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Has the “Breast Is Best” Campaign Gone Too Far?

Summary and Comment |
May 2, 2013

Has the “Breast Is Best” Campaign Gone Too Far?

  1. Diane E. Judge, APN/CNP

A physician's personal experience illustrates the shame and guilt that policies promoting breast-feeding can cause.

  1. Diane E. Judge, APN/CNP

A note from Journal Watch Women's Health Editor-in-Chief, Dr. Andrew Kaunitz:

When I read Dr. Shah's Personal Perspective (Obstet Gynecol 2013; 121:869), I realized that its messages could encourage clinicians to hit the “pause” button and think about what we routinely do, with the best of intentions, in our practices. Thus, although her account does not present research findings, we have encapsulated it here to give it the wider audience it deserves.

Professional and public health organizations, many hospitals, and even some municipalities (e.g., Latch On NYC) promote exclusive breast-feeding for 6 months, with continued breast-feeding thereafter. But has this crusade stigmatized mothers who cannot breast-feed? In a Personal Perspective, a reproductive endocrinologist describes her persistent efforts to breast-feed her newborn daughter. Initial attempts caused severe pain. A procedure to release the baby's tight lingual frenulum, the supposed cause, lessened the pain, but low milk production persisted. When the infant lost weight, pediatricians advised formula supplementation — whereupon the hospital asked her to sign a release acknowledging that breast milk is the best form of infant nutrition and that she chose “to deviate from the practice of exclusive breastfeeding.”

After consulting with lactation specialists, trying homeopathic remedies, pumping endlessly, experiencing postpartum depression, and finally being given permission to “let it go” by her obstetrician, her pediatrician, and her partner, she discontinued breast-feeding. She admits, however, to feeling inferior in the face of health warnings on infant formula labels comparable to those on cigarettes, even as her daughter grows and thrives. She cautions that public policy and individual clinician attitudes can alienate women who, “despite motivation, persistence, and utilization of all available resources,” are unable to breast-feed.

Comment

How far we've come from the era when breast-feeding was considered an inferior option for women who couldn't afford infant formula — and when women who were aware of breast-feeding's benefits had to ensure that hospital staff didn't feed their newborns formula “on demand” and had to assert themselves about breast-feeding (or pumping). Support for and encouragement of breast-feeding is entirely appropriate and necessary. But this physician's experience reminds us to weigh the risks and benefits of breast-feeding for each mother–infant pair and to encourage mothers to breast-feed while respecting and supporting the choice, at any point, not to.

Citation(s):

Reader Comments (19)

BURCU OZDEMIR Physician, Geriatrics

I had just the opposit experience . I think there will be always extremes. When I had my first baby, I was seperated from him, he was not brought to me for breast feeding. Initially when I came home, i did not have much milk. Also I had no idea how to breast fed, because no one tought me. No one endorsed it. My physcian automatically suggessted I got an injection immedietaly after delivery to stop milk production, even without asking me whether I intend to breast fed or not. He was very suprised when I refused it.
All above experience was very traumatic to me. I completely support the culture of breast feeding. We have come a long way we should not turn back

Lesli A McConnell

I think the campaign to breast feed can be a lot of pressure on a new mom. That being said, 15 years ago when working with teenage single moms not a one of them would even consider breast feeding when I asked them (which I always did). Now I am seeing more teenage single moms who try breast feeding so I think the public information was necessary. I think the people who feel guilt and shame are the educated older moms who go in wanting to breast feed and are so dissappointed when it does not work out. I think the campaign is necessary for a certain demographic. Again the delivery in the message from the provider is key.

Competing interests: None declared

Z M

As every guidelines, the recommendations are based from the most available evidence-based data. It is not a law that everybody should be doing and following the recommendation without consideration of case-by- case basis. I believe the same principle applies to the breastfeeding. One size does not fit all! Moms try their best to breastfeed babies; if there are hurdles, choose the second best options.

Competing interests: None declared

DE Preble

One of the several lactation consultants that I saw (inpatient and out) - told me this. I sighed a huge sigh of relief as I realized that although I wanted desperately to breastfeed my child, that if he was hungry and we weren't sufficiently successful at breastfeeding (I say "we" as my son was just premature enough to make breastfeeding very difficult) that formula was an available and acceptable alternative. It helped me let go of an enormous amount of guilt. While I acknowledge that there are so many advantages (especially when I had a cold when my son was only two weeks old) to breastfeeding - it is not necessarily an easy process. True, adequate paid maternity and paternity leave would help enormously. I was fortunate to be able to find and afford excellent lactation support - but this took awhile as well. As it is, working full time has put such a dent in my milk supply that I will be calling it quits at six months.

