Accentuate the negative, eliminate the positive? The problems with Wiessinger’s ‘Watch Your Language’

(This post was first posted on the Good Enough Mum blog, here.)

Fifteen years ago, Diane Wiessinger, a breastfeeding counsellor and activist, wrote an article about breastfeeding promotion for the Journal of Human Lactation, entitled ‘Watch Your Language‘.  In it, she claimed to have the answer to the thorny question of why lactation consultants and the health care profession have such poor results when it comes to persuading women in the US to breastfeed.  I find this article, and the huge following it has received, to be of great concern; not only do I see no evidence for her theory, but I see a number of reasons to believe it is likely to do the cause of breastfeeding promotion far more harm than good.

Wiessinger’s key premise is that, when we talk about the benefits of breastfeeding, we have it backwards.  Instead, we should talk as though breastfeeding is the norm, and frame all our discussions of the differences between the two in terms of drawbacks and harms of formula-feeding.  And we shouldn’t mince words while doing so.  In Wiessinger’s opinion, we should be trying to catch our flies with vinegar rather than honey, and particularly bitter vinegar at that.  For example, Wiessinger advocates telling women that ‘artificial feeding results in an abnormal and unpleasant odor that reflects problems in an infant’s gut’, and describes formula-feeding as ‘deficient, incomplete, and inferior’.  ‘Those are difficult words,’ Wiessinger writes, ‘but they have an appropriate place in our vocabulary.’

Of course they do; however, that place is not in the speech of those wishing to describe the behaviour of those whose hearts and minds they wish to win over.

I’ve had a hard time writing this post, simply because I genuinely haven’t known where to start – there are just so many things wrong with the article.  But I’ve also known that this post needs to be written.  Wiessinger’s claims are hugely influential in the world of breastfeeding activism.  Google that title and Wiessinger’s name, and you’ll find her original article posted in its entirety in multiple places on the Net.  Lactivist website after lactivist website tells us that we should refer to breastfeeding as the norm and talk about the harms of formula-feeding instead of the benefits of breastfeeding.  I’ve even seen one blog describe the approach of talking about the benefits of breastfeeding as ‘anti-breastfeeding’.  I think that a post pointing out the fundamental problems with this approach is long overdue and very necessary.  So, here are the many reasons why I disagree with what Wiessinger has to say.

It’s counter to the evidence.  One of the principles on which behavioural psychology is extremely clear is that, if you want to change people’s behaviour, the carrot is mightier than the stick.  Research in this field established decades ago that potential benefits are much better motivators for change than potential avoidance of harm.  This really is the kind of thing that gets taught in introductory psychology classes.  Which, of course, is why advertising campaigns are not generally framed around the idea that you should buy product X because the alternatives are worse – they’re framed around the many benefits product X can offer you.

Oddly enough, Wiessinger herself touches on this when she writes that the phrasing of lactation consultants pushing breastfeeding ‘could just as easily have come from a commercial baby milk pamphlet’… and then comes to the rather bizarre conclusion that ‘[w]hen our phrasing and that of the baby milk industry are interchangeable, one of us is going about it wrong’.  Logically, if two groups of people are going about something the same way, they’re either both right or both wrong.  If companies with millions to spend on employing the best advertisers are taking the approach of advertising their product’s benefits, shouldn’t we be considering the likelihood that they’re doing this because they know it to be the most effective way of convincing people?

Yet Wiessinger shows an astonishing disregard for what the evidence in psychological research has to say.  And, given that she gives nothing to back up her opinions on this point, isn’t the most likely conclusion that the psychologists all have it right and Wiessinger has it wrong?

Most people aren’t that masochistic.  People generally just aren’t that keen to listen to criticism.  Think for a minute about how Wiessinger’s words might sound to a woman who’s happily formula-fed her first child and is now expecting another.  Talk to her about the benefits of breastfeeding, and maybe she’ll be open to listening and perhaps having a shot at another way of doing things.  Tell her how deficient, incomplete, and inferior her way of feeding her first child was – letting her know, while you’re at it, that you think her precious adorable first baby actually stank – and something tells me that she’s not going to be all that thrilled about listening to anything else you have to say.   Harshness only alienates those whom we’re hoping to reach.

Of course, I’m guessing (and hoping) that most advocates of Wiessinger’s approach would have enough tact to temper their words in that kind of face-to-face situation.  But the words and actions of one part of a movement reflect on the whole, especially when the words come from those speaking on behalf of the breastfeeding movement.  If the voice of breastfeeding advocacy is telling women how awful formula-feeding is, a lot of women are going to expect – and fear – the same thing from individual breastfeeding counsellors.  And that’s going to put off that woman who’s formula-fed a previous child or children, or the woman who’s currently struggling to breastfeed but has found herself giving a few bottles of formula to get through the difficulties and is scared of what reaction she might get if she tries asking a breastfeeding counsellor for help (and, anecdotally, I’ve read stories from women who were put off asking for help with breastfeeding for precisely this reason), or even the woman with no previous experience who might have been willing to give breastfeeding a go but is too scared of how she might get harangued if it doesn’t work out.  Adopting Wiessinger’s attitude to formula will make us look horribly unapproachable to a large segment of the women we most want to have approach us.

It fails to connect with people.  When Wiessinger talks about breastfeeding being the biological norm, she ignores the fact that, for many women, it isn’t the social norm.  Talking to these women as if breastfeeding was the norm isn’t starting where they are.   When you start by ignoring someone’s own reality and life experiences in favour of focusing on where you want them to be, or think they really ought to be, you’re setting your advocacy attempt up for failure.  If you’re not starting where they are, you’re making it far harder to form the connection you need to form with them in order for advocacy to be effective.

