Wednesday, April 8, 2009

The Case for Breastfeeding

Although this post is a little late (it's been a busy month), the blogosphere is still buzzing about Hannah Rosin's article so I figure it's not too late for me to chime in since this is the field I work in professionally and a topic I feel very passionately about. I have a Master's Degree in Public Health and I am a Certified Lactation Counselor and Registered Dietitian. I am currently coordinating a breastfeeding initiative in the South Bronx.

I read Hannah Rosin's "The Case Against Breastfeeding" in the April edition of The Atlantic Monthly with great disappointment.

Rosin, a breastfeeding mother of 3, recently decided not to exclusively nurse her third child. She wrote about how she felt duped by society (and Dr. Sears) into believing that all the research regarding breastfeeding proved breastfeeding to be far superior to formula feeding, a belief that was shattered when she read a few studies questioning the benefits of breastfeeding. I wonder what kind of world she lives in to think that research never has its counter-arguments, and that when a few outliers are found, they outweigh the majority of research. Oh wait, I know...a non-research world! Her article was the result of a couple of hours of research she did during an all-night stretch on the internet. She was signed into an online medical journal database using a friend's password; a medical database with which I am sure she was not familiar. I am surprised that the Atlantic published an article based on this scanty and unprofessional research.

Okay, so Rosin is a journalist, a mom, and a mom who sounds like she is under some typical postpartum stress along with some career stress. But any review of breastfeeding research must at least address the findings of the AHRQ review. The AHRQ review is a meta-analysis conducted by the Agency for Healthcare Research and Quality to analyze breastfeeding studies to determine whether and to what extent breastfeeding yields health benefits to mothers and children in developed countries. The review, which covered about 400 studies, found "that a history of breastfeeding was associated with a a reduction in the risk of acute otitis media (ear infections), non-specific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma (young children), obesity, type 1 and 2 diabetes, childhood leukemia, sudden infant death syndrome (SIDS), and necrotizing enterocolitis. There was no relationship between breastfeeding in term infants and cognitive performance."

However, as is the case with all observational studies, even the AHRQ states that " should not infer causality based on these findings." That means that you cannot say that if you breastfeed your child, he/she will definitely have a reduced risk of disease. Instead, the major medical authorities rely on what the majority of research indicates is likely true for the general population. The result is the generally recognized recommendation that mothers breastfeed exclusively for 6 months and continue breastfeeding along with offering solid foods until at least one year.

Yet Rosin focuses on a few studies, randomly selected, that do not imply that breastfeeding yields medical benefits. Rosin fundamentally does not understand how research is conducted. Furthermore, she blends her personal feelings into a medical topic, which is a little something we like to call bias. When a researcher is found to be biased, whether by accepting money from certain companies or for personal reasons, such research must always be taken with a grain of salt.

Most importantly however, Rosin makes no mention of breastfeeding's benefits to the mother, which include reductions in breast cancer, ovarian cancer, postpartum diabetes, and possibly reduced incidence of post-partum depression among breastfeeding mothers. Huge reasons to breastfeed! Do it for yourself, if for nothing else! If Rosin found the AHRQ review or has been following breastfeeding research, she would have known that. As a Jewish woman, doesn't Rosin know her risk of breast cancer is increased? Breastfeeding for one year can reduce your risk of breast cancer by 11.3% (see my previous post here). While not a guarantee, 11.3% is nothing to sneeze at.

Here are a few more reasons and counterarguments to convince you that breastfeeding is still considered the best way to feed your infant:

* Rosin writes that she became wary of breastfeeding while breastfeeding her 3rd child upon finding an article in a reputable medical journal, which reported equivocal findings about breastfeeding's benefits for obesity. Did she really think she was breastfeeding solely to prevent obesity? Lately, the link between breastfeeding and obesity has become less clear, possibly because so many breastfeeding moms have taken to bottle-feeding expressed breast milk. The bottle is suspected of causing obesity because neither bottle-feeding moms nor pumping moms want to waste the expensive elixir inside the bottle and therefore they usually nudge the infant to finish the remaining ounce or two. Thus, they over-ride the natural tendency to stop eating when full. Likely, it's not the milk, but the package. Additionally, it is a dose-responsive relationship. The longer you breastfeed for, the less likely obesity is to occur. Many women don't make it past the 3 month mark to make a dent in obesity rates. Lastly, the benefits for obesity likely have the ability to affect disadvantaged communities more than Rosin's more affluent crowd.

* Rosin discusses immunity but never mentions ear infections. I guess she didn't find any of the multitude of studies in her all-nighter that showed a 50% reduction of ear infections.

