Reclaiming “Breastfeeding” from “Human Milk:” Politics, Public Health, and the Power of Money

If there is one thing that formula makers and breastfeeding advocates agree on, it’s that mother’s milk is amazing stuff. Researchers have identified countless compounds in human milk such as lactoferrin, erythropoietin, docosahexaenoic acid (DHA), immunoglobulins, and human milk oligosaccharides, or HMOs. There are at least one hundred different HMOs in human milk and the infant doesn’t digest any of them—rather they seem to exist to feed the bacteria in the infant’s gut, its “microbiome,” and have some other properties, too.  Each mother secretes unique sets of HMOs for her infant. Often researchers discuss adding HMOs to formula in hopes of transforming the microbiome of a formula fed infant into one that more resembles that of a breastfed infant, as the microbiome of a breastfed infant is thought to better protect against disease.

Research into human milk composition has been exploding, funded by the federal government, private foundations, but especially by the $70 billion infant formula industry and other industries looking for commercial applications for the components of human milk. The motives for research might vary: to help understand why breastfeeding is truly superior; to help use components of human milk to fight diseases in infants, children and adults; or to synthesize components of human milk in order to add them to infant formula. The US government’s interest in human milk composition revolves around ensuring that infant formulas meet minimal nutritional requirements.

At the heart of the study of milk composition is the distinction between “human milk” and “breastfeeding.” The term “human milk” disembodies the substance from the precious act of nurturing, bonding, and intimacy between a mother and child. Language around “human milk,” as opposed to “breastfeeding,” is often used by entities concerned with breast pumps and infant formula, as well as for the necessary provision of milk for infants too tiny to suckle at the breast.

For breastfeeding advocates, the dark side of research on human milk composition is its application to the formula industry. The biggest recent application has been the synthesis of HMOs, which have been patented and added to formula, now for sale on supermarket shelves where they cost at least 30% morethan formulas without HMOs. It is unclear if these products are actually better for babies, even though they might technically resemble human milk slightly more than formula without HMOs. But given that genuine mother’s milk has unique HMOs for a unique infant, it’s unclear which HMOs a manufacturer should even be adding to a formula. So, is this product actually better, or is this just a marketing ploy and an excuse to mark up the price?

Marijuana and Breastfeeding

Ryan, Ammerman, and O’Connor’s Clinical Report on “Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes” was published recently in Pediatrics.  The report, co-authored by the American Academy of Pediatrics (AAP) Committee on Substance Use and Prevention and the AAP Section on Breastfeeding, summarizes data on the prevalence of marijuana use in women of childbearing age.  Overall, rates of marijuana use have increased in recent years, according to the National Survey on Drug Use and Health.  Pregnant women use marijuana less frequently than do nonpregnant women in the same age range.

Legalization of marijuana has made both inhaled and edible forms of marijuana more widely available and have decriminalized its use in certain US states.  Medical marijuana is available in an even larger number of states. Some women report using marijuana during pregnancy to combat nausea and vomiting, and this has been advocated in certain social media postings. Federal laws in the US still prohibit the use of marijuana. 

The well-being of mothers and children is not a tradeable commodity

Breastfeeding is the foundation of public health and economic development. All major medical organizations recommend 6 months of exclusive breastfeeding, followed by continued breastfeeding through the first one to two years of life and beyond.

Evidence continues to mount that disrupting optimal breastfeeding contributes to disease burden and premature death for women and children. Globally, optimal breastfeeding would prevent 823,000 child deaths each year. In the US, enabling optimal breastfeeding would prevent 721 child deaths and 2619 maternal deaths each year, as well as 600,000 ear infections, 2.6 million gastrointestinal illnesses, 5,000 cases of maternal breast cancer and more than 8,000 heart attacks.

Optimal infant feeding is also essential for economic development. Being breastfed is associated with a 3 to 4 point increase in IQ, leading to better school performance and workplace productivity. As stated by the World Bank’s Keith Hansen, “If breastfeeding did not already exist, someone who invented it today would deserve a dual Nobel Prize in medicine and economics.”