The stress it causes may be counterproductive.  This is actually a point that hadn’t occurred to me, but that another blogger pointed out when we were discussing this online once.  She felt that Wiessinger’s approach would have been more stressful to her when trying to get lactation established, and that that stress itself might have done more harm than good by interfering with her milk production.  It’s a fair point – we do know that stress can affect milk production.  While there’s no way to eliminate all stress from breastfeeding initiation in all cases, we can at least do our best to avoid making matters worse by not making women who need to give some formula while getting breastfeeding going feel attacked for doing so.

It encourages an all-or-nothing attitude.  And this can also be counterproductive, by putting off women who might be willing to consider short-term feeding or mixed feeding or even breastfeeding with the occasional bottle given now and again, but who just can’t see themselves wanting to aim for the current gold standard of ‘breastfeed for at least a year with nothing but breastfeeding for at least six months’.  How often do you hear ‘Because I wanted someone else to be able to give a bottle sometimes when I went out’ given by a mother as a reason for her choice not to breastfeed?  How many more of these women might actually end up giving breastfeeding a try if they knew that it is perfectly possible to breastfeed and yet have somebody else give your baby a bottle when you go out?  Or that, if full breastfeeding is not an option, mixed feeding carries most of the same benefits as breastfeeding and is still worth considering?  It’s easy enough to introduce those ideas in a context of discussing the benefits of breastfeeding.  But how do we reconcile descriptions of formula as harmful and risky with the explanation that, in fact, it doesn’t appear to be a problem (despite some lactivist claims) to give a bottle of it to a fully breastfed baby now and again?  We probably don’t, is the answer – and that means yet another group of women we’ve barred ourselves from reaching.

So, with all these problems, why has Wiessinger’s approach been so popular?

When I told my husband about the article, he nodded gravely and commented ‘Some people just aren’t happy unless they’re being unkind to other people.’  Sadly, I think there’s some truth to that – there’s a nasty little satisfaction that comes from believing you’ve got a really good excuse to say unpleasant things to people, and I think that, on that subconscious level we don’t like to admit to, that may be part of the attraction for at least some of the people who espouse this philosophy.  However, I really don’t think that’s the whole story, and my guess would be that most of the people who believe this actually have much kinder motivations.

I think that a bigger reason is that, when you’re faced with a thorny and seemingly insoluble problem and someone who gives every indication of knowing what they’re talking about comes along and tells you, in authoritative tones, that XYZ is the answer, it’s pretty natural to believe them – especially when some of what they say is demonstrably true.  And, of course, Wiessinger makes a few good points in amongst the frighteningly bad ones.  Promoting breastfeeding by talking in the kind of fluffy superlatives better suited to cloud-cuckoo land isn’t that great a way of reaching women, either, and it’s easy for Wiessinger to convince people that the issue with that approach is the positive framing.  It’s true that making breastfeeding sound like something special makes it feel out of many women’s reach. (Although, oddly, by the end of the article Wiessinger seems to be taking the same approach herself.  Apparently, we should be advising women that they shouldn’t merely breastfeed, but ‘mother at the breast’ and form a ‘breastfeeding relationship’.  But, hey, no pressure to make it Really Special.)

But the use of positive language isn’t the problem with the ‘best possible start in life, special bond of breastfeeding, blah blah’ approach.  The problem is partly that that way of describing is too overblown to be taken seriously (most people, quite rightly, are just not going to be convinced by the implication that the most important choice you can possibly make to get your children well launched into a fruitful life is that of how to feed them at the beginning of it), and partly that it doesn’t connect with people any more than Wiessinger does.  The hypothetical lactation consultant Wiessinger quotes isn’t finding out where each individual woman is and dealing with her particular concerns and beliefs.  She isn’t giving women information about the differences between breast and bottle in any sort of practical, easily comprehensible way that can be used as a foundation for sound decision-making.  She isn’t having a genuine discussion.  She isn’t starting from where women are.  She isn’t connecting.  And the answer to those flaws is not to adopt an approach that keeps those flaws and combines them with several more.  The answer is to put right those flaws.

I’ve already written about what I’d like to see in breastfeeding promotion.  Wiessinger’s article is a prime example of what I don’t want to see in breastfeeding promotion.  Let’s please, please, please, forever put to bed the attitude that unpleasantness and scare tactics are the most effective ways of persuading anybody to do anything.  Let’s go, instead, for an approach that’s actually likely to work.

Breastfeeding for longer than a year – myths, facts, and what the research really shows

(This post first appeared on the Good Enough Mum blog as a submission to the April 2011 Carnival of Breastfeeding.  You can read the original here.)

Extended breastfeeding is the term given, in our society, to breastfeeding a child beyond the first year.  An increasing number of women are choosing to do this, and, sadly, are more often than not incurring heated disapproval for doing so. Breastfeeding toddlers or older children is believed to make them overly dependent, mothers who do so are accused of thinking only of their own needs and not of their children (that ultimate indictment for mothers), and the practice is looked on as inappropriate and downright perverse.

Fortunately, it’s now being increasingly recognised that this position is not supported by either logic or evidence.  Not only is there not a shred of evidence that breastfeeding beyond a year is harmful, there is positive evidence to reassure us on this score – the world is full of societies in which it is considered normal and expected behaviour to continue breastfeeding for considerably longer than a year, and the children raised thusly seem to be doing perfectly well on the practice.  It is, of course, hugely beneficial for children in developing countries where food can be scarce and malnutrition rife, and it has some potential benefits even in our affluent society – it can be a valuable source of nutrition for otherwise faddy toddlers, and it slightly reduces a mother’s risk of breast cancer or rheumatoid arthritis.

