lowers bilirubin by inhibiting intestinal reabsorption [132]. Formula-feeding in places with clean water, high literacy, and stable formula access is well established as safe and is likely often also a safer option than prolonged neonatal starvation in lower-resourced settings where medical care access to treat complications of insufficient milk intake tends to be more limited. By contrast, jaundice treatment options such as phototherapy and exchange transfusions are invasive, costly, potentially stressful for neonates and their families, and may incur substantial risk. In infants who are already medically endangered by moderate to severe jaundice, these interventions may be necessary to limit brain injury and disability; but it is uncertain to what extent damage is already done by the time of diagnosis. In any event, these cases are overwhelmingly preventable through supplementing breastfeeding with formula prophylactically, or in response to signs of persistent infant hunger at the latest. Formula-feeding appears safer for neonates than common complications from insufficient milk intake and current standard treatments for them.

***

Science doesn’t say anything, we observe, analyze, and interpret data containing lots of uncertainties and biases, including sexist ones involving ignoring women’s and infants’ literal cries for as long as there’s been modern infant feeding science.

***

Transition to PPD:

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The Breastfeeding Myth - Maternal Mental Health

[from book TOC]

PART THREE Hurting for Two: Mom Matters

CHAPTER EIGHT Turning Off the Tap: How Modernity Sabotaged Lactation

CHAPTER NINE Living on the Edge: Breastfeeding and Mental Health

CHAPTER TEN You Can’t Choose Your Tits: The True Story of Breast Cancer Risks

***

[from https://wildetruth.substack.com/p/of-milk-and-misery]

… maternal health is a confound in the relationship between breastfeeding and depression. Maternal health appears to be a fork influencing factors — known ones like

1- inflammation,

2- disordered glucose metabolism, and

3- endocrine disorder (i.e., PCOS), and probably unknown ones, too — that may contribute to both breastfeeding insufficiencies and postpartum depression. This shows why frequently observed, weak inverse correlations between BF and PPD — e.g., in Ip et al's 2007 meta-analysis and Dias and Figueiredo's 2015 review, but not Chowdhury et al 2015's meta-analysis — should not be interpreted as evidence of a causal protective effect of breastfeeding against depression, as leading researchers are careful to explicitly acknowledge. First, causal diagramming should precede these analyses. And second, it and they must account for this confounding.

In a tragic historical accident, breastfeeding the way it’s now normally promoted and practiced usually causes neonatal (newborn period) starvation in the two full days before mothers’ milk typically comes in. That starvation may risk permanent neurodevelopmental harm and death. As if evolved to sound an alarm about such risks, starving babies cry. A lot. And

1- excessive infant crying and

2- sleep deprivation contribute to PPD risk. (Not to mention sleep deprivation’s contribution to other, less common but severe problems like postpartum psychosis.)

3- child pain

In addition, common breastfeeding insufficiencies also cause neonatal starvation when milk is delayed even longer coming in, or when supply remains insufficient. In both cases (BF and BFI), neonatal starvation can cause or worsen child health problems (e.g., jaundice, underweight) that may also contribute to PPD. When your child hurts, you hurt, too.

4- mom pain

Breastfeeding commonly causes pain (e.g., nipple pain in 50% of mothers); pain also contributes to depression risk. Add to that the well-established fact that mental health problems including depression can also contribute causally to sleep problems (more on this later).