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Making Breastfeeding Normal

Diane Wiessinger, MS, IBCLC, La Leche League Leader,
Ithaca, New York, USA
From: Leaven, Vol. 45 No. 4, 2009, pp. 4-8

Formula is not as good. There's no doubt about it. The list of proven risks grows longer every year. Artificially-fed babies are not only more susceptible to a huge range of infections; they also suffer lifelong deficits, from lower intelligence to a higher risk of obesity and diabetes.

That statement never appeared in print. It would be a more accurate opening to the 2008 New Scientist magazine article on "improved" formulas: "Breast is best. There's no doubt about it. The list of proven benefits grows longer every year. Breastfed babies are not only protected against a huge range of infections, they also enjoy lifelong benefits, from higher intelligence to a lower risk of obesity and diabetes" (Whelan J, 2008).

Why is the first version more accurate?

Let's look at some basic science:

  1. Studies involve a control group that is not exposed to the experimental treatment or condition, and an experimental group to which something experimental happens. The spotlight is on the experimental group. Breastfeeding is not an experiment.
  2. Health studies link the problem outcome to the problem behavior. U.S. cigarette packages do not say, "Surgeon General's Encouragement: Clean air may result in bigger, healthier babies, born closer to due date." That would leave the reader without a clear understanding that smoking by pregnant women may result in fetal injury, premature birth, and low birth weight.
  3. Biology-based studies do not rely on a cultural norm. Sears et al. ran into trouble with their 2002 study on allergic responses in breastfed and non-breastfed children because many of their breastfed cohort* received formula in the early days when their mothers slept (Sears M.R. et al. 2002). Their decades-long study went awry from the start in 1972 because of a cultural belief in the safety of formula. (*A cohort is a group of persons who have shared a particular experience during a particular time span.)
  4. Percentages cited in a study are affected by the perspective chosen. Did the study find, as an unpublished recent study did, that the breastfed children were 37 percent less likely to have a medically diagnosed behavioral or conduct problem (Gordon S. 2008)? Then it actually found that experimentally fed children (non-breastfed children) were 59 percent more likely to have a medically diagnosed behavioral or conduct problem!

Retailers use the same math when they mark a coat down 20 percent, from 100 money units to 80 units. After the sale, the coat is marked up 20 units to get back to 100, but those 20 units now represent one quarter of the 80 unit price. So it has to be marked up 25 percent (20/80) to get back to the original 100, even though it was marked down only 20 percent (20/100) in the first place. If it's marked down 50 percent at the start (50/100), to 50 units, and at the end of the sale it will be marked up 100 percent (50/50). Mark it down 37 percent (37/100), and at the end of the sale, it's marked up 59 percent (37/63) to get back to 100.

Surely this is information to which parents are entitled. If children who ever breastfeed are about 20% less likely to die between one and 12 months of age, then the reality is that children who never breastfeed are about 25% more likely to die between one and 12 months of age (Chen and Rogan, 2004). When we hide information by choosing the wrong norm, parents cannot see the risks. What they see, instead, is that breastfeeding is just an ideal -- a goal to miss and not a normalcy to expect.

Who, after all, is a "perfect parent"? Perfect, ideal, optimal -- every time we use those words to describe breastfeeding, we reassure the public that formula feeding is normal. Normal is everyone. Normal is safe. The perfection of breastfeeding is much easier to talk about than its normalcy, because perfection allows everyone to fall short without consequences.

La Leche League hasn't always talked that way. The very first edition of The Womanly Art of Breastfeeding stated, "Statistics have been compiled and studies are still being made which reveal that allergies, notably eczema, are as much as seven to ten times more common in the artificially fed baby than in the breast fed baby" (The Womanly Art of Breastfeeding, 1958). Why did we feel the need to change our approach? Who first cautioned that "we don't want to make the mother feel guilty"? Could it have been the formula industry itself? How can a well-designed, well-executed, control-based health study create so much guilt that its conclusions must be hidden from the public?

Now imagine a world in which the spotlight shifts to the experiment of artificial feeding. Suddenly the media alert us to each newly discovered risk of the experimental fluid, rather than heralding each "new advantage" of the original. Everyone sees the articles. Widespread discussions, denials, debates follow...and a scandal-craving general public wants to hear more. Bottles begin to seem too controversial for new-baby cards. Doll manufacturers begin to worry that including a bottle may hurt sales. "You can feed our brand with confidence" on the formula can begins to look silly. Babies with bottles no longer add visual appeal to articles and ads. Mothers breastfeeding in public meet less resistance. And one by one, the little cultural brush fires that breastfeeding supporters have fought for years begin to sputter out all by themselves.