I’m delighted to see it becoming more widely recognised that there is absolutely no reason why a mother should feel obliged to wean simply because an arbitrary date on the calendar is approaching.  However, there’s a twist to this; the pressure is starting to go the other way.  A small but vocal minority are pushing for breastfeeding past a year to be seen not merely as an option for women who want to do so, but as a goal for everyone to aim for.  Breastfeeding a toddler (or older child) is enthusiastically touted as having a host of physical and psychological benefits.  Lactivists are advising mothers that they should do their best to continue nursing until two years at the very least, and preferably longer (nursing until the child decides spontaneously to stop is held up as the ideal).  And the problem is that there really isn’t any decent evidence to support this attempted move towards yet another blanket parenting ‘should’.

I’m not objecting, here, to an individual woman deciding that there may be particular circumstances in her child’s case – deprived circumstances, an unusual health problem, or even just food faddiness – that might lead to her wanting to continue to breastfeed in hopes that it will be of some benefit.  Also, of course, I’m talking specifically about the situation in the developed world here, not about breastfeeding in developing countries where it is indeed likely to remain beneficial for long past infancy.  My objection is to the claims that extended breastfeeding has been shown to be of general benefit even in situations where other sources of nutrition are plentiful.  It hasn’t.  And while this kind of pro-extended-breastfeeding advocacy has been a huge comfort to plenty of women who, having struggled with the pressure from others to wean before they wish to, now feel vindicated, it’s also putting some women in the position of feeling obliged to nurse for longer than they really want to, in the belief that they’ll be somehow depriving or disadvantaging their children if they don’t.  That is not a trend I want to see.

That position, of course, is controversial enough in lactivist circles that it’ll need some defending; to break up what’s now set to be a very long post, I’m going to go for the ‘Debate With Imaginary Opponent’ format.

What do you mean, there’s no evidence that nursing past a year is beneficial?  Are you trying to claim that a fluid so packed with nutrition, antibodies, and general goodness somehow magically loses all its benefits just because a child has passed the age of one?

Of course not.  What happens is that the child gradually grows, develops and reaches the point where breast milk just doesn’t have anything much further to add.  (Just to clarify, in case anyone was forgetting how I began this post, I’m fine with children continuing to nurse after that point if they and their mothers so wish.   All I’m objecting to is the claim that they should continue to nurse, which I don’t agree with any more than the claim that they should stop.)

But there’s plenty of evidence that breasfeeding is beneficial to toddlers.  For starters, one study by Gulick (1) showed that breastfed toddlers between 16 and 30 months old get sick less often than non-breastfed toddlers and get better more quickly when they do…

No, it didn’t.

Huh?

It didn’t.  Although lactivist websites all over the Internet claim that that study shows a decreased rate of infections in breastfed toddlers between 16 and 30 months old, it actually shows nothing of the sort.  I know this because I’ve got hold of a copy of the study and read it for myself.  The toddlers being studied weren’t breastfed toddlers – they were toddlers who’d been breastfed in the past but had stopped breastfeeding before entering the study.  What the study was actually looking at was whether longer duration of breastfeeding during infancy had any benefit in terms of reducing infection rates in toddlerhood after breastfeeding cessation.  (It didn’t, in case you’re interested; at least, not in that study.)  Somehow, someone has managed to utterly and crashingly misreport what the study was into and what it showed, and lactivists across the Internet have simply repeated this misinformation without question.  It’s one of the biggest breastfeeding myths I’ve seen out there.

Well, come on – what about the other studies on the topic?  Look – Kellymom has a whole list of studies showing the immunological benefits to breastfed toddlers!

One of those is a study set in a developing country, showing benefit to children who are severely malnourished children.  As I said, breastfeeding can indeed be beneficial past infancy in such a setting, but it just isn’t valid to assume that those results will be applicable to children living in our relatively privileged Western settings.  One wasn’t even studying toddlers – it was a study of breastfeeding benefits in babies up to the age of 20 weeks, which is not toddlerhood by any remote stretch of the imagination.  The rest, as far as I can see, all just look at concentrations of antibodies in breastmilk of mothers of nursing toddlers, not at whether those antibodies are actually adding anything to the toddler’s own antibodies when it comes to fighting off infections.

Oh, come on.  Surely all those antibodies have to be doing something.

Not necessarily.  Bear in mind that a child’s own immune system also develops rapidly during the early years, and at some point it’s going to reach the stage where breast milk just doesn’t have a lot else to contribute.

That surely can’t be as early as a year, though.  I can’t believe that breastmilk doesn’t still have some benefit to children older than that.

You’re welcome to believe what you like.  It’s the claim that it’s been proved to be beneficial that I’m objecting to.

So have you any evidence that it isn’t?

In the one study I have been able to find on infection rates in breastfed vs. non-breastfed toddlers – a study in New Zealand that followed over a thousand children up to the age of two, looking at respiratory and gastrointestinal infections – breastfeeding didn’t show any benefit in toddlers, or for that matter, in older babies (2).  Of course, there are flaws in every study, and I can think of several possible reasons why this one might have underestimated results enough to miss a small but genuine benefit, but it does seem to me that, if that’s the case, we can’t be talking about that great a benefit.  And, frankly, when the one study we have on the subject shows a complete lack of any benefit, I don’t really think that the people claiming evidence of benefit are on solid ground.

But, what about the other benefits for breastfed toddlers?  Just look at the way that it helps an upset or tantrumming toddler to calm down.

I agree that that can be a wonderful convenience of breastfeeding.  However – and feel free to take this or leave it as you like, because we are temporarily stepping out of the realm of objective scientific evidence and into that of my own opinion – I do have my doubts as to whether it’s a good idea to do so.  After all, what message does it send children when we regularly and repeatedly teach them to turn to a sweet-tasting food source at times when they need comfort?  I wouldn’t use any other form of food or drink to distract my child from a tantrum, because that’s not the message I want to be giving to my children about how food should be used; it’s not encouraging healthy eating habits.  Why should I make an exception for breastfeeding?  I tried to avoid doing so, for both my children.  Just because something is the most convenient way to calm an upset child doesn’t mean it’s necessarily the best way in the long term.