Breastfeeding is vital and essential to protect the world’s children, the most vulnerable who cannot speak for themselves.  Given the essential role of breastfeeding in global health and wellbeing, it is imperative that every nation supports policies and programs that enable women and children to breastfeed. It is therefore deeply troubling that the United States delegation to the World Health Assembly actively undermined efforts to enable optimal breastfeeding, as reported by the New York Times.

Every time a baby goes to breast, the $70 billion baby food industry loses a sale

On Sunday, the most shared story in the New York Times was about breastfeeding – specifically, about how the US government threatened multiple countries with trade sanctions and withdrawal of military support if they backed a resolution calling for more support for breastfeeding mothers and their babies.

According to the Times:

American officials sought to water down the resolution by removing language that called on governments to “protect, promote and support breast-feeding” and another passage that called on policymakers to restrict the promotion of food products that many experts say can have deleterious effects on young children.

Why would the US government stand in the way of global breastfeeding advocacy? There are a number of theories – but my money is on the $70 billion baby food industry – upon whom the US dairy industry relies to convert massive milk surpluses into profitable products. In a face-off between a powerful industry lobby and global maternal and child health, the powerful industry carried the day.

This is the critical take-home message for anyone who cares about the health of moms and babies: When it comes to global infant and young child feeding, industry profits take precedence over public health.

ABM Ethics Committee Formal Grievance Review is Ongoing

November 9, 2017 – The Academy of Breastfeeding Medicine has a formal process in place to address any member grievances, including potential conflict of interests. These routine procedures are outlined in our bylaws and our Code of Ethics. Both documents are available to all with no restricted access at www.bfmed.org.

Last week, the grievance review process was activated. Today, the Board of Directors discussed this ongoing matter in person at the regularly scheduled board meeting.

The Ethics Committee is actively reviewing ABM’s Conflict of Interest policies. The results of this policy review and any recommendations will be shared with membership following the January meeting of Board.

 

 

It’s time to disarm the formula industry

The WHO Code is turning 35, and this vital public health policy is more critical than ever. The World Health Organization Code of Marketing of Breast Milk Substitutes was passed in 1981 to regulate predatory marketing tactics by infant formula companies. After World War II, formula sales boomed in the US, reaching their apex in the 1970s – the year I was born, just 22 percent of babies were ever breastfed. As they saturated the US market, formula companies looked overseas to expand markets for their products. They promoted formula as a modern, advanced approach to infant feeding, and dressed up sales representatives as nurses in clinics, pushing their product in communities where breastfeeding had been the norm for generations, and where clean water was in short supply.

Companies raked in profits, and babies died in droves. International outrage led the World Health Organization to adapt the Code, which banned marketing of artificial breast milk substitutes to consumers.

The US has never adapted the code, but formula companies did not market directly to consumers until the late 1980s  – when, coincidentally, breastfeeding rates were rising in the US, cutting into formula profits. Today, families are inundated with formula marketing and free samples, and the formula market is big business in the US. Formula sales totaled US$4.8 billion in 2013 – that’s  $1220.69 in sales for each of the 3,932,181 babies born in the United States in 2013.

Update: Research studies quantify risks of risk-based language

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

… 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.

In face, such a study has been done, by Lora Ebert Wallace and Erin N. Taylor, in the departments of Sociology and Anthropology and of Political Science at Western Illinois University. When they contacted me, they reminded me that I’ve blogged previously about their work on “shame” and “guilt” in discussions about breastfeeding. And – spoiler alert – they found that risk-based language did not increase breastfeeding intentions; rather, risk-based language reduced trust in the information provided.

Might there be risks of risk-based language?

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.

Promotion without Support: A Reply to Editorials that Attack Breastfeeding Advocacy

I would like to reply to Courtney Jung’s op-ed, and many other similar editorials that attack breastfeeding advocacy as bad for women. This argument posits a false dichotomy, supported by formula advertising, that the true battleground for breastfeeding exists between “lactivists” and mothers who choose to, or must, formula feed their infants. Rather, breastfeeding advocacy today focuses on the social conditions that prevent women around the world from being able to make choices that support their health and empowerment, and the futures of their babies.

