Breastfeeding Medicine

Physicians blogging about breastfeeding

Why we still need to “Watch our language”

with 31 comments

One of the family medicine physicians here at UNC wants to make sure doctors-in-training know the facts. “There are no benefits of breastfeeding,” he tells his students. “There are risks of formula feeding.”

Logically, these two statements are identical, but they feel completely different. In 1996, Diane Wiessinger spelled out the issues beautifully in her classic essay, ‘Watch your language.” Cathy Theys posted it on ABM’s Facebook page Friday. It’s a must-read for anyone who cares about mothers, babies and breastfeeding. Wiessinger writes:

Best possible, ideal, optimal, perfect. Are you the best possible parent? Is your home life ideal? Do you provide optimal meals? Of course not. Those are admirable goals, not minimum standards. Let’s rephrase. Is your parenting inadequate? Is your home life subnormal? Do you provide deficient meals? Now it hurts. You may not expect to be far above normal, but you certainly don’t want to be below normal….

When we fail to describe the hazards of artificial feeding, we deprive mothers of crucial decision-making information. The mother having difficulty with breastfeeding may not seek help just to achieve a “special bonus;” but she may clamor for help if she knows how much she and her baby stand to lose. She is less likely to use artificial milk just “to get him used to a bottle” if she knows that the contents of that bottle cause harm.

A decade and a half later, we’re still talking about the “benefits of breastfeeding,” as though breastfeeding were an optional extra credit assignment for over-achievers, rather than the biologic norm. And yet, I find my voice straining when I use my colleague’s rhetoric, “There are no benefits of breastfeeding.” It’s harder to get the words out than you might think. When I lecture to medical students and residents, my first slide presents the risks of not breastfeeding, but I still feel like I’m apologizing. What if one of the women in my audience couldn’t breast-feed? Will I make her feel guilty?

Wiessinger’s essay takes on the widely-accepted dogma that counseling on the ‘risks of formula feeding’ will make mothers feel guilty:

Most of us have seen well-informed mothers struggle unsuccessfully to establish breastfeeding, and turn to bottlefeeding with a sense of acceptance because they know they did their best. And we have seen less well-informed mothers later rage against a system that did not give them the resources they later discovered they needed. Help a mother who says she feels guilty to analyze her feelings, and you may uncover a very different emotion. Someone long ago handed these mothers the word “guilt.” It is the wrong word….

Let’s rephrase, using the words women themselves gave me: “We don’t want to make bottle-feeding mothers feel angry. We don’t want to make them feel betrayed. We don’t want to make them feel cheated.” Peel back the layered implications of “we don’t want to make them feel guilty,” and you will find a system trying to cover its own tracks. It is not trying to protect her. It is trying to protect itself. Let’s level with mothers, support them when breastfeeding doesn’t work, and help them move beyond this inaccurate and ineffective word.

Formula feeding vs. breastfeedingIn fact, I’ve come to realize that physicians and policy makers cover all manner of sins with the “don’t make her feel guilty” mantra. If we accept that breast is best, but formula is fine, then we’re off the hook when we don’t know how to advise a breastfeeding mother, when we send her home with a duffle bag filled with formula samples, or when we maintain pitiful maternity leave policies that undermine her efforts to sustain breastfeeding. If breastfeeding is extra credit, then it’s up to mom to over-achieve. The rest of us are off the hook.

We need to talk about the “risks of formula feeding” so that we hold policy-makers and health care providers accountable. The “Booby traps” are more than a clever pun: they are a public health problem that’s undermining the health of women and their children.

What about moms who don’t want to breastfeed? When I meet a mom for the first time, I start the conversation by asking, “What have you heard about breastfeeding?” At a recent prenatal visit, my patient scrunched up her face and said, “I’ve heard you’re supposed to do it because it’s good for the baby.” I asked her why she was wincing, and she told me that she has really sensitive breasts, and she’s afraid that nursing will be painful, but she knows she’s “supposed to breastfeed.” We talked for a bit about early feeding and strategies for getting a comfortable latch. I shared with her the data on the risks of not breastfeeding, from more ear infections, diarrhea and pneumonia for baby to more diabetes, hypertension, heart disease and breast cancer for mom.