But it has psychological benefits over and beyond just calming tantrums.  Breastfeeding for longer actually helps children become more independent!

No evidence for that claim.

Look, Jack Newman says so!  And Elizabeth Baldwin!

And they’re entitled to their opinion on the matter.  However, I don’t see any reason why I should automatically believe it, any more than I should automatically believe the equally unreferenced opinions of the doctors who claim that longer breastfeeding makes children more dependent.  Either way, they’re opinions, which are not the same thing as evidence.

But there is evidence!  Check out this quote on Kellymom’s site – ‘One study that dealt specifically with babies nursed longer than a year showed a significant link between the duration of nursing and mothers’ and teachers’ ratings of social adjustment in six- to eight-year-old children’ (3).  Or are you trying to claim that that study’s being misrepresented as well?

Oh, not with the kind of spectacular degree of inaccuracy as the study by Gulick we discussed above.  However, that quote makes the results sound far more impressive than they were.  We’re not told that the differences found were very small, that they showed up in only one of the several measures of psychosocial adjustment that were tested, that adjusting for other factors eliminated practically all the difference found in the teachers’ ratings, or that the researchers themselves were pretty unimpressed by their results.  To quote from their conclusion: ‘In general the evidence above gives only very weak support for the view that breastfeeding makes a significant contribution to later social adjustment.  The research findings tend to be both inconsistent over time and between measurement sources and at best suggest a very small association between breastfeeding and subsequent social adjustment.  Further it is more than likely that even the small and inconsistent associations that have been reported could have arisen from factors which have not been controlled in the analysis.’  As evidence goes, I have to say that that doesn’t really strike me as compelling enough to justify trying to persuade women to continue breastfeeding if they don’t want to.

So what about all the other studies listed on Kellymom?  Showing that breastfed toddlers suffer from fewer allergies and have higher IQs?

I’ve checked all five of the papers she lists as supposedly backing up her claim about reduced allergies in breastfed toddlers (full text of four of them, the abstract of the other), and none of them are about toddlers.  They’re all looking at breastfeeding in infancy.  In fact, one of them (a review rather than a study) actually mentions in passing that the existing research shows ‘some suggestions’ that longer breastfeeding may be related to an increase in allergy risk.

When it came to the studies on breastfeeding and intelligence, after a while I simply gave up.  The only study I did manage to find that looked at breastfeeding over a year didn’t find any substantial difference in intelligence or school performance between children breastfed for that length of time and children who stopped shortly before that – longer duration of breastfeeding was initially associated with a slight increase in intelligence level, but then the effect leveled out.  (That one’s not available on line, but you might be interested in checking out this one by Mortensen et al that Kellymom also links to, which also studied the association between intelligence and breastfeeding duration and reached a similar conclusion – initially the increased duration of breastfeeding was associated with slight improvement on the intelligence scales, but the effect then levelled off, with children breastfed for longer than nine months having scores no better than those breastfed for 7 – 9 months.)

I checked several other studies on her list which, again, all turned out to be follow-ups on breastfed babies, not children breastfed past a year.  So, as I say, I gave up.  Checking all the studies she lists would have taken forever and I’m afraid there are limits to the amount of time and effort even I can put in to checking references from someone who’s clearly such an unreliable source of information.  (And, before anyone gets offended at me dissing Kellymom, I do actually think she’s a great source of information when it comes to dealing with breastfeeding problems; I’ve just found her to be appallingly bad at giving accurate information on any research dealing with any question in the general category of ‘Is it possible that breastfeeding in circumstance X is anything less than incredibly beneficial?’)

So, for all you know, there might be studies on her list that do show benefits of toddler breastfeeding and you just haven’t seen them?

Well, if you find any, by all means let me know.  I mean that – I’d be interested to read them and happy to spread the word about them.  But, until I actually see a decent-quality study providing good evidence that breastfeeding past a year is actively beneficial for children, I’m not going to tell women it is.  And, given how many studies are being erroneously cited as showing benefits of toddler breastfeeding when they show nothing of the sort – frankly, I think my scepticism about the existence of any studies that do show benefits is completely excusable.

Well, I don’t care!  I love breastfeeding my older child and I want to carry on whether or not you’ve found any studies proving that it’s beneficial!  We’re both enjoying it, and that’s benefit enough!

EXACTLY!  And that’s the ONLY reason you need.  You don’t need to prove that it’s in some way superior to what all the other mothers are doing.  You don’t need to score Good Motherhood points on some imaginary scale to justify your choice to others.  You just need the confidence to believe that it’s OK and that it’s what works for you.  Enjoy nursing your toddler or older child, accept that mothers who have made a different choice from you are doing just as well by their child and shouldn’t be conned into nursing for longer than they want to, and support every mother in the choice she makes on the matter, in the knowledge that, as far as we can see from the available evidence, nursing or not nursing a child of that age are equally good options to go for and thus we can happily leave this one in the realm of personal preference where it belongs.

 

References

1. Gulick E. The Effects of Breastfeeding on Toddler Health.  Pediatric Nursing 1986; 12(1): 51 – 4. 

2. Fergusson D.M., Horwood L.J., Shannon F.T., and Taylor B.  Breast-feeding, gastrointestinal and lower respiratory illness in the first two years.  Australian Paediatric Journal 1981; 17: 191 – 5.

3. Fergusson D.M., Horwood L.J., and Shannon F.T.  Breastfeeding and subsequent social adjustment in six- to eight-year-old children.  Journal of Child Psychology and Psychiatry 1987; 28(3): 378 – 86.

