Breastfeeding Medicine

Physicians blogging about breastfeeding

Might there be risks of risk-based language?

with 36 comments

Six years ago, I wrote a blog reflecting on Diane Wiessinger’s seminal essay, “Watch your language.” “There are no benefits of breastfeeding,” I wrote. “There are risks of formula feeding.”

That post remains the most-viewed piece I’ve ever written, with more than 74,000 views as of this writing. I’ve taken the lesson to heart. I’ve published a peer-reviewed study on the increased risk of hypertension among women with curtailed breastfeeding, and I’ve flipped odds ratios in teaching slides and review articles to frame associations as the “risk of not breastfeeding” or the “risk of formula,” rather than the “benefits of breastfeeding.”

Weissinger’s 1996 essay rests on the position that breastfeeding is the physiologic norm, against which all other feeding methods should be compared. Moreover, she notes, mothers who are facing difficulties will be more likely to seek help to avoid a risk than to achieve a benefit:

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.

Thus, when we talk about risks of formula, we will motivate mothers to “clamor for help,” and thereby increase breastfeeding rates and improve the health of mothers and babies.

It’s a compelling logical argument. And yet, I’ve been unable to find empirical evidence that it is true. To generate that evidence, we’d need to compare outcomes among mothers and babies counseled that formula increase risk with outcomes among those told that breastfeeding improves health and wellbeing. To my knowledge – and please let me know if there is a peer-reviewed study out there! – such a study has not been done.

risk_rhetoric

In the absence of such evidence, I’ve become increasingly concerned that risk-based language might do more harm than good. In her spectacular keynote address at Breastfeeding and Feminism, Kimberly Seals Allers used a baby bottle with the head of Darth Vader to frame a discussion about how “risks of formula” might be perceived among women of color. For a mother worried that her teenage son might be gunned down for walking down the street wearing a hoodie, “risks of formula” seem pretty trivial. Furthermore, Seals Allers noted, invoking medical experts may ring hollow for communities that remember the legacy of Tuskegee and endure routine undertreatment from medical professionals. Instead, Seals Allers suggests that moms taste infant formula, or read the list of ingredients, and contrast that with mom’s own milk. Similarly, in her address at the First Food Forum, she notes that for her, breastfeeding wasn’t about the health benefits, much less avoiding the risks of formula – it was about rewriting the narrative. (If you haven’t yet seen her talk, stop reading, and watch the YouTube Video here.)

Moreover, there’s mixed evidence that fear changes health behavior, particularly for individuals who lack self-efficacy. In an analysis of six studies that measured threat and self-efficacy, Peters and colleagues considered the impact of threat-based health messages on people with high vs low self-efficacy. Among those with high self-efficacy, threat-based messages worked well – if I learn that sedentary behavior increases my risk of dying, and I can go for a run every morning on a safe, well lit route, and have time to shower and dress before my work day begins, then the threat of premature cardiac death may be effective to get me to work out. But if my home faces a busy roadway with a 55 MPH speed limit, no shoulder and no sidewalks, and I can barely punch in on time at my low-wage job after my kids board the school bus, it’s a very different story.

In a breastfeeding context, messaging that formula feeding increases childhood leukemia risk is unhelpful for the 22% of employed women who return to the workforce by 10 days postpartum, or for the mother who lives 3 hours from the nearest lactation consultant. If the purpose of risk-based language is to motivate mothers to clamor for help, there has to be help within clamoring distance.

Indeed, evidence suggests that when the recommended health behavior is not possible, threat-based messaging might actually INCREASE the undesired behavior, because people shut-out messages that they cannot act upon. The figure shows how Peters and colleagues conceptualize this in their paper.

rhpr7_S8_f1-2

The left graph shows the effect fear appeals have in theory (the black line represents the effect under high efficacy, the grey line the effect under low efficacy, and the dotted line is the main effect observed when efficacy levels are disregarded); the right plot shows the distribution of threat and efficacy associated to a random sample of behaviour-population combinations. (Peters el al)

This is of particular concern for the effects of risk-based messaging on health equity, because many women of color live in First Food Deserts that lack support and resources for breastfeeding. In this context, it’s plausible risk-based messaging might turn them off from breastfeeding entirely.

The message that formula is risky is further fraught by the fact that a substantial proportion of infants born in the US require supplementation. Delayed onset of lactogenesis is common, affecting 44% of first-time mothers in one study, and 1/3 of these infants lost >10% of their birth weight. This suggests that 15% of infants — about 1 in 7 breastfed babies — will have an indication for supplementation. If we counsel women prenatally that Just One Bottle will permanently alter the infant gut, then we set up 1 in 7 mothers to believe the horse is out of the barn in the first week of life. A mother might even conclude that the damage has been done, so she might was well wean altogether.