And then I reminded her that this is her decision. She can breastfeed in the early days, see how it goes, and then decide whether, for her, the pain that she’s anticipating outweighs the risks of formula feeding. If she cringes every time she feeds her baby, breastfeeding may be considerably worse for her and her child than formula feeding. She is the only one who can make a trully informed decision about how she should feed her baby. My goal is for each of my patients to be able to state, in a concise and clear fashion, “I decided to feed my baby this way because… ” It’s uninformed decisions, not well-informed decisions, that lead to guilt and regret.

And when lactation doesn’t work? That’s another blog post, but we still need to watch our language. If we talk about breastfeeding benefits, then breastfeeding is an add-on, not a fundamental part of female reproductive health and wellbeing. Loss of normal function implies a disease that requires treatment. Loss of “optimal” physiology does not.

So read Diane’s essay, and then practice — in front of the mirror, if it helps. “There are no benefits of breastfeeding. There are risks of formula feeding.”

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine.

Written by astuebe

May 3, 2010 at 8:05 pm

Posted in ethics, policy

31 Responses

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  1. Love this. I have often thought the same thing. I do think the language we use is so important and I hope that more people will discuss the risks of artificial milk with their patients.

    Teresa Keever

    May 3, 2010 at 8:20 pm

  2. Excellent! I have heard Diane speak about this and it is eye opening. Thank you!!

    StorkStories

    May 3, 2010 at 9:24 pm

  3. I have a good friend who is a current medical student at UNC. She told me about a class during her first year which was about breast cancer. A student asked about the link between breastfeeding and breast cancer, and the instructor replied that there was no link. My friend was shocked that this was what he was teaching, but didn’t know what to do about it so let it go. I wish more of the faculty teaching the next generation of doctors was more like the one you mention here, who wants students to know the risks of formula-feeding, but unfortunately there are still some that are not up-to-date on breastfeeding, even at UNC, and are passing along misinformation.

  4. Thanks so much for this. I teach Childbirth Ed and I am definitely going to try out “There are no benefits of breastfeeding. There are risks of formula feeding.” in class. The majority of couples coming to my class are already planning on breastfeeding, but I’m sure that statement will bring about a fantastic discussion.

    Also this is SO TRUE: “It’s uninformed decisions, not well-informed decisions, that lead to guilt and regret.”

    Thanks!

    Lori

    May 3, 2010 at 10:14 pm

  5. Excellent article. Now, how do we get MORE physicians on board sooner than later?

    Betsy Riedel RNC, IBCLC

    May 4, 2010 at 6:35 am

  6. Why is it that when we want to impart accurate information about childhood nutrition, such as eat more fruits/veggies, less processed food, healthier snacks, no refined flours/sugars, less fast food, etc., we do not hold back for fear of sending a “guilt message” to some working mom in the audience who relies on frozen/canned veggies,prepackaged snacks, fast food, and never quite got her toddler to love whole whole wheat bread…we seem to have no problem sending THAT message, and we certainly don’t follow this up with “but, you know, if you are really busy, white bread, canned veggies,fast food, and processed snacks are fine”. Even though it is now well known that these eating habits lead to childhood obesity and a host of other illnesses. The phrase “risks of formula feeding” is great, I will now use this!

    clementine

    May 4, 2010 at 5:55 pm

  7. [...] Why we still need to “Watch our language” One of the family medicine physicians here at UNC wants to make sure doctors-in-training know the facts. “There [...] [...]

  8. Thank you for the reminder. I am guilty of talking about the “benefits of breastfeeding” for fear of offending. It feels like such a fine line to walk between educating and inducing guilt, even when I am not trying to assign “blame” or “fault.”

  9. Hear Hear

    Liz Brooks IBCLC

    February 28, 2011 at 5:05 pm

  10. [...] Diane Wiessinger gave us all a critical guidepost for talking about breastfeeding – and an important wake-up call – when she wrote “watch your language” for the Journal of Human Lactation. (Read about the Academy of Breastfeeding Medicine’s take on it here) [...]