The Case Of The Lactivist Propaganda – A Reply To Ann Calandro

(This post was originally published on the Good Enough Mum blog, in response to a link to Calandro’s essay in a comment on someone else’s blog.  Since the particular comment seems fairly irrelevant now, I haven’t bothered with the references back to it, and have thus edited the beginning and end of it slightly – the substance of the post is unchanged.  You can read the original here.)

It is generally accepted as gospel within the lactivist world that mothers should not only breastfeed, but should, for at the very least the first six months, avoid any exposure at all of their precious babies to that scary horrible formula.  A well-known and particularly lurid example of this is  ‘The Case of the Virgin Gut‘, by Ann Calandro, which I have also seen posted under hammer-the-point-home titles such as ‘Even The Occasional Bottle Of Formula Has Its Risks’ or, from someone who doesn’t appear to have quite grasped the use of the subjunctive,  ‘Yes! Just ‘One’ Bottle Of Formula Will Hurt’.  The content of the article is even more unnerving:

Since my baby had received lots in her stomach besides breast milk, her little gut was not virginal. What did this mean? Had the hospital nurses inadvertently done some kind of damage to her? Had I? What was going on inside my little girl?

But what happens when breast milk is not the only food in that little gut? The truth is very interesting and also very scary.

…destroying the characteristic intestinal flora of the breast-fed baby. [This one was a quote from a breastfeeding book.]

…there is very little that can be done to remedy the situation and save the virginal gut.

A huge increase in diarrheal diseases occurs in babies who do not have optimal “intestinal fortitude,” which is only possible with guts that have never been exposed to infant formula.

Not to mention, of course, the story of the baby who had a few innocent-seeming bottles of formula and then developed a severe allergic reaction to cow’s milk and was rushed into hospital and had stacks of medical tests and nearly DIIIIIIIEEEEED, all because of that scary formula.  If you can make it through that lot without being reduced to a quivering wreck at the prospect of your baby possibly ending up consuming some formula and being irrevocably damaged, you’re a much more confident mother than I was in those scary first-time-around days.  It’s thanks to that article, and others like it, that breastfeeding my first baby was turned from the pleasant and relaxing experience it should have been to a miserable, anxiety-ridden chore haunted by the fear of dire consequences if I fell down on the job the least little bit.

Which is terribly sad.  Because – surprise, surprise – despite Calandro’s claim that there is ‘much research to support avoiding supplementation if at all possible’, the available evidence doesn’t really seem to support her alarmist tone.

There’s not much back-up, for example, for the claim that risks of diarrhoea are hugely increased.  A study in New Zealand in the late ’70s comparing babies receieving various amounts of formula in their diet with exclusively breastfed babies (Fergusson et al, the Australian Paediatric Journal, 1978, vol 14(4), pages 254 – 8) found that giving some formula supplements to breastfed babies on an irregular basis carried slightly greater than a one in twenty chance of causing diarrhoea. Now, those were the figures unadjusted for possible confounders, so that will in fact be an overestimate – and it’s still hardly the ‘huge risk’ claimed by Calandro. And that, of course, is more than thirty years ago, when sterilisation techniques were poorer than today. What do more recent figures look like? Well, a 1997 study available in Pediatrics looked at the infection rates in babies receieving different proportions of formula in their diets. Babies getting formula supplements up to around 10% of their total diet showed *no* increase in rates of diarrhoea over babies who were exclusively breastfed. Seems like all those babies were somehow managing to do just fine despite the defloration of their precious virgin guts. Maybe getting a bottle of formula now and again, despite what it might do to bacterial counts, is actually not such a big deal in terms of outcomes that actually matter?

As far as the risk of cow’s milk allergy goes, a couple of studies have indeed shown a small risk of cow’s milk allergy associated with early formula top-ups (in the one for which I have figures, the risk of developing some sort of later reaction to cow’s milk as a result of having had some in the hospital was around one in forty), but the research is actually quite conflicting – another study showed negligible effect, and a randomised controlled trial actually showed a marked decrease in risks of milk allergy in babies with a strong family history of allergy who received formula before having any breast milk. So that one is a possible risk, but far from conclusive.  As for other forms of allergic disease, again, two studies into the effects of early cow’s milk exposure haven’t shown any increase in later risk of allergies.

The increase in risk of developing Type 1 (insulin-dependent) diabetes does seem to be backed up by better evidence, but needs to be kept in perspective – this is effectively only going to be an issue for children who are genetically predisposed to develop Type 1 diabetes in the first place. In other words, only a tiny minority. If your baby has a close family relative with Type 1 diabetes, it’s probably worth trying to avoid any formula in the early months. If not, then this one is likely to be a negligible enough risk not to be worth bothering about.

It’s fair to say that the available evidence, despite what Calandro and her ilk claim, is in fact fairly limited, and can’t currently exclude a small chance that there might be risks associated with even the occasional bottle.  If so, they certainly don’t appear to be wildly significant in practical terms, and neither the evidence for them nor the likely magnitude of them justify the kind of scaremongering Calandro is indulging in. If the only reason you’re giving a bottle is to get your baby used to one, then I think it’s probably worth trying to pump a couple of ounces of milk for that, if possible, rather than giving formula. But, for those parents who’ve already given or need to give their breastfed babies some formula now and again, do I think that these uncertain and largely theoretical risks are worth getting worried about? Hell, no.

Stats.org breastfeeding article, Part 2 – In which we get bogged down in the murky details of statistics

(This post first appeared on the Good Enough Mum blog, here.)