Competing interests: None declared

Manuel Moya

In western countries with a majority of mothers working outside, the pressure from maternity nurses, midwifes and perhaps doctors, has negative consequences that probably are not known by these strong recommenders.

Competing interests: None declared

Anne M. Arikian

I've been fortunate enough to have been able to breast feed each of my four children. The first was the toughest and required supplementation early on, and despite my own training and interest in lactation issues, I still felt under supported in my efforts. Through experience I gained the skills needed to exclusively nurse my second, third and fourth babies until they started solids. Despite many gains in this area, I feel we still don't have enough qualified practitioners helping new moms learn how to breast feed. The few that are available vary in effectiveness. While there may be limited support in the hospital, there are definitely not enough community resources, especially for patients of limited financial means. Pediatricians and family practitioners can support and advise struggling moms but we're no substitute for a skilled lactation advisor. It's not enough to just tell moms to breastfeed, we have to provide the necessary support. Our academies need to keep up the advocacy efforts.

And I agree completely with the author that it's entirely counterproductive to berate a mother who is struggling with breast feeding at the expense of the health of her child. As long as mom is asking for support, let's give it, and let's always put the health of the baby first and foremost.

Competing interests: None declared

Sara G Shields

Until formula companies no longer give free formula to maternity hospitals and until we have universal paid maternity and paternity leave, we are not going to get the breastfeeding results that our infants, mothers, and families deserve. Yes there will always be women and their newborns who for complex reasons struggle with breastfeeding and milk supply, but there are so many more who with better support from experienced professionals (and peers)--which some of the doctors giving advice to new moms mentioned here do not sound like, given lack of understanding of "failure to thrive"--AND better support to NOT have to return to work right away would be able to breastfeed fully for 6 months.

Competing interests: None declared

John S Anderson

There is a very old (30 years) study on biofeedback assisted relaxation training encouraging positive results in both the labor and delivery process and in the ability to have a successful breast feeding experience. It is a simple training paradigm that uses a variety of modalities including breathing practice with heart rate variability training, muscle relaxation using EMG feedback, autonomic control using peripheral skin temperature training and/or GSR and sometimes EEG training to facilitate a deeper state of relaxation. The labor/delivery outcomes included reduced time in labor and improved Apgar scores.

Competing interests: I am a biofeedback provider in Minnesota

Ashley Peko

As a 34 yo MD who just had our second baby 4 mos ago, this article really struck me. Breastfeeding was excruciatingly uncomfortable with both of my children, to the point that I can clearly identify that I had postpartum depression with our first. And yet when I finally had the courage to stop, the guilt was incredible. When I look back, it seems so silly as both children are thriving. I think you have to do what's best for both mom and baby and be supportive of whatever other moms choose. There is no room for pressure or guilt with either feeding style; parenting is hard enough.

Competing interests: None declared

K Blaustein

My first pregnancy was a difficult twin pregnancy. I had planned to breast feed from the outset but as my pregnancy progressed I became confined to bed with multiple pregnancy related issues during my second trimester. At that point my OB began preparing me for the possibility that exclusive breast feeding might not work out for me. He and his colleagues encouraged me to consider supplementing formula with breast milk. I consulted the local La Leche League and that was a big mistake. The counselor there told me that male doctors were notorious for not supporting breast feeding (which isn't what my docs did) and that exclusive breast feeding of multiples, even after a difficult pregnancy, would be "a piece of cake". I tried briefly to exclusively breast feed but my babies were small, one being a low birth weight baby, so with a lot of guilt I switched to formula. Eventually I realized that healthy babies are the only important outcome and if formula is the best route then take it and don't look back. In my experience other women can be a major source of guilt and misinformation. I realize now that the LLL consultant had no business commenting on my situation while lacking thorough knowledge of my medical situation.

Competing interests: None declared

Mike Marsh

Breast is best in the vast majority of cases. Some will of necessity need to settle for the next best. There are many reasons for this. The signed release was a bad idea, especially in this case with an educated mother. The campaign is needed, just the same. It combats the commercialism of formula and speaks for the one unable to speak for itself. This is about the baby....less so about mom.

Competing interests: None declared

Alan Berzen

I have always believed and still believe a happy Mom, happy baby. I think this is the most important issue and should always be the pediatricians primary guide in advising parents.