  11. YES!!!

    The Badass Breastfeeder

    April 4, 2012 at 12:13 pm

  12. I like this a lot. I just wish more people felt this way. I breastfed my little girl for the first (almost) 8 weeks. Long story short, she is now exclusively formula fed. I felt guilty while trying to make the decision to quit because I knew the risks of formula feeding. However, my emotional well-being was more important to my being a good mom than being able to breastfeed.

    Alysha Elkin

    April 4, 2012 at 3:44 pm

  13. I think Diane Wiessinger’s article is brilliant. My only reservation is that some medical students will stop listening after the first sentence. They’ll learn “There are no benefits to breastfeeding.” — and tell their patients that they learned this in medical school. :( I think we need to leave off any comment about breastfeeding and just start with “Let’s talk about the serious health consequences and illness/death risks associated with formula use.”

    Kathy Dettwyler

    April 4, 2012 at 5:58 pm

  14. Right on

    lindajsmith

    April 4, 2012 at 7:53 pm

  15. Maybe I’m not the intended audience here, and as such have misinterpreted a bit, but as a breastfeeding mother I would like to say that there is huge guilt in hearing the phrase “risks to formula feeding.” I have struggled to breastfeed my LO for very close to 6 months now. I am educated about the fact that this is the natural and best thing for him. I fully believe in its necessity and have researched all of the positive outcomes. I have rallied against daycare workers who try to tell me he should be eating more and he should be given solid supplements before I am ready for him to have them. It has been a battle to get to this point, but I have tried fervently to continue for his health and mine. Now I am unable to keep up with the supply needed to get him through a day of daycare, and am facing the very real need to supplement with formula. It is before I am ready to give up the fight, but if I don’t there will not be any food to feed him. So please try to understand that after working through this battle and trying as hard as I possibly can to do what is best for my son, it is hurtful to think I am harming him by needing to feed formula. I do appreciate your perspective regarding the need for greater support as well as maternity leave policies that support breastfeeding.

    Susan B

    April 4, 2012 at 11:13 pm

    • if he is close to 6 months, the day care can give him baby food instead of formula to fill in where your pumped milk is falling short. He could also be having a growth spurt. Keep pumping and keep offering him your breast when you’re together and he expresses interest – these are the best ways to keep your milk supply going. I have three sons that were all breastfed exclusively for 6 months, my 3rd while I was in my 2nd year of graduate school, and I know it’s hard. It is so worth it though. For what it’s worth, my boys’ favorite first finger food was freeze-dried banana slices. I got them from Trader Joe’s but they also sell them at Target (the Target ones aren’t sliced as nicely). I broke them into small pieces and let the babies have them around 6 months of age, much less messy than carrying around fresh bananas and they turn to swallowable mush almost as soon as they hit the baby’s tongue so they’re not a choking hazard (be watchful with any thicker slices though as they don’t mush as fast). Good luck to you and you’ve done an amazing thing already keeping him on just breastmilk for this long with all the obstacles you mention!

      Ahmie (@DragonMama)

      April 5, 2012 at 10:44 am

    • Hi there. Have you thought about supplements to increase milk supply? I have in the past used more ” More Milk Plus” from http://www.motherlove.com. they also sell them at Whole foods. This increased my milk supply 10 fold. Good luck, you are doing the best for your son!