The story so far: Goldin, Smyth, and Foulkes, of STATS.org, claim to have the truth about What Science Really Says About Breastfeeding – unlike the AAP and the NYT, who are, allegedly, using sloppy science and misleading us all on the issue.  They start out their article by listing what would appear to be every possible or potential breastfeeding-related problem they could manage to come up with.  Having thus set the scene for their impartial and unbiased approach to the subject, they proceed to discuss the statistical evidence.

Hang onto your hats – we may have to start getting technical at this point.  If I’m going too fast, just wave your arms at me and yell loudly, or something.

The article does raise some crucial points about the difficulties with research into breastfeeding.  As they point out, it is not possible (for obvious ethical reasons) to conduct the gold standard of research – a trial in which mothers are assigned by the toss of a coin or equivalent procedure into breastfeeding or non-breastfeeding groups.  (One point that I must make here, to soothe my pedantic little soul – this type of trial would be a randomised controlled trial, not, as they called it, a ‘case-controlled study’.  A case-control study is something completely different.  While it doesn’t ultimately make a difference to the point they were making, I did find it bizarre that two statistics professors could make such an elementary mistake.)

Non-randomised studies have a flaw in them from the start – they’re subject to what we call  confounding factors.  Mothers and babies who breastfed are likely to differ in other crucial ways from mothers and babies who didn’t.  Women who choose to breastfeed may well be making other choices about their parenting that differ from those of women who choose to formula-feed; women who are unable to breastfeed or to continue breastfeeding may have been rendered unable by some factor that, in itself, is relevant to the baby’s health.  This makes it difficult to know to what extent the differences found between breastfed and non-breastfed babies are due to the breastfeeding itself, and to what extent they’re due to factors that tend, in practice, to be associated more with breastfeeding than with formula feeding or vice versa.

There are statistical ways to take confounding factors into account in a study analysis and hence cancel out their effect on the end results, and any good-quality research will do this as far as possible.  The problem, however, is that we can only do that for confounders that we know of and can collect data on.  This is a potential source of bias in any non-randomised study.  It’s an inevitable flaw in breastfeeding research, and STATS.org are quite right to point it out.

However, using this problem as a reason to be appropriately cautious about interpretation of results is one thing; using it selectively as an excuse to reject only the research whose results you don’t like is another.  I’ve previously mentioned one of our most deep-rooted sources of bias; our tendency to reserve our criticisms of study design only for studies whose conclusions we don’t like.  This article was, as it happened, the perfect example.  Smoking can no more be randomised than breastfeeding can, and hence all our existing research into the harms of smoking in humans is based on non-randomised studies. But STATS.org’s criticism of the research into breastfeeding (which they ultimately dismiss as “voodoo science”) stands in stark contrast to their unquestioning acceptance of the research showing that smoking during pregnancy is harmful.

Please don’t misunderstand this: I am not saying that smoking during pregnancy is harmless.  Quite the reverse.  I am saying that in spite of the flaws inherent in non-randomised studies, we have no problem saying that the research on smoking and pregnancy is sufficient for us to accept a harmful effect.  We don’t dismiss that evidence out of hand simply because the studies aren’t perfect; and, similarly, we are not justified in simply dismissing the huge number of studies that show beneficial effects from breastfeeding.

A far more realistic and constructive approach would be to consider what criteria a good-quality study should fit, pick out the studies that met those criteria, and consider the strengths and weaknesses of the evidence overall.  An article aimed at doing that could have been both useful and fascinating.  (Writing it is on my list of things to do in that mysterious alternative universe I keep hoping to stumble into where I actually get large amounts of spare time.)  Goldin, Smyth and Foulkes, however, simply seem to have picked out a few studies they could pick at and acted as though these were representative of the body of research generally.

For example, the article’s conclusion that the benefits of breastfeeding are limited to ‘certain kinds of low-risk infections’ seem to be based largely on analysis of a single study. Not only was the study in question fairly small, but, from the STATS.org description of it, it seems the two groups being compared could be roughly described, not as “ever breastfed” and “never breastfed”, but as “sometimes breastfed, quite a lot of formula” and “sometimes formula-fed, quite a lot of breastfeeding”.  This is a design flaw that is automatically going to cause the study to underestimate any breastfeeding benefits, because the effect is going to be so diluted by the overlap between the groups.  In view of these problems, it’s telling that this study came up with any benefits for breastfeeding – we really can’t deduce much from the fact that the benefits it found were limited.  STATS.org, however, seem to be taking it as the final word on the matter.

Now, the AAP position paper on breastfeeding from which STATS.org takes this reference cites – by my count – sixty-eight references for studies showing possible short-term or long-term benefits for breastfed babies (plus fourteen references to potential benefts for the mother).  STATS.org single out a grand total of five of these for specific discussion (if we count the passing mention of the studies on breastfeeding and diabetes as ‘discussion’).  So, out of all those dozens of studies, why did STATS.org place so much weight on one that seems so likely to underestimate benefits of breastfeeding?

The only reason we’re given why this particular study is singled out for mention is that it is, supposedly, an example of one of many studies that, according to STATS.org, “simply didn’t find what AAP claimed they did”.  In other words, STATS.org claim that AAP are making incorrect claims about study findings.  A serious accusation indeed.

Except that it doesn’t seem to be true.  Or, at any rate, the authors totally fail to produce any evidence to support it.  They claim that the lack of difference of rates of respiratory infection in the study “contradicts the AAP’s claim that there were decreased upper and lower-respiratory illnesses for nursed babies”.  But the AAP didn’t claim that this particular study showed a difference in rates of respiratory infection.  They say that it showed a difference in rates of diarrhoea – which it does indeed.  (They cited nine studies as reference for their claim that rates of respiratory tract infection are decreased.  Goldin, Smyth and Foulkes discuss none of these.)