* Rosin also never mentions the CDC's National Maternal Infant Health Study, which found reductions in illnesses such as diarrhea, runny nose, wheeze, vomiting, and pneumonia for exclusive breastfeeder's. The CDC is a big supporter of breastfeeding. I would trust them more than Hannah Rosin.

* Rosin barely discusses the actual composition of breast milk: breast milk contains probiotics, hormones, growth factors, white blood cells, B12 binding factor, lactoferrin, and fibronectin- each of which have their own role such as lowering the Ph of the gut or preventing microorganisms or aiding in digestion; breast milk creates longer villi along the small intestine; breast milk is rich in lactose, which helps increase calcium absorption and teach the body to keep its lactase enzymes; breast milk has more whey than casein, making it easier to digest than formula (that is why breastfed babies need to eat more frequently and have softer stools).

* When Rosin does discuss IgA content of breast milk, she seems surprised that this immunoglobulin does not enter the bloodstream. What she doesn't know is that IgA binds to microbes in the gut to reduce diarrhea; it's not supposed to enter the bloodstream with the microbes. Maybe she meant to talk about IgG or IgM.

* In addition to obesity, Rosin also seems very concerned about the future intellect of her children. She is correct that breastfeeding studies have shown mixed results, so one should no breast feed solely to create smart kids, although that may be an added benefit. However, breast milk does contain cholesterol, which is important for brain growth, and formula does not contain cholesterol. Cholesterol in infants is actually very important for cell growth and it teaches the body how to process it appropriately for when they get older. Breast milk also contains DHA and EPA, which are omega 3 fatty acids that help the brain and eyes. Formula contains chlorinated-algae based DHA (no EPA), and the research about this type of DHA is very iffy. Rosin can research that next.

* Rosin does give credit to the important physical interaction that comes with breastfeeding and the fact that it is something that bottle-feeding moms can imitate if they wish. There is research that this type of interaction (talking, touching, skin-to-skin contact) promotes healthy brain development.

* There are dentists who believe that breastfeeding impacts shape of oral cavity, risk of TMJ, position of teeth, dental alignment, width of posterior nasal space and airway shape.

* Rosin also seems very concerned about the unequal parenting that breastfeeding may foster. Yes, women are the only ones with breasts. But they are not the only ones who can cook, clean, change diapers, bathe, sing, rock, read stories, etc... Additionally, I do not know many breastfeeding mother's (including Rosin herself!) who would give up the bond they have with their breastfed children. Should we give up that bond so we don't make the fathers jealous? They can find their own way to bond, and they do.

* Rosin does bring up a very good point: sometimes our careers suffer because of breastfeeding or we jump through crazy hoops to pump our milk at work. That is true. Maybe one day, we will have better maternity leave and pumping policies and that will change.

* Rosin has stated in her article and on an MSNBC interview, that breastfeeding is not like taking a prenatal vitamin, it is a lot more time intensive. Well, you know how I feel about prenatal vitamins just from the title of my blog: vitamins are an easy way out that may not even be worth it, and certainly not a model for how we should care for the health of our families.

* I would also question Rosin's integrity of her article. She sounds like a mom who has been peer-pressured into believing that breast is best by women in skinny jeans and big sunglasses who hang out at the playground (those are her words!). Well, she is clearly living amongst a certain segment of the population. However, that same segment often also receives free gifts from formula companies. Just as doctors have started reporting free gifts, I want to know if Rosin received any free formula, free diaper bags, free feedings kits, free developmental guides, etc... from the formula companies. If she did, you must question her bias since those gifts are designed so darn well that they could convince almost anyone to formula feed. That is why the formula companies make them. In future posts, I will deconstruct some of these advertisements for you to show you some major loopholes in their argument.

In Rosin's description of her breastfeeding, I hear hints that Rosin could have benefited from a good lactation consultant: she hears sucking sounds (bad sign), she finds herself breastfeeding in public 10 times in a day (total breastfeeding sessions in a 24 hour period should be 8-12; or maybe she is never home); and her mom is worried about how the baby is gaining weight (potentially bad sign). Breastfeeding should be comfortable, with no sucking sounds (only swallowing sounds), efficient, and enough to produce enough wet/dirty diapers and appropriate weight gain in order to get all of the benefits mentioned above. If you think your baby is not drinking enough, contact a lactation consultant or visit a local support group.

I agree with Rosin that families need to weigh the wife's sanity, career, and independence when making decisions regarding how to feed and I wholeheartedly agree that an unhappy breastfeeding mom is not a sustainable or positive life choice. The question for families to consider is how to best remedy the unhappiness while remaining committed to healthiest practicable lifestyle.