In my own clinical work, I see another potential unintended consequence of risk-based language. Many of my patients are coping with excruciating pain, minimal milk production, or postpartum depression. Some have internalized the “risk of formula” messaging such that they are clenching their teeth and dreading every feeding, yet soldiering on because they believe that “every time I feed formula, I am poisoning my baby.” While one might argue that “risk based language is working,” because this mother-baby dyad is still exclusively breastfeeding, it’s not at all clear to me that risk-based language has improved overall health and well-being. Indeed, if we are going to study the effectiveness of risk-based messaging, we can’t just measure breastfeeding duration and intensity – we need mother-centered measures of a woman’s breastfeeding experience. “Although I never fed my baby formula, I hated every second” should not be considered a good outcome.

In reflecting on the potential risks of risk-based language, I was fascinated to read an essay by Robert J. Vallerand, ‘On the psychology of passion.’ Vallerand notes that individuals can experience passion that is harmonious, or that is obsessive. For example, an injured athlete with harmonious passion will sit out her daily run to let an injury heal, whereas an athlete with obsessive passion will keep training through the pain, potentially worsening the injury.

My UNC colleague Barbara Fredrickson has suggested that whether we develop obsessive or harmonious passion relates to the positive or negative emotions we experience with an activity. Positive emotions encourage us to engage with people around us, seek support and build resources, and develop harmonious passions. Negative emotions, on the other hand, foster fear, isolation, and obsessive passion. This body of work has led me to worry that fostering “fear of formula” to motivate breastfeeding may isolate mothers and engender obsessive passion around infant feeding.

This issue of obsessive passion seems to be particularly prominent among middle class, privileged women. As my colleague Cecilia Tomori pointed out to me, the mandate to be “effortlessly perfect” is especially prominent among white middle-class women. I remember agonizing over parenting books filled with acronyms and regimens, desperate to provide a “perfect” environment for my firstborn child. I nodded along with a recent essay, “Motherhood Helped Me Let Go of Perfection.” And yet, I am struck that my life was pretty insulated for me to make it to motherhood without letting go of perfection. As a Native American lactation consultant noted at the First Food Forum, “My clients are not freaking out if they have to supplement a baby with formula.” As we reconsider how to frame the health impact of breastfeeding, we must take care not to center the discussion on how language about “risk” or “benefit” affects well-to-do privileged women.

I’ve also thought about the risks of risk vs. benefit language when talking with health professionals. Shouldn’t we use breastfeeding as the normative standard in that context? Here, again, I’ve not found a study. It would be ideal to compare a health provider’s motivation to engage with patients after hearing a talk on the “risks of formula” vs the “benefits of breastfeeding.” However, my experience is that in every audience, there are parents, and there are friends and relatives of parents. For many, the topic of infant feeding stirs deep emotions. And when we frame the conversation about “risks of formula,” there’s a real risk that we will trigger negative emotions that will cause those in the audience to shut down, such that they will not be able to hear the evidence-based, clinically applicable messages that could enable their patients to achieve their own infant feeding goals.

Finally, it’s critical that however we seek to motivate families to breastfeed, we pair that motivation with a much bigger dose of practical, actionable ability to initiate and sustain breastfeeding. In the book “Influencer: How to Change Anything,” Joseph Grenny and co-authors note that to change a behavior, an individual has to answer “yes” to two questions: “Is it worth it?” and “Can I do it?” Far, far too often, we plead, beg, bludgeon and entice people to change a health behavior, with minimal consideration for whether that behavior is actually possible. The futility of that strategy is reflected in steadily rising breastfeeding initiation rates in the US, followed by a precipitous drop in the first weeks after birth. The vast majority of families want to breastfeed – the problem is the barriers that prevent them from doing so.

My sense is that when we remove the “Booby Traps” that undermine so many women, and when we ensure that every mother and baby had access to appropriately trained lactation support providers, long term breastfeeding rates in the US will soar, regardless of whether we frame health outcomes as “risks of formula” or “benefits of breastfeeding.”

And until we have evidence that risk-based language improves the wellbeing of mothers and children, we might do well to reconsider our rhetoric. It’s past time to conduct the research that’s needed to sort the real risks and benefits of risk-based language.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician and breastfeeding researcher. She is an associate professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and Distinguished Scholar of Infant and Young Child Feeding at the Gillings School of Global Public Health. You can follow her on Twitter at @astuebe.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Addendum, posted 4-15-16, 8:15 am

This post has inspired spirited discussions on a number of forums, and one of the refrains I’ve heard from many is that health care providers would never talk about the “benefits of not smoking” – they would talk about the risks. One commenter on a Facebook group stated, “Humans by nature ARE risk-averse, it’s psych 101. We act to avoid risk, not accrue benefit.”  Why, many have asked, would we withhold from families that there are risks of formula, compared with the biological norm of breastfeeding?