Are the authors deliberately lying, or are they just very sloppy about checking details?  Either way, it doesn’t say much for their reliability.  We are given no details on the other supposed studies that “simply didn’t say what the AAP claimed they did”, so I couldn’t assess whether there was any truth to this claim at all. However, this mistake on the part of STATS.org doesn’t bode well.

What did STATS.org tell us about the other studies it discussed?  The most important was the Chen and Rogan study on which the AAP base their claim of reduced mortality in breastfed babies.  STATS.org dismiss this on the grounds that the study showed that breastfed infants were less likely to die of injuries.  True, but certainly not the whole truth.

There’s another statistical concept that needs explaining briefly here – the idea of statistical significance.  Simply put, statistical significance is the likelihood that any findings in a study are down to something more than just coincidence.  It’s normal to get small differences between the outcomes in two groups purely by chance, just as it’s normal to get 501 heads rather than 500 if you flip a coin a thousand times.  But if a thousand coin flips come up with 600 heads, there’s probably something about the coin that’s giving you that result; and, similarly, the larger the differences in outcomes between two groups that differ only in the factor you’re studying, the larger the likelihood that the differences in outcomes are genuinely due to differences in that factor rather than to sheer coincidence.  By convention, once the chances of getting a particular result by sheer chance are less than one in twenty then that result is held to be ‘statistically significant’.

The difference in size between two outcomes necessary for the result to be statistically significant depends, among other things, on the frequency of the outcomes.  With small groups, a tiny difference between the numbers is less statistically significant than it would be with big groups.  (If you flip a coin 1000 times and get 600 heads, there’s probably something odd about the coin – if you flip a coin 10 times and get 6 heads, there’s nothing particularly significant about that, even though the proportion of heads is the same in each case.)  Hence, when you’re studying an outcome that’s as rare as infant death in the USA fortunately is, a difference between the figures in two groups has to be quite a sizeable percentage of the overall numbers in order to show up as statistically significant.  The more you split the groups down into sub-groups, the less likely it is that even a genuine difference will achieve statistical significance, because there just won’t be the numbers for it to do so.

This, as far as I can tell, is what seems to have happened in the Chen and Rogan study.  The author looked at death rates across the board (the only causes excluded from their analysis were cancers and congenital birth defects).  Death rates were down overall and in each subgroup studied.  However, when the deaths were divided into separate groups, although each group showed a reduction in death rates, the groups of babies dying from infections, SIDS, or other causes were too small for a small difference to show up as statistically significant.  It’s only when you combine all the deaths from all causes that you get a group large enough for the statistical significance to show up.

Now, this study is certainly not without flaw (something the authors themselves freely acknowledge).  And it’s also worth noticing that even if the 21% reduction in death rates is the true figure and not due to some confounding factor for which the authors couldn’t adjust, that equates to an extremely small risk for any individual formula-fed infant – that level of risk would mean that for every fifty thousand children not breastfed, nine would die as a result.  But looking at the results realistically is one thing; dismissing them on spurious grounds because they don’t happen to suit you is another thing entirely, especially when other studies have come up with similar evidence.  (STATS.org tell us that the reduced rates of SIDS in this study weren’t statistically significant; what they don’t mention are the other studies cited by the AAP that show a possible link.)

The only other three studies about which STATS.org had anything to say were the three pointing towards a possible association between breastfeeding and decreased risk of diabetes.  Two of these were apparently dismissed on the grounds of being based on Chilean and Pima Indian children respectively (why this should be grounds for ignoring them was not explained).  The third study, the authors claim, “only found results for children exposed to food. Infant formula wasn’t even considered!”  Which is most peculiar, because when I checked out the abstract it certainly mentioned finding an association between diabetes and early cow’s milk exposure (in babies who were already at high risk of diabetes), and cow’s milk was a major ingredient of formula last time I checked.

Of course, although STATS.org are incorrect in saying that no benefit has hitherto been shown of breastfeeding as far as diabetes prevention goes, it’s true that the evidence so far is still in the early and tentative stages.  But the AAP’s paper doesn’t try to claim otherwise – diabetes was one of the conditions listed in the section that specified “Some studies suggest decreased rates… Additional research in this area is warranted.”  So, again – why did the authors single out this particular topic for further discussion, when several important risks for which the AAP do claim strong evidence of benefit from breastfeeding (meningitis, sepsis, necrotising enterocolitis) were ignored?

Because, it seems, this was their chance to get in a swipe at the NYT.  “The Times takes the concept that an indictment is as good as a conviction to new heights” trumpet the authors, under the subheading “Baseless reporting”.  What they conveniently omitted to mention was that the Times did actually specify that there wasn’t enough evidence to prove a link.  I don’t know whether STATS.org are bashing the NYT solely in order to discredit what they have to say about breastfeeding, or whether it’s actually the other way round and they have some grudge against the NYT which is colouring their interpretation of subjects on which the NYT report.  What I do know is that by this stage it was clear that, whatever the authors pretended, they weren’t even attempting to look at the NYT article impartially.

They use the same technique of telling only part of the truth in order to pooh-pooh the AAP’s conclusions about the economic benefits of breastfeeding.  The AAP, they say, “is not officially in the business of making economic calculations” (side note: is that true?  As an employee of the National Health Service, I’m intrigued by the idea of a country in which a major medical body can get away without being in the business of making economic calculations), and their arguments about the economic benefits “are simply bad (social) science, and are fed by conviction or opportunism rather than hard evidence”.  But what they fail to mention is that the AAP aren’t simply making it up as they go along; they cite four studies and two economic analyses (which appear, from the government think-tanks mentioned in the article, to have been done by people who are officially in the business of making economic calculations) as evidence for their claims.  (One of the studies was a comparison of breastfeeding and formula-feeding among employed mothers, making a nonsense of STATS.org’s claim that economic benefits would be cancelled out by the incompatibility of breastfeeding and full-time employment.)