      Jazzy B

      April 14, 2012 at 6:28 am

    • I am also a breastfeeding mother, for the past 19 months. I understand the low supply dilemma, but honestly, and you have probably heard this before, supplementing with any formula at all will make this problem worse, much worse. I am not trying to criticize, I am trying to offer support and some possible remedies to this issue. I do not know if you have tried anything to increase your supply, but some easier ones are to drink lots of water, lots and lots, and eat oatmeal every day. Also, there are types of herbal supplements which work very well. I tried Mother’s Milk tea which is inexpensive and available at most drug stores. After drinking 3 glasses a day, with a little sugar or honey added for taste, I saw an improvement in my supply after about 3-4 days. Also, you could try Fenugreek which is an herbal supplement in pill form. I do know that stressing over a low supply can cause even more supply problems. Try to always remain calm and remember why you chose to breastfeed in the first place. If your supply problems are drastic, you could talk with your doctor because there are medications that can boost supply, if necessary. As for the problems with daycare, I would have a heart to heart chat with the daycare provider about why they are pushing solids on you. I would come to this chat with research to back up how you feel your child should be fed. Basically every organization relating to children’s health and nutrition recommends not starting any solids at all before 6 months and it should be a slow process. Also, I would recommend researching baby-led-weaning. Some people confuse this term, I do not mean weaning off of breastmilk, I mean weaning onto solids. I know many healthy, happy babies who even reached 10-12 months without ever having solid foods. Also try to remember that breastfeeding has been around since the dawn of time and formula has been around since the 1920s. Humans made it that far without formula and with the proper support and education (except for a select for moms who can not breastfeed which is less than 2%) we can continue without formula. I applaud you for making the conscious choice to give your child the best possible start in life!!! Also, another possibility for supply problems could relate to your pump or how you are pumping. How often do you pump when at work, I would recommend at least every 2-3 hours. Try arriving a little early to daycare with baby and breastfeed him before you hand him over or at least immediately before leaving the house. I had problems pumping and it took me over a year to find out that the part of the pump that is on your nipple (it’s late and I can’t think of the name of the piece), was the wrong size and more of my nipple was inside the tube thingey than it should have been for that particular pump. I would also recommend a double electric pump for full time working moms as it is quicker and easier to pump at work. Also, keep in mind that your breasts refill as quickly as 15 minutes after a nursing or pumping session so frequent pumping, as often as every hour at work, might help. I have heard from some moms that this made them feel to drained of energy and they actually got more milk in the end by pumping every 2 hours, but we each have to figure out what works for us… One last thing, you are awesome for doing this for your child. I know this article has a different perspective that I do relate to, but when you are facing struggles during breastfeeding, it does help to remember that not only is breast best, but that you are great for being an educated parent and making informed parenting decisions.

      foranybody

      April 22, 2012 at 11:11 pm

      • Foranybody, thanks for giving good advice about increasing output while pumping at work. However, I’d have to question your statement that ‘supplementing with any formula at all will make this problem worse, much worse’.

        Why? While formula supplements can certainly cause increased problems with a poor milk supply, the problem isn’t that formula exudes some sort of mysterious anti-supply vibe – it’s the associated reduction in nursing that causes the problem. In this particular situation, however, the problem is that Susan’s work requirements mean that there is already a part of each day where she can’t nurse him. She may, as you say, be able to compensate for this with more frequent pumping, circumstances and physiology permitting; but whether or not her baby gets formula while he’s apart from her isn’t going to change the fact that she isn’t going to be able to breastfeed him during those hours. So it’s hard to see why feeding her baby while he’s away from her would change the supply problem.

        Dr Sarah

        April 24, 2012 at 8:03 am

    • Susan, you’ve identified one of many problems I have with the ‘risks to formula’ approach – it doesn’t really allow for the fact that age and circumstances make a big difference to the question of whether giving formula is actually risky or not.

      You’re not talking about deciding to feed a newborn formula instead of breastmilk. You’re talking about feeding formula to a breastfed six-month-old (in a situation where the alternative would be for him to go hungry, which is hardly going to be to his benefit). And, having done a great deal of reading on this topic as a doctor as well as a mother, I can tell you that I have not yet found ANY evidence that mixed breast/formula feeding for a six-month-old has that much in the way of disadvantage compared to full breastfeeding at that age.

      Most of the benefits of breastfeeding come in the early months, and most are available from breastfeeding with some formula supplements just as they would be from full breastfeeding. Your baby will still be breastfed, and is of an age where he would normally be starting to get some foods other than breastmilk anyway. Why should a bottle of formula be more harmful to a six-month-old than a piece of cheese made from that same cow’s milk would be? Granted, there may be more risk of bacteria breeding in the bottle, but that risk can be minimised by making sure the daycare are careful about using proper sterilisation and hygiene techniques.

      I know there may be people who will misread this and think I’m dismissing the benefits of breastfeeding (or the harms of formula feeding, if they insist on putting it that way). Not in the slightest – like you, I am a very firm believer in the benefits of breastmilk for young babies. I have just not found any research to indicate that giving a breastfed six-month-old some formula as well as his breastmilk does any harm. So, good for you for your work in keeping him breastfed, and rest easy on the question of formula. It’s quite all right for your baby to have formula at day care if he needs it.