With that question in mind, I reviewed the evidence-based recommendations for smoking cessation among pregnant women, and I was struck by how providers are advised to encourage women to quit smoking:

Advice to quit should be clear, strong, and personalized with unequivocal messages about the benefits of quitting for both the patient and her baby. An effective way to start the discussion about quitting is to say, “My best advice for you and your baby is for you to quit smoking.”
Additional advice can then be tailored to the patient’s situation and their responses to the multiple choice “Ask” Question, using positive language and focusing on the positive benefits of quitting. Although clinicians are keenly aware of the danger smoking poses to infants and the longterm health risks for mothers, it is common for patients to minimize risks.
Focusing on bad outcomes such as low birth weight or delivery complications may be ineffective for patients who believe they are not at risk, especially if they or people they know have had uncomplicated, healthy pregnancies while smoking. Describing the good things the patient can do for herself and her baby by quitting smoking appeals to her desire to be a good mother. Table 3 includes examples of benefits of quitting that clinicians can use when advising patients

When you stop smoking…

  • your baby will get more oxygen, even after just one day of not smoking
  • your baby is less likely to have bronchitis and asthma
  • there is less risk that your baby will be born too early
  • there is a better chance that your baby will come home from the hospital with you
  • you will be less likely to develop heart disease, stroke, lung cancer, chronic lung disease, and other smoke related diseases
  • you will be more likely to live to know your grandchildren
  • you will have more energy and breathe more easily
  • you will have more money that you can spend on other things
  • your clothes, hair, and home will smell better
  • your food will taste better
  • you will feel good about what you have done for yourself and your baby

(Italics mine; Reference: Page 8, Smoking Cessation During Pregnancy: A Clinician’s Guide to Helping Pregnant Women Quit Smoking )

These recommendations are based on studies that have tested the effectiveness of risk vs. benefit language for encouraging women to stop smoking — a behavior that is universally understood to be unhealthy — and the recommendation is NOT to focus on the risks, but to emphasize the benefits, to motivate women to change behavior.  While we may believe that humans act to avoid risk, the evidence from smoking cessation suggests that we change health behaviors to accrue benefit.

I am not suggesting that we should banish risk-based language from every conversation about infant feeding. What I am suggesting is that we’ve embraced risk-based language based on a rhetorical position that framing formula as risky will inevitably make breastfeeding the cultural norm.  This argument assumes that individuals will react to messages about the risk of formula by enacting behaviors and policies to enable all families to breastfeed — and we simply do not know if that is true. Those of us who are already actively engaged in breastfeeding work may be motivated by risk-based framing, but our intended audience is not breastfeeding activists.

The fundamental question we have to ask is “What Do We Really Want?” Do we want to broadcast the message that breastfeeding is normal, and formula is risky, even if that message might be ineffective for a substantial proportion of the population? Or might we want to find an approach meets each family where they are and engages them on their terms?

 

 

Written by astuebe

April 13, 2016 at 3:51 pm

36 Responses

Subscribe to comments with RSS.

  1. Very good article and very close to what I have been saying for years! The thing that prob did it for me was that terrible health ed film of pregnant women (apparently) log rolling – not shown here in the uk, but tried out in the us, to demonstrate how risky formula was. It’s that sort of thing that is counter productive – leads to a lot of unhappiness, stress and anger against BF advocacy.

    Heather Welford

    April 13, 2016 at 4:36 pm

  2. I really don’t feel that framing ‘breastfeeding as beneficial’ or ‘formula is risky’ is really all that different (unless. of course, a woman is afraid of feeding her baby formula, and chooses);
    a) NOT to supplement at all and risk low weight gain or dehydration or
    b). supplement with goatsmilk or some homemade concoction
    (BTW I have seen both of these scenarios happen–and I guess that this can happen with ‘benefits’ framing as well). I think that most women are smart enough figure out that if there are benefits breastfeeding, their child will not be receiving those benefits if he/she is fed formula, and be put at extra risk for those conditions.

    Considering your statement that behavior will change and women will chose to breastfeed and stick with it if it’s worth it– I think that most women have decided based on the many ‘benefits’ that it IS worth it. As you point out in your article, most women start out breastfeeding and many quit because of pain. latch and low supply.

    My question is, if women knew that the research (unless I am missing something) on the many of the benefits of breastfeeding was mixed at best, with many studies not finding breastfeeding protective for chronic disease or improving IQ), would they find that powering though all breastfeeding problems/pumping full time, etc, was worth it?

    If new mother knew that the chances of her child getting leukemia was about one in 10,000 and the reduction from breastfeeding was less than 20% (if that –the research is mixed), would she feel as guilty or worried if she failed at breastfeeding, or be as afraid to feed her baby formula?