It is unclear why discourse on the “minimal” or “moderate” effects of breastfeeding continues; it is likely related to influence from both personal experiences of writers and influence from formula marketing. I will not engage this discourse here, as it is clear from every medical expert panel in every country in the world that the benefits of breastfeeding for health of mother and baby, decreasing economic and health inequities, and supporting a healthy environment, are well established. As breastfeeding is the physiologic norm, high rates of infant formula feeding negatively impacts all of these factors. Also, if what we are discussing is an over-emphasis on the social critique of women’s work, this is beside the point.

I am therefore saddened that media discourse on breastfeeding continues to undermine women by putting forth articles supporting the notion that a battleground exists between mothers. This classic patriarchal technique, of pitting women against each other, keeps the focus away from the systematic factors that undermine women around the world, including unequal access to paid maternity leave, evidence-based birthing practices, postpartum lactation support, breast milk banking, employer support of breastfeeding, and misleading advertising from infant formula companies. It is also the result of insufficient funding for public health infrastructures that therefore focus on breastfeeding promotion, without addressing breastfeeding support.

I urge us to notice that breastfeeding advocacy has moved on. The conflation of negative social experiences of mothers and breastfeeding advocacy is overstated. Advocacy has moved the dialogue, and we are saving our justified anger for the development of much-needed policies, medical practices and community movements that support women to have the real possibility of making choices that support the health and well-being of their families. The social and media conversation needs to move on as well. Editorials like Jung’s in the ‘Times’ only serve to continue the false conflation of advocacy and social blaming, and the false battleground between mothers.

ADDENDUM 10-19-2015 / 3 pm
Let me be clear: No one is saying this isn’t happening to moms. No one is saying that promotion without support is a good idea. Rather, I am criticizing the New York Times for continuing a conversation that pits women against each other and keeps our focus away from the ongoing structural inequities that women face. On both sides of this false battle, we are all agreeing that the battle shouldn’t be between each other, feeling critical or criticized for breastfeeding (or not). We should be joining together to force a conversation about how to create social conditions that actually support women in making choices that support their health and well-being. After all, what kind of choice is it if only one option is possible? As Gandalf would say: “YOU HAVE ONLY ONE CHOICE!” That is just improper diction…

(Also, FYI: research is being done on this, it’s just not getting published in the New York Times… exactly to my point. They are too busy with articles that radicalize breastfeeding advocates and dispute the value of breastfeeding.)

Casey Rosen-Carole, MD, MPH is an Academic General Pediatrics Fellow and Breastfeeding Medicine Fellow at the University of Rochester Medical Center

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

Day of Action: get out from under the influence of a lifetime of formula marketing

May 21, 2014 marks the 33rd anniversary of the World Health Organization’s adoption of the International Code of Marketing of Breast-Milk Substitutes (or “the Code”) in an effort to promote breastfeeding and limit formula companies’ influence over women’s infant feeding decisions.

Today more than 20 organizations and thousands of moms and citizens are participating in a day of action led by Public Citizen, directed at the largest formula makers in the U.S. and Canada – Mead Johnson (manufacturer of Enfamil), Abbott (Similac) and Nestle (Gerber Good Start — and aiming to end the unethical practice of promoting formula in health care facilities, particularly through the distribution of commercial discharge bags with formula samples – a longstanding violation of the code.  Efforts include the delivery of a petition with more than 17,000 signatures to Mead Johnson at its headquarters outside of Chicago as well as to Abbott and Nestle;  sending photos and messages to companies on Facebook, Twitter and other online platforms; and blogs such as this one.  The day of action is not meant to advocate against formula use in cases where it is necessary, but to focus on the need to give mothers unbiased information about infant feeding, information that hasn’t been influenced by formula companies.

In reflecting on the influence of formula companies, I realized that the history of my life  parallels the history of the Code:

 The 27th World Health Assembly in 1974 noted the general decline in breastfeeding related to different factors including the production of manufactured breast-milk substitutes and urged Member countries to review sales promotion activities on baby foods and to introduce appropriate remedial measures, including advertisement codes and legislation where necessary.

I was born a bit before this.   My mom says that she wanted to breastfeed me but that nobody, including hospital personnel, could tell her how.  My baby book contains the crib card with the formula company logo.