The Case For Rethinking Breastfeeding Goals

Scores of parenting sites and Facebook commenters remind mothers, relentlessly, that “breast is best.” (Photo: lolostock via Getty Images)
Scores of parenting sites and Facebook commenters remind mothers, relentlessly, that “breast is best.” (Photo: lolostock via Getty Images)

Before she had her first baby two years ago, Stephanie, 36, was hellbent on following the breastfeeding guidelines set forth by major public health organizations to the letter: Her son would get nothing but breast milk for the first six months and she would continue to breastfeed him for at least a year.

Almost immediately, Stephanie’s plans began to slip away from her. She was rushed into an emergency cesarean section that left her utterly drained. She nursed her newborn around the clock, but he struggled to bulk up and required regular weigh-ins. About one month in, Stephanie met with a lactation consultant who watched her nurse and offered an assessment: First, the baby’s mouth had some structural issues that can make latching difficult. And second, he wasn’t getting enough food.

“She said, ‘Just feed him a bottle and I guarantee he will be a different child,’” said Stephanie, a Virginia-based attorney who requested that only her first name be used. “I gave him one and he sucked down two ounces and immediately fell asleep. From that point on, we supplemented with formula.”

Stephanie’s relief was instantaneous. Her baby was finally satisfied. Her husband could give him a bottle at night, which let Stephanie stitch together more than an hour and a half of continuous sleep. That rest provided a small buffer against the symptoms of anxiety that had sprung up during her pregnancy.

But she also felt as though she was — as she described it — in mourning. No one in her life expressed any kind of disappointment in her decision to supplement with formula, but Stephanie felt like she had failed her first big test as a mom.

“They paint it as if breastfeeding is the most natural thing you can do … so when you fail at it, you’re failing at something you ‘should’ have been able to do as a woman,” said Stephanie, who eventually switched over to formula entirely.

And “they” in this case truly means everyone — from major medical organizations to overzealous strangers who scold moms for buying formula. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding — which means only breast milk and any necessary medicines and supplements, no other liquids or foods — for the first six months of a baby’s life. So does the World Health Organization (WHO). Then there are the scores of parenting sites and Facebook commenters who remind mothers, relentlessly, that “breast is best.”

But there are reasons to consider modifying the goal of only breast milk for six months, because women don’t have enough support to hit that target. And the science behind that goal isn’t as black-and-white as many evangelists make it seem. Historically, many studies have failed to differentiate between exclusive breastfeeding and any breastfeeding, meaning women who have given their babies some breast milk, but not necessarily only breast milk.

Breastfeeding rates declined steadily in the first half of the 20th century as formula became readily available and was widely marketed to mothers. But they began to creep up again by the 1970s thanks to groups like La Leche League and studies suggesting breastfeeding keeps babies alive. By 1989, the U.S. Surgeon General was proclaiming that breastfeeding benefits society at large and by 1997, the AAP recommended exclusive breastfeeding for the first six months of a baby’s life.

But the fact remains that there are far more mothers around the world who do not feed their babies breast milk only for the first six months of their lives than there are women who do. Globally, only 40 percent of babies are still exclusively breastfed until six months, according to the World Health Organization. In this country, only 41 percent of babies are exclusively breastfed at three months, and by six months closer to 20 percent are. The WHO and UNICEF have said there is not one single country — anywhere — that sufficiently supports breastfeeding mothers through measures like paid parental leave, workplace protections for moms who pump and access to breastfeeding help. Issues like these are also infinitely more challenging for low-income women with unstable jobs.

So why has the recommendation of six months exclusive breastfeeding become public health gospel both here and abroad — a target that so many mothers strive for and so many fail to reach?

A Blunt Approach To A Nuanced Problem

There are plenty of health benefits associated with breastfeeding, particularly in poor, resource-strapped countries. The WHO recommends exclusive breastfeeding for six months in no small part because it helps prevent diarrhea in areas where contaminated food and water are common, and where recurrent infections regularly lead to life-threatening malnutrition. One in 9 child deaths worldwide are due to diarrheal diseases, making it the second leading cause of deaths in children under the age of 5.

The fact that breastfeeding very clearly reduces those types of infections in parts of the world where they remain a clear, deadly threat explains why — from a global public health perspective at least — it is incredibly important to promote, Dr. Valerie Flaherman, an associate professor of pediatrics at the University of California, San Francisco, told HuffPost.

Notably, poorer countries tend to have higher rates of breastfeeding than wealthy ones partly because many don’t have what some Western researchers call a “bottle culture,” where breastfeeding isn’t the norm and is even looked on as somehow shameful or sexual, and partly because it’s much more clearly a matter of life and death.

But in developed countries, the immediate benefits of breastfeeding are not necessarily as clear-cut, “because diarrheal disease is not a major cause of infant mortality here,” Flaherman said.

That is why the AAP tends to highlight other health research in its promotion of breastfeeding to American doctors and moms. The group points to research that has shown a decreased risk of respiratory tract infection, a reduced risk of Sudden Infant Death Syndrome and even a drop in the risk for Type 1 diabetes. The AAP also singles out the potential benefits for moms, like decreased postpartum blood loss and even a drop in subsequent breast cancer risk.

But while many of the studies that are the basis of the AAP’s recommendations distinguish between exclusive breastfeeding and “any” breastfeeding — i.e. moms who offered their babies some amount of breast milk, but not necessarily only breast milk — others do not. Researchers will not perform randomized controlled experiments directly comparing outcomes in women who exclusively breastfeed, versus those who supplement or opt for formula altogether, which means there is always the chance that the benefits suggested by some studies have more to do with confounding factors than breast milk itself.