    Out of curiosity, What exactly are the benefits of breastfeeding/the risks of formula that you use in breastfeeding promotion at this time? Your paper was from 2009.

    Anne Risch

    April 13, 2016 at 5:53 pm

  3. I’m going to reread this a few times but my sense is it deserves to be a seminal essay in its own right.

    “Far, far too often, we plead, beg, bludgeon and entice people to change a health behavior, with minimal consideration for whether that behavior is actually possible.” Indeed. This is especially true in cases of primary low supply, for which little meaningful support currently exists (though it could exist in future with more research).

    Just last week I was speaking to a mother whose health problems had affected her supply. Her baby had dropped from the 91th percentile to the 10th because she was avoiding ‘risky’ formula.

    Jimso

    April 13, 2016 at 5:53 pm

    • Evaluating risk is tricky. What is the lowest risk option in the scenario you mention where the baby has excess weight loss? There are risks for all the potential paths forward. Contextualising the risks in this situation is important.

      But it’s also important to evaluate what has led to this difficult situation, and to submit an incident report using your regular risk assessment procedure.

      Melanie F

      April 14, 2016 at 2:07 am

    • Thank you. As an L&D RN with primary low supply (completely gone by 14 days PP) I wished for any other support besides hearing “Breast is best” from my provider and my sons provider. 11 1/2 years ago breast milk banks were only for sick children and my son was “healthy”. If I had the option, I would have exclusively breastfed. Seeing my son have a sunken anterior fontanel and having over 15% loss in his first few days of life was scary. I’m absolutely positive that hearing formula is like poison would have made me feel even more desperate.

      KJK

      July 16, 2016 at 9:31 pm

  4. Although I am not aware of studies that demonstrate increased breastfeeding rates as a result of using risk-based language, I recall that in preparation of the 2004 United States Breastfeeding Campaign, focus groups representing populations at risk for low breastfeeding rates indicated the need to use risk based language to emphasize the importance of breastfeeding. Hence the video clip of the pregnant woman on the electronic bucking bronco.
    I don’t believe that risk-based language needs to be couched in a negative, threatening manner. As a family physician, I know that informing my patients about the risk of certain behaviors would be taken much less seriously if I said, ‘Well, you would have some health benefits if you quit smoking’, ‘you would benefit from weight loss’, or ‘you will be healthier if you can bring down your cholesterol.’ I feel responsible in making sure that my patients have received informed consent regarding their higher risk of a major vascular event or cancer with these behaviors. I once had a patient with a family history of breast cancer who was a smoker and developed breast cancer. She expressed disappointment that I didn’t emphasize the increased risk of breast cancer due to smoking.
    It is our responsibility as health care providers to inform our patients about how behaviors influence health risks. We should not take for granted that families know these facts.
    For example, there are times that parents need to understand that not breastfeeding their infant increases the infant’s risk of morbidity and mortality from severe RSV and influenza infections, especially during a major outbreak. If dad lost his hearing due to recurrent otitis media as a child, it behooves us to let that family know that not breastfeeding increases the risk that his son will have recurrent ear infections too. These are facts, not threats. I would feel personally responsible for the morbidity of these children if they had worse health outcomes, and I didn’t explain how not breastfeeding increased their risks of these illnesses.
    This information can be couched within supportive, understanding, and empowering language, and do not have be perceived as threats. It makes sense that if I, as a health care provider, am encouraging a healthy behavior, I am going to have resources for my patient to be successful, whether it means a referral to a therapist, dietitian, a lactation consultant, support groups, or the best medication to lower those risks.
    I agree that we are past-due for research on the best way to deliver this information in a constructive, supportive fashion.

    Anne Eglash MD

    April 13, 2016 at 6:20 pm

  5. Reblogged this on Workstationny's Blog.

    workstationny

    April 13, 2016 at 6:27 pm

  6. We need to avoid black/white either/or thinking. There is no need to threaten mothers. There is a need to be honest. There is a risk to every single thing we do in life – we choose the best we can as we go along. Formula is better than starving; that is its place, a substitute, and substitutes are necessary sometimes.

