The AAP's New Breastfeeding Guidelines Are Completely Tone-Deaf
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Last week, as many parents of young children were celebrating that COVID-19 vaccines finally were available for children under 5, the American Academy of Pediatrics released an updated policy statement about breastfeeding. In addition to the previous recommendation that babies are exclusively breastfed for six months after birth, it ups the ante: "Furthermore, the AAP supports continued breastfeeding, along with appropriate complementary foods introduced at about 6 months, as long as mutually desired by mother and child for 2 years or beyond."
Immediately, parents responded with a flurry of reactions, the most overwhelming being a resounding: Two years? Really?
Considering the last few overwhelming, nearly impossible years of parenting, particularly mothering, the new recommendation seemed incredibly tone-deaf. Mothering in America has never been easy. We remain the only modern, industrialized nation without guaranteed paid family leave, a dedicated time that many experts say is crucial for successful breastfeeding and is also, simply, a vital time for new parents to bond with their children. We are also in the midst of a childcare crisis due to soaring costs (outpacing the cost of college in a majority of states) and continued worker shortages. The pandemic made parenthood exponentially more difficult, leading to millions of women leaving the workforce. They still haven’t returned. And a few weeks ago, the Supreme Court overturned Roe v. Wade, stripping millions of the ability to decide when to become a parent in the first place.
Breastfeeding for the previously recommended 6 months has been a difficult enough goal for many nursing parents. Until 2018, nursing in public was not legally protected in all 50 states. And the PUMP Act, which would have protected the right to pump breastmilk at work for millions of nursing people, failed to pass just days after the AAP updated its recommendations. As the formula shortage continues, a recommendation for a longer period of breastfeeding only reinforces a damaging (and sometimes deadly) stigma for new parents and babies.
Reading through the guidelines, Suzanne Barston, a writer and editor who has spent a decade researching infant feeding, was struck not only by the recommendation itself, but at how the update didn’t seem to be based on any particular research. “Nothing has changed [in the science],” says Barston, the author of Bottled Up: How the Way We Feed Babies Has Come to Define Motherhood and Why It Shouldn’t. “You would think there would be some impetus for why they would make such a leap to two years.”
What has changed, she explains, is the understanding of the overwhelming pressures new parents feel to breastfeed. The backlash to “breast is best” has been steadily growing for years as more and more parents are sharing their struggles with exclusive breastfeeding, from insufficient supply to harrowing lack of sleep due to multiple middle-of-the-night nursing or pumping sessions, to the struggle to find appropriate places and significant time to pump when returning to work. Yet, these guidelines don’t take any of these very real concerns into account.
“We know that women feel extremely pressured,” she says. “There has been a lot of evidence that moms do feel judged. And there’s no acknowledgement of that. So really what [the AAP is] asking is pediatricians to have conversations telling [new parents] that this is a fundamental public health concern, but it is based on no substantial new research which is really disingenuous.”
Emergency physician Christie del Castillo-Hegyi and Jody Segrave-Daly, a registered nurse, have seen firsthand the extreme pressures new parents have faced striving to follow recommendations that they exclusively breastfeed and the heartbreaking consequences for both new parents and their babies. They co-founded the Fed Is Best Foundation, a nonprofit that works to identify critical gaps in current breastfeeding protocols, guidelines and education programs, as well as to provide families and health professionals the most up-to-date scientific research, education and resources to practice safe infant feeding with breastmilk, formula or a combination of both.
“It’s harming babies,” del Castillo-Hegyi says of the universal recommendation that all babies be exclusively breastfed. “Babies are failing to thrive. They are being admitted for jaundice and dehydration because their mother’s milk is not sufficient or not coming in on time.”
Segrave-Daly continues, “If you’re going to be implementing these guidelines, our babies need to be protected. And they’re being used for a policy that has weak scientific evidence.”
That’s not to say there’s anything wrong with the desire to exclusively breastfeed for those who want and have the means to do it. And some are hoping that the guidelines can work to normalize and support breastfeeding and extended breastfeeding particularly for groups that have been largely disenfranchised by the healthcare system as a whole, specifically calling for addressing “implicit bias, structural bias and structural racism” all of which have created large disparities not only in breastfeeding rates but healthcare in general.
Dr. Kimarie Bugg is the CEO of Reaching Our Sisters Everywhere, Inc. (ROSE) which was founded in 2011 to address breastfeeding disparities in the African American community. Bugg says that aspect of the updated guidelines is needed to combat the continued disenfranchising of Black families prevalent in nearly every other aspect of healthcare in this country. “It has been a Herculean effort,” she says, referencing the decades-long work, dating back to 2000 with then Surgeon General David Satcher’s Blueprint for Action on Breastfeeding, which made direct reference to the low breastfeeding rates in minority communities.
She says she witnessed these disparities in her work, recently seeing three breastfeeding mothers in a support group all be told individually by their pediatrician, at 1 to 2 weeks, that they would need to supplement because their babies were not growing as fast as they’d like. “Three out of three is just ridiculous,” she says, explaining how each mother consulted a lactation specialist and ended up not needing to supplement as their babies were growing fine on the growth chart by the next visit.
“Besides just putting out the guidelines, there needs to be training and education, which there is not,” she says. “What we really need is for pediatricians to learn how to speak to families about breastfeeding. We have a long way to go to combat this.”
Still, many are balking at the extended timeline for exclusive breastfeeding and the particular focus on parents themselves. Barston points out the extreme gender dynamics extended breastfeeding would lead to. “You can’t just put blinders on,” Barston says, referring to the fact that the guidelines, if followed explicitly, could take the breastfeeding parent out of the workforce for two years, per child, or at the very least saddle them with multiple pumping sessions per day.
And Segrave-Daly says the guidelines are promising things that breastfeeding simply cannot deliver. “They’re saying at two years it boosts the immunity, but immunity from human milk is passive,” she says. “And it's also dose dependent, which means if you’re nursing your toddler twice a day, they’re just getting a little swig. So those benefits are moot. It’s nutrition, obviously, but saying it's for their immune system is just incorrect.” She adds that, at 2 years old, even children who are extended nursing derive most of their nutrition from solid food and immune protection for vaccines.
When looked at this way, the new recommendation becomes yet another example of individual parents being tasked with solving structural, institutional and public health crises.
Many are hoping these new recommendations will lead to not only the de-stigmatization of extended breastfeeding, particularly in public, but even more dramatic policy changes. The idea being that stating what’s best for babies could force changes around guaranteed paid leave, the right to pump in the workplace, to subsidize childcare or pay parents for their caregiving time. To get lawmakers and policy makers to actually, finally, truly care about parents and children enough to make real and necessary change outside of more weight on the shoulders of parents.
But, even if that is the case, the fact remains that we should not have to sneak these beneficial, progressive family policies in through the backdoor via incredibly burdensome recommendations that feel near impossible to achieve in the real world. Nor should we have to tie them so explicitly to policies that actively work to reinforce traditional gender stereotypes, set up a gender hierarchy in heteronormative couples, and tether birthing people to the home in a way that doesn’t allow them to fully participate in public or working life.
“Co-parenting is really the foundation for our modern day parents,” Segrave-Daly says. “To be able to pay the mortgage, to keep their careers, and to provide nutrition for their baby. [The guidelines] don’t mention any of that.”
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