Competing interests: None declared

Mary Marygaret Breed

Extremism and self-righteousness are a threat in many facets of life. Breast-feeding extremism and the self-righteousness behind it are as harmful as any other of the many kinds of oppressive thinking that have been directed at women through the ages, and they hit a woman at her most vulnerable time and state, the onset of motherhood. The harm Breast- Feeding Police can do is not trivial. Perhaps it's no accident this essay on breast-feeding orthodoxy appears in the same issue of Physician's First Watch as the reversal on PSA testing for men; it's long been clear to me broadsides demanding PSA testing for all men did more harm than good, and many men have suffered for it. "When you have a hammer, everything looks like a nail," is an unintelligent approach unworthy of the medical profession. When PSA became available, it became the "hammer" and all men looked like "nails." Indeed PSA hits men at their vulnerable core as well. Univeral PSA testing was no doubt a big money-maker for test manufacturers and many surgeons. Mammography was likewise overused, we now know. I wonder where the statin craze will lead. Evidence-based medicine is only as good as the evidence, and we know a lot of it is tainted. The medical profession would do well to be vigilant against the phenomenon of fads in general and critically examine the driving force behind many "public education campaigns."

Competing interests: None declared

Paul D

reminded me of this article: http://www.theatlantic.com/magazine/archive/2009/04/the-case-against-breast-feeding/307311/

Competing interests: None declared

Arlan L Rosenbloom

Nearly a decade ago, I published a report of 2 tragic outcomes from the social pressure to breast-feed combined with inadequate/incompetent follow-up: Permanent Brain Damage from Hypernatremic Dehydration in Breastfed Infants: Patient Reports DOI: 10.1177/000992280404300911 Clin Pediatr (Phila) 2004; 43; 855 The online version of this article can be found at:http://cpj.sagepub.com

Competing interests: None declared

Tien-Lan Chang

As a pediatrician who promotes breastfeeding, I have seen some mothers who had inadequate milk supply despite doing everything right. Prior to formulas' development, the infants of these mothers would fail to thrive unless a wet nurse was available, For these mothers and infants, the formulas are the appropriate alternative. For women who choose not to breastfeed for other reasons, it is simple to inform the nurse at the hospital that you understand the benefits of breastfeeding but you choose not to. Just as some people are unable to follow our advice to become more active or to eat healthier, we still try to tell them what is best for them. The art of medicine is how to say the right things to achieve the right result. We are not perfect, and our good intentions are sometimes expressed or taken in the wrong way.

Competing interests: None declared

Gary McDonald

Sounds a little insensitive to me; I am sure there is more to this. No physician would demean a woman like this. It is obvious that mummy's milk is best, however, it presents a huge challenge to some mothers. Health professionals are correct when pointing out the obvious but must also be skilful in communicating their zeal.

Competing interests: None declared

Ayelet Shai

I am a physician, a feminist and a mother of 3. Thank you for publishing the piece on the breastfeeding crusade. In my opinion, the pressure put on women to breastfeed at any price is harmful and moreover, reactionist. I liked breastfeeding and I know it can be a fulfiling and cheap way to feed babies. However, the evidence that support the harm of fomulas are minor at best. It seems that breastfeeding is most important for women from undevelopped countries where life threatening diarrhea is a real danger. So many factors affect the heath and development of babies, and the food they consume early in life is just one of them. The article speaks of women who cannot breastfeed despite many efforts. What about those who do not wish to breastfeed? Or those that tried only several times and then they gave up? The breastfeeding crusade makes young women uncertain of their motherhood and takes women back to the times when they had to appologize for not adhering to the rules of how a woman "should be". I hope women physicians will be the first to tell new mothers that breast feeding is good for them (loose weight, decrease breast cancer risk, have a nice cuddle with your baby) and their babies, but that one can be a wonderful mom feeding her child formula. Just like we tell our young colleagues that they can be good mothers and have a career. There is no one way to be a mother.

Competing interests: None declared

Kate K

....I was a 36 year old MD with a full term first-born after an uneventful pregnancy and a natural childbirth. I confidently expected to breast feed as my mother had done. I nursed and nursed and nothing seemed to happen. No poop. I gave her sugar water to keep her urinating. Finally, after about 7-10 days, an older pediatrician suggested that I put my little finger IN HER RECTUM to dislodge an impaction. There was no impaction and no stool, either. Finally, a younger pediatrician said that I could continue to "nurse", but I had to supplement. She had lost 6-8 oz. I stopped breast feeding then and there. I gave her a bottle and she pooped. I congratulated myself on turning my healthy first-born into a failure to thrive (I didn't, of course). I don't think that I have ever recovered from it.

Competing interests: None declared

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