    I believe that the first priority is to frame studies on the outcome of infant feeding, in terms of breastfeeding as the normal/physiological/control, comparing dose and duration of any substitutes given. When more evidence in these terms is in, health professionals will be in a position to show that while exclusive breastfeeding is best, for most mothers, any breastfeeding is better than none. And all mothers do the best they can under their circumstances. Formula has a place, but it is a substitute, necessary to the extent that breastfeeding can’t or doesn’t happen. Which is the norm in the USA and most industrialised countries. I believe the tide of cultural acceptance of formula feeding is slowly turning, which will mean more support for breastfeeding so mothers will be able to breastfeed more than they can at present.

    nanjolly

    April 13, 2016 at 8:06 pm

  7. In the interim between a practice and “evidence” that the practice is either good for health or bad, does it make the final positive outcome less valid, because there was not previous “evidence” ? Did breastfeeding not matter to children and their mothers until there was “evidence” that it did?
    I don’t think that we should stop counseling mothers about the risks of formula but rather continue to counsel about all the options in a particular situation and how the risks of one option differ from the others, as far as we currently know, in her particular situation.

    Patrice

    April 14, 2016 at 1:34 am

  8. When we discuss “risk” we invoke a fear response. And that has a strong effect. Sometimes, people who feel vulnerable will reject both the fearful-message, and the messenger. That means they won’t speak with the lactation consultant, and it means they aren’t able to access good health counselling because they won’t engage with other health workers either. That’s not a good outcome.

    With mothers, I suggest that instead of using “risks of artificial breastmilk substitute” or “benefits of breastfeeding”, we instead change our language to say “the significance of breastfeeding” or “the importance of breastfeeding”. It’s true, and reflects reality, to talk about the importance and significance of breastfeeding, and it doesn’t put formula into opposition. Moreover, it avoids the problems with contextualising risks which have dogged this debate for a long time.

    However, when we are discussing policy matters with people who are not vulnerable, it would be entirely appropriate to discuss the risks of formula feeding. There are very real risks and denying them enables them. Moreover, making explicit the links between under-investment in lactation, and excess healthcare costs, helps frame the discussion and provides the very context that is needed for good resourcing decisions to be made.

    Melanie F

    April 14, 2016 at 2:03 am

    • I agree that there are important differences between talking with families and talking with policy-makers. However, the challenge is that policy makers and health professionals ARE families. My sense is that this is because the experiencing of parenting and infant feeding is (nearly) universal, and it is also deeply personal. It’s especially fraught because the health impact of infant feeding is lifelong, and so a presentation about risk may stir regrets that are decades in the making.

      The fundamental question in communication about infant feeding, as with all communication, is what we actually want to achieve. If we want to drive home the position that breastfeeding is the biological norm, then we want to use it as our reference group, and any collateral emotional responses are irrelevant. However, if we want to move policy-makers to action to remove barriers to breastfeeding, then risk-based language may win the point, but the collateral emotional impact may cost us key partners and lose the policy war.

      I’ve learned a great deal from the book, “Crucial Conversations” ( https://www.vitalsmarts.com/crucialconversations/ ) – one of the central tenets if that when we are having conversations about difficult topics, we need to constantly remind ourselves What We Really Want. If what we really want is to increase investment in lactation and enable more women to succeed, is it effective to invoke the health risks of formula? That likely depends on exactly how we say it, and, more crucially, on who we are saying it to. If we’re meeting with a hospital medical director to advocate for Baby Friendly, and that medical director’s children were formula fed, then talking about “risks of formula” may be a very poor communciations stategy, even though our audience is a policy-maker. We can win the rhetorical point and communicate our position that breastfeeding is the biological norm, but we might lose the policy war, and potentially never be invited to another meeting with that medical director. And (following your example above), if the medical director of the hospital won’t participate in meetings about breastfeeding, that’s not a good outcome.

      My sense is that, in one-on-one conversations, good clinicians intuitively tailor their language to the individual patient. The trickier part is in mass communication through billboards, brochures, and lectures, where we don’t have the luxury of reading the body language of each person we are trying to reach and adjusting our language accordingly.

      astuebe

      April 14, 2016 at 9:37 am

      • Thank you for this article Dr. Stuebe. I truly applaud you for starting this conversation, and I agree that framing formula is risky is unhelpful. I do think that the content of the information given to parents and healthcare professionals is just as important as the wording, however.

        I feel that an honest discussion on what benefits/risks are supported by the science is long overdue.

        You write, “the health impact of infant feeding is lifelong”, Could you expand on that comment? And again, I would like to ask, what benefits of breastfeeding/risks of formula do you feel are strongly supported by the research?