What is La Leche League International's role in this reversal of approach? It needn't be noticeable in order to be effective. The World Health Organization encourages us to Protect, Promote and Support breastfeeding. But suppose individual breastfeeding helpers leave the promotion to the researchers and the media? Imagine the little girl who goes to the doctor's office for a health-promoting immunization. Shots hurt, and the little girl clings to her mother for protection and support, never considering that it is her mother who made the appointment with the doctor in the first place!

The media and the researchers, like the doctor bearing the injection, deliver an uncomfortable, even painful, form of health promotion. We breastfeeding helpers, like the mother above, work to encourage promotion behind the scenes, through our contacts with journals, researchers, health agencies, the media. Our public image focuses on protection and support. And new mothers know where to turn.

We can avoid glorifying breastfeeding by discussing "the importance of breastfeeding" instead of "the advantages of breastfeeding."

We can walk mothers through the change that we ourselves have undergone: "After a generation of artificial feeding we now understand that constipation, allergy, and a marked increase in ear infections, digestive problems, and many other types of illnesses -- both during infancy and later in life -- are side effects of these human milk substitutes rather than the norm" (Mohrbacher N. 2003). We can focus on the process of breastfeeding, rather than on the product called breast milk. Long-term bottle-feeding is not fun, and the formula industry knows it. They acknowledge that breast milk is "superior" (not, of course, that formula is inferior). But they avoid comparing bottle-feeding with breastfeeding, beyond sustaining the bottle-feeding norm by glorifying breastfeeding's "special" bond. All the more reason for us to let mothers know how pleasurable breastfeeding is, once they learn the basics!

We can use humor. The formula industry does not, perhaps because they cannot be playful with the hospitals and clinics that create their customers.

But humor is a fundamental marketing tool. All normal relationships and processes are sources of humor; that's one way we judge normal. Is there a cartoon about it? Then it must be a common experience. Let's rediscover all those great old breastfeeding cartoons and find new ones. The dominant side of any argument can afford to laugh -- and asserts its dominance when it does.

These are simple, easily learned, easily implemented, even fun techniques that allow mothers gentle access to difficult truths or that avoid the difficult truths altogether. We simply stop normalizing the experiment. And then we leave the researchers and the media -- those who speak to the wider public -- to do the heavy lifting, with our behind-the-scenes encouragement, calling for nothing more complicated than an adherence to the basic tenets of science. The media will take it from there. And the public will learn.

The change in focus is inevitable. More and more journal articles are connecting the problem with the problem outcome: "Lack of breastfeeding and higher use and cost of health care are significantly associated" (Cattaneo A. et al. 2007). The American Academy of Pediatrics (AAP) wrote, in its 2005 breastfeeding policy statement, "Exclusive breastfeeding is the reference or normative model against which all alternatives must be measured with regard to growth, health, development, and all other short- and longterm outcomes" (AAP Work Group on Breastfeeding 2005). Although the AAP failed to follow through in the rest of its paper, the American Academy of Family Physicians wrote, in its 2007 policy statement on breastfeeding, "Because breastfeeding is the physiologic norm, we will refer to the risks of not breastfeeding for infants, children, and mothers" (AAFP 2007). Then it did so, through all the rest of its powerful statement. The change in focus must happen, is happening, and we can help. Quietly. Simply. And with humor.

References

1. Whelan J. Winning Formula? New Scientist 2008; 14 July: 38-42.
2. Sears MR et al. Long-term relations between breastfeeding and development of atopy and asthma in children and young adults: a longitudinal study. Lancet 2002; 360:901-907.
3. Gordon S. Breast-fed baby may mean better behaved child. HealthDay News (Internet) October 29, 2008.
4. Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States. Pediatr 2004; 113(5): e435-439.
5. The Womanly Art of Breastfeeding. Franklin Park, IL: La Leche League International, 1958; page#3.
6. Mohrbacher N. When You Breastfeed Your Baby: Getting Started. La Leche League International, 2003.
7. Cattaneo A, Ronfani L, Burmaz T, Quintero-Romero S, Macaluso A, Di Mario S. Infant feeding and cost of health care: a cohort study. Acta Pediatrica 2006; 95: 540-546.
8. American Academy of Pediatrics Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatr 2005; 115(2): 496-506.
9. American Academy of Family Physicians. Breastfeeding, family physicians supporting (position paper). 2007. http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.html

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