That is one reason why a growing chorus of researchers and writers have begun to view breastfeeding not quite as the orthodoxy it once was. In 2013, Flaherman published a very small study that suggested giving some newborns a little bit of formula early on may improve their breastfeeding rates at three months and decrease the likelihood of them being fed formula months later. Last spring she presented findings from a slightly larger follow-up investigation that suggests giving newborns who’ve lost a lot of weight some formula does not necessarily hamper breastfeeding rates. She is currently at work on research looking at the gut health of babies whose mothers supplemented in the first three months versus those who did not to see what differences, if any, exist.

Although those studies have been small, they have generated significant media attention — in part because they offer exhausted moms the appealing possibility that breastfeeding does not necessarily have to be all or nothing as the public health goals would seem to suggest. A sweeping 2016 review of studies looking at the exclusive breastfeeding recommendations found there was no reason to change the existing guidance on exclusive breastfeeding. But this wasn’t because the idea of supplementing is somehow preposterous. It was because the quality of the existing research on the topic is insufficient.

“The full truth is that many babies end up requiring some formula at some point despite maternal intention to breastfeed exclusively,” Flaherman said. Some of the countries that are held up as models of breastfeeding success, like Norway, are full of mothers who supplement. Surveys suggest that from the 1960s to the early 2000s, the number of moms breastfeeding jumped from 20 to 80 percent, but six months out only 10 percent of those babies were being given breast milk alone.

Yet many moms feel supplementing is something they must keep secret or that others will judge them for — even if they themselves believe it’s the only thing keeping their babies happy and fed.

Like Ellen Walter, a 29-year-old mom of a six-month-old. Her daughter has been getting formula off and on from day one following an overnight in the neonatal intensive care unit that led to some initial breastfeeding challenges. She believes that giving her daughter some formula is one of the primary reasons she is still breastfeeding, as it relieved the emotional and physical pressure she felt while waiting for her milk to come in. Now she gives her daughter one bottle of formula a day and breast milk the rest of the time, but she doesn’t really talk to her friends and family about what she’s doing.

“Even close friends who know this is what I do, they kind of ignore it,” she said. “I think they basically don’t want you to know they’re judging you.”

The reality is that while there certainly are women who adore breastfeeding, and who are extremely successful at it, not every woman can make enough breast milk to breastfeed exclusively, Alison Stuebe, a maternal-fetal medicine physician and medical director of lactation services at University of North Carolina Health Care, told HuffPost.

It seems like an obvious statement, yet the internet is awash with articles and comments aimed at reassuring moms that their “perceived” lack of milk is just be in their head, and warning them that if they start supplementing with formula their supply will drop and eventually disappear altogether. Online stores and mom blogs peddle fixes like breastfeeding teas and cookies, which to a woman who is struggling with genuine physiological challenges can make it seem like all that’s missing is a little bit more hard work and ingenuity.

“I do think that some folks who are evangelists for breastfeeding don’t recognize that it is humanly possible to not produce enough milk,” Stuebe said. “You would never say to someone with diabetes, ‘Just squeeze your pancreas more.’”

A Pressing Need For More Support

Then, of course, there is the reality that for working mothers “exclusive breastfeeding” means months of pumping on the job.

One-quarter of moms are back at work within two weeks of giving birth — when they’re still bleeding through their postpartum mesh underwear and mastering the mechanics of sustaining a newborn with nothing but their own breasts — and America has the dubious distinction of being the only developed nation in the world without a paid leave for new moms or dads. Many mothers begin to supplement when they return and find that fitting in ample pump breaks is impossible, or even if they do their pump simply can’t do as good of a job of keeping their supply up as having a hungry baby at the breast.

The real problem, Stuebe believes, is not the core recommendation that all women should exclusively breastfeed for the first six months; it is how that recommendation is communicated to mothers and what is done to actually support them.

Nicole, 35, had been back at work for about a month when she sent her daughter to daycare with a formula bottle for the first time. She got only one break a day to pump — two on good days — and by the time her daughter was 4 months, she simply could not keep up with her appetite. At daycare, her daughter got a mix of formula and breast milk. At home, they nursed.

She was at peace with it. “It was what it was,” said Nicole, who also asked to use only her first name. “My daughter needed to eat.” But other moms take their inability to meet the breastfeeding goals set forth by experts personally, almost like a moral failure. They write personal essays asking if they’re a failure for supplementing with formula, and head to forums in the middle of the night seeking reassurance from other moms.

“I think the huge disconnect,” Stuebe said, “and this is true of all public health recommendations, is our American concept of, you know, ‘pull-yourself-up-by-your-bootstraps.’ That if we tell people, ‘exercise 150 minutes a week,’ that’s all we need to do.”

Yet public health officials say they are confident things are moving in the right direction — and that more can be done to support women in reaching breastfeeding goals rather than scrapping them altogether. Roughly 80 percent of moms in this country now at least start out breastfeeding and more than half are still giving their babies some breast milk at six months, a clear indication they’ve gotten the message that breastfeeding has benefits for them and their babies, Dr. Joan Younger Meek, chair of the American Academy of Pediatrics’ section on breastfeeding, told HuffPost. There are other hopeful signs, like the fact that there are far more highly trained lactation consultants who can help women address their breastfeeding challenges than there were just a decade ago.

“But [women] experience a lot of challenges,” Meek said. “I think our biggest work now is how do we eliminate those barriers to help them be successful, and ultimately support them in whatever feeding choices they end up making. You know, we don’t have to play the blame game.”

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This article originally appeared on HuffPost.