        Do you agree with the AAP SOBr website that claims that there is unequivocal evidence that breastfeeding can protect against obesity, diabetes, UTI, childhood cancers, and late onset sepsis?
        http://www2.aap.org/breastfeeding/policyonbreastfeedinganduseofhumanmilk.html
        Or the ABM protocol that suggests women with family histories of eczema and asthma be encouraged to breastfeed in order to prevent these conditions in their children?
        http://www.bfmed.org/Media/Files/Protocols/prenatal%20setting2015.pdf

        Anne Risch

        April 14, 2016 at 3:22 pm

  9. I can follow the train of thought, but do not entirely agree. Shifting back from ”risks of formula” to ”benefits of breastfeeding” is turning back to dishonesty, because, as Wiessinger pointed out,breastfeeding is the biological norm and thus cannot have benefits. Talking about the benefits of breastfeeding is being dishonest to your clients. The argument that talking negative of formula is bad for mothers who cannot reach the goal of exclusive breastfeeding is invalid. The choice is not between breastfeeding or formula feeding. The choice is to get good support and counseling, to enhance ones own milk production, to express ones own milk, to use prenatally expressed own milk, to use donor milk or to use formula. In that order of prioritizing. Human milk for human babies is the norm and turning to non-human milk increases the risk of negative health outcomes. That is a fact, that is not risk based language. That said, there is no need to demonise formula feeding nor bottle feeding. Being in favour of going by the biologic and physiologic norm does not imply to be anti anything else.

    eurolacpuntnet

    April 14, 2016 at 2:19 am

    • I sympathise with the dislike of dishonesty. But however truthful it might be to point out that BF is the biological norm, it surely is not the cultural norm, or the social norm, or for some women, the emotional or psychological norm. The rest of your post shows clearly you recognise this, and its implications. Of course we are in favour of the physiological norm, but it’s no use saying this does not imply being ‘anti’ anything else. Because the perception is that it does – and people feel very negative towards BF support as a result.

      Heather Welford

      April 14, 2016 at 1:15 pm

  10. Another thought-provoking, stop-and-ponder blog from you, Alison, and a great one at that. Thank you.

    I like to say: “Information never hurt anyone, and parents by-and-large want to do right by their children.” Families dserve to understand the benefits and risks of any course of action involving their children, including the difference is breastmilk and formula. And they deserve non-judgemental support in whatever they decide to do. My corollary is “Informed decision-making means we [healthcare providers] do the informing; the family does the deciding.”

    I agree whole-heartedly that the gravest underlying issue (here in the USA) is the systemic failure to provide coordinated, meaningful and accessible support for breastfeeding, before-during-and-after the birth.

    The manner of the messaging is critical. Making formula out to be “the bad guy” is all wrong, for many clinical and political reasons. Trumpeting the benefits of breastfeeding — and then drop-kicking families out of the hopsital into communities without skilled lactation care — is equally wrong.

    ECBrooks

    April 14, 2016 at 5:42 am

  11. I wholly agree, Dr. Steube. As a private practice IBCLC, the families I work with call me when they are in dire straits. If they weren’t committed to breastfeeding I wouldn’t be visiting them. Using risk-based language when they are already working so hard to breastfeed doesn’t help the situation and only adds to their feelings of inadequacy and fear.

    Rachel O'Brien IBCLC

    April 14, 2016 at 6:43 am

  12. Risks are routinely communicated by physicians to their clients. Risk of heart disease, cancer, diabetes etc are described in the doctor-patient relationship, and often individualised to produce a personalised risk profile. This includes discussion of modifiable factors such as smoking and obesity.

    Giving up tobacco, or losing weight, are often described by patients as difficult, and they don’t feel that they have much efficacy in these arenas. But the health messaging still needs to be communicated. And doctors have an obligation to their patients to discuss these hard topics, even though most patients don’t want to be nagged by their physician.

    What are the differences between these clinical risk discussions, and those around infant feeding?

    Melanie F

    April 14, 2016 at 9:57 am

  13. I was pleased, if hardly surprised, to learn that the 2010 post “Why we still need to watch our language” has been viewed so often. I’ve easily shared it more than a hundred times myself.
    As for the dearth – complete absence? – of empirical evidence demonstrating that risk-based language works better than benefit-based language in motivating mothers to breastfeed, my sense is that we might not be paying adequate attention to how artificial feeding is still framed in many environments.
    Surely, no one would argue against protecting children from disease, using an approved car-seat to transport them, holding their hands firmly as we cross a busy street together, or keeping medicines and cleaning products out of their reach. A no-brainer, in popular jargon, since everyone agrees that to do otherwise would be unconscionably … risky.
    However, despite the abundant pro-breastfeeding rhetoric during the last half-century or so, the jury still seems to be out in the case of collective attitudes toward routinely offering and consuming the unique first-food that is tailor-made for our children. And it strikes me as unlikely that the jury will be called back in anytime soon to deliver the definitive verdict we’re striving for unless we do what George Lakoff, professor of cognitive science and linguistics, urges in terms of reframing public discourse.
    Here is the first paragraph from Lakoff’s preface to Don’t think of an elephant! Know your values and frame the debate: “Frames are mental structures that shape the way we see the world. As a result, they shape the goals we seek, the plans we make, the way we act, and what counts as a good or bad outcome of our actions. In politics our frames shape our social policies and the institutions we form to carry out our policies. To change our frames is to change all of this. Reframing is social change.”
    By all means, let us continue to approach individual mothers, carefully and respectfully, where our child-feeding messages are concerned. Let us ensure that we begin where they are rather than by insisting on instant allegiance, booby traps notwithstanding, to where we think they should be.
    But in terms of reframing public discourse, I remain impenitent in observing that there are no benefits to breastfeeding, only varying degrees of risk, for the health of mothers and children, of not breastfeeding. Indeed, extolling the “benefits of breastfeeding” makes as much sense as touting the “benefits of walking upright on two feet”. Both are defining features – no more and certainly no less – of what it means to be human.