So, the authors conclude, what should we take away from this?  Their “inescapable conclusion” is, apparently, that it is “nothing short of irresponsible” for a public health campaign to have compared not breastfeeding to smoking during pregnancy.  (This was, apparently, their biggest concern with the whole NYT article; I was somewhat amused that it was that, rather than the comparison with riding a mechanical bull during pregnancy, that apparently struck them as shockingly inappropriate.)

They also make one rather good point in their conclusion; namely, that we take risks every day, with our children as well as ourselves (crossed a road with your child recently?), and that it’s quite normal to accept a certain amount of risk if you feel the benefits are worthwhile.  But to make these sorts of choices, we need accurate information about what the risks and benefits actually are.  On the subject of choosing not to breastfeed, STATS.org mislead us sadly, and to an extent that can only be deliberate, about both.

Stats.org breastfeeding article, Part 1 – Spin The Breast

(This article first appeared on the Good Enough Mum blog, here.)

The post I’m writing about the STATS.org breastfeeding article is getting so long that I’m splitting it into two parts.  I’ll look at their use of data and statistical analysis in the second part, but first I wanted to discuss the view of breastfeeding Goldin, Smyth and Foulkes present at the beginning of their article.

They start out by stating that “the costs of nursing are substantial”.  If they had genuinely been out to present a fair and balanced viewpoint, a statement that the costs of nursing can be substantial for some women would have served that purpose much better.  I struggled to nurse a baby with a tongue tie despite a sad lack of local facilities for the simple procedure that would have put things right, and then pumped regularly for eight months after my return to work; I know damn well that breastfeeding can sometimes be difficult.  And my experience was a bed of roses compared to that of some women I know.  But we’re the exception rather than the rule.  For the majority of women, breastfeeding is actually a lot easier overall than formula feeding.

I say “overall” because the first few weeks can be difficult, and breastfeeding at this stage often is more difficult than formula feeding.  However, by far the most common experience of women who can hang in there for long enough to get through the initial difficulties is that a few weeks down the line, breastfeeding becomes much easier than formula feeding, to the point where it’s well worth the initial investment of time and energy even from a purely practical point of view.  The problems settle down, and you can enjoy not having to spend your time over the rest of the first year mixing formula or sterilising bottles.  Of course it doesn’t always happen this way – sometimes the problems don’t settle, and sometimes they’re so severe in the first few weeks that a woman just can’t get past them (although these situations would happen far less frequently if all women had proper advice and support).  But a sweeping statement that the costs of nursing are substantial is unwarranted scaremongering.

The article continues: “[T]he reduced time for work due to the need to pump, nurse, eat and sleep has a huge economic and social impact on women and their families.”  Pumping can certainly be a hassle, though it’s not necessarily as negative as they make out – as I said, I pumped at work for eight months, and neither my employers, my family nor my salary suffered as a result.  I just rearranged my schedule to spend the pumping sessions on the paperwork and phone calls that would have had to be done in any case.  It was boring and a nuisance, but it was doable.  I know that this depends on the job and there are a lot of women for whom pumping at work just isn’t an option – but for a lot of others it’s perfectly feasible, and it’s a possibility of which I’d like to see more women aware.  (Mixed feeding is also an option that should be mentioned much more frequently than it is – women who want to breastfeed but can’t/don’t want to pump at work can nearly always still nurse during the times they’re at home.)

But I’m a little confused as to how eating and sleeping ended up on a list of supposed disadvantages of nursing; if I hadn’t breastfed, would I somehow have been magically transformed into a superhuman who could eschew such frailties and work 24/7?  I’m also not quite sure why nursing is supposed to take more of women’s time than formula feeding would (surely the reverse is more likely to be true?), unless the authors are trying to suggest that women shouldn’t feed their babies at all but should palm this task off entirely on others while they go and dedicate their time to earning money.

The article continues with a discussion of possible disadvantages of nursing which appears to owe more to a weakness for popular myth than to an attempt to present the facts in a reasonably balanced way.  It is indeed possible that an unsuccessful attempt at nursing could worsen depression, but it’s also possible, given the anecdotal evidence of nursing triggering hormonal reactions that lead to relaxed euphoric feelings, that nursing could actually offer some protection against post-partum depression.  (In the absence of prospective studies, we can only guess.  That applies to STATS.org too.)  Nursing can sometimes be painful, but something that is not nearly as widely known as it should be is that pain, far from being an inevitable part of nursing, is nearly always an indicator of a problem that can be straightforwardly solved. There are indeed sometimes medical reasons not to breastfeed, but there are also sometimes medical reasons not to exercise, and for some reason we don’t tend to see that disclaimer showing up in discussions of the overall health benefits of exercise.

CMV infection via breastmilk can affect premature babies, but a quick search through Medline shows that the currently available evidence doesn’t support this being a major problem, and STATS.org somehow failed to mention that the risk doesn’t seem to affect full-term babies.  Drug addicts may well, depending on the drug, be better off not nursing, but I wouldn’t go so far as to call this conclusion obvious – I was told by one of the paediatric consultants I worked for that, apart from cocaine, no drugs are absolute contraindications to breastfeeding, and I know there’s a theory that it may actually help ease withdrawal symptoms in a neonate.  Maternal smoking or drinking may affect breastfed babies, but don’t seem to do so at low levels.  And while some mothers genuinely don’t have enough milk, it’s worth knowing that most of the mothers who think or have been told they don’t have enough actually could have with the proper advice.

Most of what the authors say is not, technically speaking, actually inaccurate.  The problem is with the spin they put on it.  They seem to be setting out to present breastfeeding in as unmitigatedly negative a way as they can.