      I’m happy to discuss this further if you or anyone else wishes.

      Dr Sarah

      April 24, 2012 at 7:57 am

  16. When I wanted to nurse my first child (who came to us through adoption), my OBGYN offered no support, “I don’t know why anyone gets all up in arms about this. There’s no difference really”. And this was a very young, just out of school MD, who I’d have thought would have had good education about why breastfeeding is so important, and the dangers of formula feeding. Forunately, I didn’t pay any attention to her and nursed him for 6months. Our 2nd son and I are going on 19mon of nursing. While I wasn’t able to produce enough milk through inducing to provide anywhere near as much as they needed, we have been able to use donor breastmilk which meant my 2nd child had no formula from the time he was 2mon old. If more people (MDs, parents) knew about the availability of donor milk, there would be a decreased need for those guilty feelings, because, even if actual feeding at the breast wasn’t an option, breastmilk still would be.

    Becky

    April 5, 2012 at 7:59 am

  17. [...] Why we still need to “Watch our language” « Breastfeeding Medicine. [...]

  18. This is great! I am a licensed midwife in a community where breastfeeding is the norm. When we have a client who is having trouble breastfeeding she will still get messages that she should just stop tormenting herself, depressing herself, starving her baby, etc, from well-meaning people who just don’t understand why she is so motivated to breastfeed. (Don’t get me wrong: if a baby needs calories and donated breastmilk is not available, then the benefits of formula outweigh the risks in this case, but it doesn’t necessarily mean the end of breastfeeding.) Arming her with the “risks of formula” would be very empowering.
    We talk a lot these days about birth trauma but people have breastfeeding trauma, too, especially when they lack support or no one seems to understand why they feel the way they do. We need to hear people’s stories with empathy and without judgment. But we still, as maternal and child health advocates, need to give everyone the best information possible.

    Melanie Dickson

    April 5, 2012 at 11:45 pm

  19. The trouble with Weissinger’s ‘Watch Your Language’ is that, as good as the theory sounds and as popular as it’s been, there doesn’t actually seem to be any evidence to support it (or, at any rate, I’ve never seen Weissinger or any of her followers present any), and there are a number of potential concerns about trying her approach. I’ve written about this at http://parentingmythsandfacts.com/2011/08/12/accentuate-the-negative-eliminate-the-positive-the-problems-with-wiessingers-watch-your-language/

    Dr Sarah

    April 6, 2012 at 10:56 am

  20. [...] posted a link to an article by Alison Steube entitled “Why We Still Need to Watch Our Language” on their Facebook page in recent days; the article goes back to 2010, but has been getting renewed [...]

  21. I like this. I struggled for two months to BF and never got more than 2 oz on my best day. I wanted to BF so badly, but had to use formula because it just wasn’t working. At the time I felt really guilty that I wasn’t making enough milk, but now I know that I did all I could. The reason I like the language this article mentions is that I get so MAD at moms who could BF and choose not to. I don’t think it should be a choice at all– formula should be a last resort, as it was for us. And yes, I did everything I could including taking several supplements and working with our LC several days a week.

    Laura

    April 22, 2012 at 10:43 pm

  22. Thankyou, Alison, for this intelligent, well-written post!

    You are right, an informed-choice is a guilt-free choice. BUT an informed choice can only be made when information is made available! Action is needed to inform healthcare practitioners about the realities of infant formula – what my French publisher calls ‘industrial milk’ – so that they can pass this information to mothers and enable them to make an informed choice.

    For this reason I included an Appendix on Infant Formula in my book ‘Breastfeeding Older Children’ and have posted the Appendix in full under Notes on ‘Breastfeeding Older Children’ Facebook page, see here https://www.facebook.com/pages/Breastfeeding-Older-Children/199651282295?ref=ts&sk=notes

    Ann Sinnott

    Ann Sinnott

    May 20, 2012 at 3:40 am

  23. Can I marry this post? I truly love it.

    thesinglecrunch

    May 20, 2012 at 7:34 am

  24. […] idea of reframing how we talk about breastfeeding vs. formula feeding is not new. But more and more, we as lactation educators and support people are encouraged to talk about the […]


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