    James Akre

    April 14, 2016 at 10:54 am

    • Thank you James Akre, for excellently explaining. Especially this ”However, despite the abundant pro-breastfeeding rhetoric during the last half-century or so, the jury still seems to be out in the case of collective attitudes toward routinely offering and consuming the unique first-food that is tailor-made for our children.” and this ”But in terms of reframing public discourse, I remain impenitent in observing that there are no benefits to breastfeeding, only varying degrees of risk, for the health of mothers and children, of not breastfeeding. Indeed, extolling the “benefits of breastfeeding” makes as much sense as touting the “benefits of walking upright on two feet”. Both are defining features – no more and certainly no less – of what it means to be human.”
      Mothers and children have the right to get good, accurate information. Sitting next to that information, and unbreakably sewn into it, is good care for mothers and infants as they go on their breastfeeding journey, better still, far before the start of it, like in school. Efforts should not be made to promote breastfeeding, it doesn’t need promotion, like breathing does not need promotion; it needs protection and it needs to become the cultural norm and the medical norm as well as the biological norm. And there definitely need to be more options presented (other than formula) for mothers who are not able to produce (enough) milk or to suckle their children.

      eurolacpuntnet

      April 14, 2016 at 12:17 pm

  14. Alison, this is one of the best things that I’ve read in a very long time. Thank you for your words.

    Bobby Ghaheri, MD

    April 14, 2016 at 3:54 pm

  15. Alison, you bring up excellent points and I agree we need to continue this discussion. Feeding one’s child is a basic human instinct that involves emotions in mothers that they may not have control over. I too worry that we may do more harm than good in situation where mothers for what ever reason cannot breastfeed.

    Eyla Boies

    April 15, 2016 at 12:59 pm

  16. Thank you, Alison. Very well-said…as always.

    I have been pondering this very thing for a few years now, as I watch mothers agonize over wanting to do what is best for their babies in a society that is so pervasively unsupportive.

    I think the crux of the issue is summed up in the cover quote of the Lancet series. (Sorry, I am not able to figure out how to provide a fancy link here! http://www.thelancet.com/journals/lancet/issue/vol387no10017/PIIS0140-6736(16)X0005-0 )

    “Success in breastfeeding is not the sole responsibility of a woman — the promotion of breastfeeding is a collective societal responsibility.”

    Both articles in the series are available online free of charge, and highly recommended reading.

    There is no doubt in my mind that we are asking the impossible of a lot of mothers in our current culture. We as a society need to wake up and provide what they need, so they can do what is best for them, their babies, and all of us.

    Kathy Leeper

    April 15, 2016 at 1:25 pm

  17. Thank you for this post! I think you make excellent, important points, even if they’re not ones we’re very comfortable with.

    I have to say… the metaphorical equating of formula-feeding to smoking is ridiculous. Formula isn’t an addictive poisonous substance, it’s food. It may not be as good a food as breastmilk, but it’s still food. A better analogy would whole grain bread vs white bread.

    Verity

    April 15, 2016 at 2:21 pm

  18. Bravo, Dr. Stuebe, for publically repudiating the shaming language so beloved of breastfeeding advocates!

    Amy Tuteur, MD

    April 15, 2016 at 5:29 pm

    • “Publicly”

      Amy Tuteur, MD

      April 15, 2016 at 5:32 pm

  19. Having just returned from visiting refugee camps in Greece where health workers will refuse to add teaspoons of sugar to infant formula bottles when people ask “because that would be dangerous” and yet freely fill filthy bottles with formula in an environment with no sanitation to anyone who asks because they asked for it I cannot agree with you. It is a privileged world where one can suggest that it is at all reasonable to not speak about the risks of a baby under 6 months being fed anything but breastmilk- including infant formula.

    Karleen Gribble

    April 15, 2016 at 6:51 pm

  20. […] Ik begrijp het idee erachter, maar ben het er niet mee eens. In voorlichting over zuigelingenvoeding moet duidelijk en eerlijk worden gesproken. De waarheid verdoezelen omdat die pijnlijk kan zijn daar schiet niemand iets mee op. Eerlijke onverdoezelde informatie moet wel gepaard gaan met werkbare alternatieven en oplossingen. De waarheid moet geen lege retoriek worden. ”In the absence of evidence that risk-based language works, I’ve become increasingly concerned we might be doing more harm than good.”: Might there be risks of risk-based language? | Breastfeeding Medicine […]

  21. Well, I’m glad someone shared this with me — there actually ARE a few empirical studies that have evaluated the use of risk language in breastfeeding promotion.

    My co-author and I have conducted two studies to evaluate the use of risk language, and have several peer-reviewed publication on the topic. The latest is is here http://www.tandfonline.com/doi/full/10.1080/23293691.2016.1150133#.Vx-semPyd64. Here is the full citation:
    Wallace, Lora Ebert and Erin N. Taylor. 2016. “Running a Risk: expectant mothers respond to “risk” language in breastfeeding promotion,” Women’s Reproductive Health, 3(1): 1-14.

    The article includes references to the other evaluations to date.

    Not enough, but something!

    Lora Ebert Wallace, PhD
    Western Illinois University
    le-wallace2@wiu.edu

    Lora Ebert Wallace

    April 26, 2016 at 1:03 pm

  22. Thank you Dr. Steube. As usual, I love your writing. Another problem with risk-based language is that some mothers have become deathly afraid of supplementing their babies with formula in medically fragile situations, leading to dehydration and scary levels of weight loss.

    As with most IBCLCs, a large percentage of my patients struggle with delayed and low milk production. It is excruciatingly painful for these mothers to watch their babies be hungry while they pump droplets of milk, with no guarantee of when their supply will be sufficient to get that milk drunk look on their baby’s face.

    Maybe this is exposing my ignorance, but is there any evidence that altering the baby’s gut bacteria for a few days has any long-term health implications? And if so how does this compare with the risks of not supplementing a baby who appears unsatisfied on Day 3/4? Beyond any medical implications, I am concerned that many mothers would give up breastfeeding entirely if their instincts are screaming that their babies are hungry. This small study supports that: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666109/pdf/peds.2012-2809.pdf

    If we can increase the number of women who have long-term breastfeeding success, even if that comes at the cost of a few small formula supplements in the hospital, we should really think about it carefully. Which is more important, exclusivity or duration? Virgin gut, or letting mothers and babies experience the sweetness of a long-term nursing relationship?

    Lynnette Hafken

    April 28, 2016 at 11:06 am

  23. Thank you Dr. Steube. As usual, I love your writing. Another problem with risk-based language is that some mothers have become deathly afraid of supplementing their babies with formula in medically fragile situations, leading to dehydration and scary levels of weight loss.

    As with most IBCLCs, a large percentage of my patients struggle with delayed and low milk production. It is excruciatingly painful for these mothers to watch their babies be hungry while they pump droplets of milk, with no guarantee of when their supply will be sufficient to get that milk drunk look on their baby’s face.

    Maybe this is exposing my ignorance, but is there any evidence that altering the baby’s gut bacteria for a few days has any long-term health implications? And if so how does this compare with the risks of not supplementing a baby who appears unsatisfied on Day 3/4? Beyond any medical implications, I am concerned that many mothers would give up breastfeeding entirely if their instincts are screaming that their babies are hungry. This small study supports that: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666109/pdf/peds.2012-2809.pdf

    If we can increase the number of women who have long-term breastfeeding success, even if that comes at the cost of a few small formula supplements in the hospital, we should really think about it carefully. Which is more important, exclusivity or duration? Virgin gut, or letting mothers and babies experience the joys of a longer-term nursing relationship?

    Lynnette Hafken

    April 28, 2016 at 11:24 am

  24. […] month, I blogged on my growing discomfort with ‘risk-based language’ to support breastfeeding. I explained that rationale for risk-based language is […]

  25. […] month, I blogged on my growing discomfort with ‘risk-based language’ to support breastfeeding. I explained that rationale for risk-based language is […]

  26. […] language works, I’ve become increasingly concerned we might be doing more harm than good.”: Might there be risks of risk-based language? | Breastfeeding Medicine Over onder andere eerlijkheid schreef ik zelf ook al eerder, bijvoorbeeld hier: ”Mijn […]

  27. […]  Stuebe AM.  Might there be risks of risk-based language? Breastfeeding Medicine Blog. April 13, 2016. Accessed online: https://bfmed.wordpress.com/2016/04/13/might-there-be-risks-of-risk-based-language/ […]

  28. Thank you. As a middle class white woman I have been put down and felt a failure for my inability to sustain breastfeeding due to a hormonal and tissue problem despite having great support, education and the desire to exclusively breastfeed.

    KJK

    July 16, 2016 at 9:22 pm


Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: