Why brutally unpleasant lactivism is everyone’s business

I have just read Why the way you feed your baby is MY business, by The Alpha Parent, who describes her blog, with unusual but impressive honesty, as 'The snobby side of parenting'.  The post is very long and very unpleasant reading.  It consists of luridly emotive descriptions of every possible real or imagined consequence to others of formula feeding, including a long list of every proved or claimed risk to babies associated with it, some of them repeated several times as different synonyms (I'm not sure whether that's a deliberate attempt to ensure the list is padded out still further, or whether she's just sloppy with her cut-and-pasting).  I think the best way to summarise her reasons in one sentence would probably be 'Because I don't want to be saddled with the environmental damage, increased medical costs to me as a taxpayer, and other dire consequences to me/to others that will result from your decision to feed your child formula, bitch'.

I was going to start out by correcting/questioning some of her claims, but not only is life too short, I think it would actually be exacerbating one of the underlying issues here – that people who take this sort of line on formula feeding (or any other behaviour of which they disapprove) generally see the only issue with this sort of unpleasantly critical post as being whether or not what they say is Right.  ('Right', here, usually means 'can come up with some kind of argument, no matter how weak or flawed, in favour of these statements being correct.').  And one thing life's taught me about trying to persuade other people is that it's not actually enough to stop at considering whether or not what you say can be justified on purely factual grounds.  It's also crucial to think "Is this helpful?  Is it constructive?  Is it going to achieve the end I want?"

The end the Alpha Parent wants, it seems fair to assume, is for more women to breastfeed.  Is her post going to achieve that?  Because I have yet to hear of a case where a woman who would otherwise have chosen formula feeding has decided to breastfeed because someone lectured her on her duty to society, the taxpayer, the cause of feminism, or the environment.  Women want to breastfeed because it has health benefits for their children and because it's usually vastly more convenient.  Women don't breastfeed, despite these advantages, for a variety of reasons – lack of good information, lack of support, medical issues, genuine milk insufficiency, flashbacks to an abuse history.  How is the Alpha Parent's post going to help with any of those?

How are women going to react to this article?  I know how I reacted to it – anger, upset, a churning in my stomach at the hectoring, judgemental tone.  I read a bit more of her blog as well, and rapidly concluded I just didn't want to read any more of what she had to say, because the combination of dubious and distorted facts and the tone she uses is so unpleasant to have to deal with.  And I'm a woman who breastfed both of her children in the face of considerable problems; I can look back and say with absolute confidence that I did everything feasible in order to provide them with breastmilk.  The only guilt issue I feel the need to deal with about my breastfeeding history is guilt that I was so stubborn-headed about not giving my son formula supplements a darned sight sooner.  So, if I react to this article this way, how is someone else going to react to it?  A woman who formula-fed a previous baby, perhaps, and who might have been persuaded to try breastfeeding her next baby?  What about the woman who has no previous feeding experience but is still put off by the tone in this article?  How is this furthering the cause of breastfeeding? 

The facts in her post could have been presented in a warm, positive, encouraging way.  Instead, she presented them as an incredibly off-putting lecture.  If her goal is to persuade more women to breastfeed, I'm guessing she's failed to do so.  And I fear her post may even have backfired, by putting more women off seeking help from the pro-breastfeeding movement for fear of the reception they'll find there.

Formula bans in hospitals

Ask women who formula-fed what led them to that decision, and you'll get a sheaf of answers.  Some tried to breastfeed but didn't get the support they needed; some couldn't get breastfeeding to work even with support; some never really thought about it, just opting for what all their friends and family had done; some had medical or practical issues that made breastfeeding a no-go; some hated the whole thought of breastfeeding from the start; some believed myths about breastfeeding; some researched the facts carefully before making their decision.  No doubt you can think of a few I've missed off that list.  But there's one reason I've never yet seen and really don't expect to see showing up significantly often, and that's "Because I knew the formula in the hospital would be free".

However, it seems an increasing number of policymakers in British maternity units do believe this to be a significant factor.  At the beginning of June, a news article reported that the Hull and East Yorkshire NHS Trust would, except in emergencies, no longer be providing formula milk to new mothers.  Women who plan to formula-feed have to bring supplies with them; women who plan to breastfeed but find things going badly and want to change their minds/give some supplementation while they get breastfeeding started, have to find a friend or family member that they can send to get one.  Several other hospitals have followed suit, assuring us that it is not a cost-cutting exercise but simply a way of encouraging breastfeeding.

It took me a while to articulate the reasons behind my automatic feeling of dislike of this policy.  My first thought was that this sounded like some sort of regression to a Third World country in which the hospital would expect the family to bring in a patient's food, rather than supplying it on site.  If we treated any inpatients apart from newborns this way there would be an uproar; why was it considered acceptable to single out formula-fed babies in this way?  Well, because it was all in the interests of encouraging breastfeeding, of course.  So I did give some careful Devil's Advocate-style thought to whether that was a good reason.  After all, it is fair to say that newborn babies are a unique case in that their mothers do normally produce their food supplies.  Besides, hospitals are meant to be promoting healthy behaviour – is it worth treating newborn babies as a special case if this encourages breastfeeding?

Then it hit me that I was actually focusing on completely the wrong question.  The most important question here was actually "How in the blue bleedin' heck is this supposed to be encouraging breastfeeding??"

I repeat: patients will make the choice to formula feed for a variety of reasons, but "Because I can get free formula while I'm still in hospital" just isn't one of them.  So, conversely, who is going to decide to breastfeed just because the hospital will otherwise make them pay for their own formula?  Women giving formula to their newborns while still in hospital fall, as far as I can see, into two categories: women who've decided to formula-feed from the start, and women who've decided to breastfeed but are struggling so much they turn to formula (either for good, or as a supplement to tide them over as they continue trying to get breastfeeding going).  How is the decision to ban hospital-supplied formula going to play any part in encouraging breastfeeding in either of those two groups? 

Women who've decided to formula-feed have, presumably, already weighed up the fact that one of various disadvantages of this choice is going to be the necessity of paying for 360+ days' worth of formula for their infant and have decided to go ahead anyway.  Is the news that they'll have to add an extra few days' worth of formula costs to that bill really going to be the tipping point that makes them decide, oh, well, better breastfeed, then?  If you think women might not have already thought about the costs of formula, discuss that with them beforehand in antenatal consultations and leave them to weigh it up and make up their own minds.  If they've decided the bill is worth it to them, is a marginal increase in the total really going to make a difference to their decision?

Women who've decided to breastfeed, by definition, want to breastfeed.  They're likely to be extremely happy to get support and help in the matter.  If they're struggling so much they want to give formula then either all the support and advice you can give them will solve the problems effectively enough that they'll no longer feel that way (in which case, the decision over whether or not to let them have some formula will be a moot point anyway), or it won't (in which case, denying them free formula is not going to alter their decision). 

So, either way, it's very hard to see just how the buy-your-own-formula rule is going to do anything whatsoever to encourage breastfeeding. Of course, what it might end up doing is putting the latter group of women through an extremely frustrating and distressing time.  Imagine struggling mightily with feeding, feeling absolutely at the end of your tether, hearing your baby screaming with hunger, desperately wanting to be able to give even a bit of formula to ease the burden on both of you to the point where you could bear to carry on.  Imagine, further, that it is the early hours of the morning, there is no-one that you can reasonably call up at that time to go get formula, your only chance of getting some is the midwife who is supposed to be your mainstay and support at this time… and she tells you that, no, dear, you can't have any formula because it's all for your own good and your baby's that you don't.  Anyone think that scenario couldn't possibly happen, on a maternity unit with that sort of anti-formula attitude?

I can also think of a couple of ways in which this policy could backfire.  Let's say a woman who hopes to breastfeed is planning to give birth at one of those units, she's aware that it might not all go smoothly, and she doesn't want to take the risk of ending up in the scenario outlined in the last paragraph.  What's the obvious, sensible thing to do in that case?  Take a carton of formula in just in case.  If she doesn't need that formula while she's still in hospital, is she going to throw it away?  Not likely – no point wasting it now she's got it, might as well put it in the cupboard just in case she needs it at a later date.  What is the usual position of breastfeeding advisors on having formula sitting in the cupboard just in case it's needed?  DON'T DO IT!  DON'T DO IT!!  On nights when breastfeeding is going badly, that formula will lure you with its siren song!  And, if you yield to temptation and give it, it will interfere with the delicate balance of supply and demand and start you on an irreversible downward spiral of needing to give more and more formula until your supply fails completely!  Don't have it in the house in the first place!! Just say no!

As you can possibly guess, I'm a wee bit sceptical over the whole 'just one bottle will inevitably cause the breastfeeding relationship to topple around your ears' theory – I suspect that, in fact, women who are going to be able to make breastfeeding work out are able to bounce back perfectly well from giving 'just one bottle', and, in cases when it doesn't work out, it's usually because of various other factors stacked against the woman rather than because of that One Bottle.  However, it's possible that it might be the breaking of the camel's back for a woman who is having difficulties; and, regardless of what substance there may or may not be to the advice, having formula in the house is quite definitely a no-no in the book of most breastfeeding supporters.  So, if buying some formula for emergencies is something that women are supposed to avoid, why set up a situation that positively encourages them to do so?

Another issue is the potential missed opportunity to talk to a woman who's reached the stage of feeling she needs to give some formula.  Of course, most women who are struggling with breastfeeding while still on the maternity unit are going to come and ask the staff for help anyway; but some might not, and some might get so little help from the first midwife they ask that they conclude it isn't worth asking anyone else (probably not a hugely uncommon scenario, sadly).  If a woman who wants formula has to go ask the midwife on duty for it, then that's a chance for that midwife to talk to her about whatever problems she's having and see if she can suggest anything.  And while "No, we aren't going to give you any formula" doesn't do a darned thing to sort out whatever problems have led the woman to ask for it, a sensitive, sympathetic, non-authoritarian exploration of what's going on may identify something that can be helped and may give the woman the strength she needs to keep going a bit longer.  If that woman is, instead, getting the formula out of her bag that she's brought in with her because she knows she'll have no joy asking for it and is worried she'll only get a lecture for her pains, then the midwife isn't going to hear about that problem and isn't going to have a chance to help.

So, there is a real chance this policy could do more harm than good to breastfeeding rates.  Probably not a lot more: I'm guessing there aren't that many women for whom a carton of formula lurking in the cupboard, or a missed chance for an opportunistic chat with a midwife whom they wouldn't otherwise have thought to approach, was the one factor that led to them ultimately formula-feeding when they would otherwise have successfully continued breastfeeding.  But I'm also guessing that that's still greater than the number of women who are unmoved by all the other practical, financial, and health drawbacks of using formula but decide that the need to pay for the amount of formula a newborn can drink in its first couple of days of life is the one factor that brings them round to breastfeeding.  So, yes, overall I'm estimating more harm than good.  (And, let's face it, if the best thing you can say about a policy is that it probably isn't going to do much more harm than good then that's a policy that shouldn't ever see the light of day.)

However, I also think that for the most part the practical effects of this are going to amount to nuisance value only; so, although that plus the occasional more serious impact is quite enough for me to oppose this policy, it doesn't quite account for the distaste I felt when I first heard about it.  I thought more about that one, and finally managed to pin it down and put it into words.  The problem is what it says about the attitude of the people who came up with it.

What we have here is a policy that is being sold as 'encouraging breastfeeding', when it clearly doesn't.  It is in no way an attempt to look at how the obstacles in the way of breastfeeding can be removed, or how women can be helped to surmount them.  Instead, it's an attempt to throw an extra obstacle in the way of formula feeding.  This is not the sort of policy that gets thought up by people who see their goal as working together with women to help them make informed choices and achieve what they want to achieve in infant feeding.  It's the sort of policy that gets thought up by people who see their goal as figuring out how to get women to do things the policymakers' way.  The former lot of people want to work with us; the latter want to work on us.  And, while it is not news to me that there are rather too many people with the latter goal in positions of power, it still isn't something I ever like to see examples of.

Accentuate the negative, eliminate the positive? The problems with Wiessinger’s ‘Watch Your Language’

Fifteen years ago, Diane Wiessinger, a breastfeeding counsellor and activist, wrote an article about breastfeeding promotion for the Journal of Human Lactation, entitled 'Watch Your Language'.  In it, she claimed to have the answer to the thorny question of why lactation consultants and the health care profession have such poor results when it comes to persuading women in the US to breastfeed.  I find this article, and the huge following it has received, to be of great concern; not only do I see no evidence for her theory, but I see a number of reasons to believe it is likely to do the cause of breastfeeding promotion far more harm than good.

Wiessinger's key premise is that, when we talk about the benefits of breastfeeding, we have it backwards.  Instead, we should talk as though breastfeeding is the norm, and frame all our discussions of the differences between the two in terms of drawbacks and harms of formula-feeding.  And we shouldn't mince words while doing so.  In Wiessinger's opinion, we should be trying to catch our flies with vinegar rather than honey, and particularly bitter vinegar at that.  For example, Wiessinger advocates telling women that 'artificial feeding results in an abnormal and unpleasant odor that reflects problems in an infant's gut', and describes formula-feeding as 'deficient, incomplete, and inferior'.  'Those are difficult words,' Wiessinger writes, 'but they have an appropriate place in our vocabulary.' 

Of course they do; however, that place is not in the speech of those wishing to describe the behaviour of those whose hearts and minds they wish to win over.

I've had a hard time writing this post, simply because I genuinely haven't known where to start – there are just so many things wrong with the article.  But I've also known that this post needs to be written.  Wiessinger's claims are hugely influential in the world of breastfeeding activism.  Google that title and Wiessinger's name, and you'll find her original article posted in its entirety in multiple places on the Net.  Lactivist website after lactivist website tells us that we should refer to breastfeeding as the norm and talk about the harms of formula-feeding instead of the benefits of breastfeeding.  I've even seen one blog describe the approach of talking about the benefits of breastfeeding as 'anti-breastfeeding'.  I think that a post pointing out the fundamental problems with this approach is long overdue and very necessary.  So, here are the many reasons why I disagree with what Wiessinger has to say.

It's counter to the evidence.  One of the principles on which behavioural psychology is extremely clear is that, if you want to change people's behaviour, the carrot is mightier than the stick.  Research in this field established decades ago that potential benefits are much better motivators for change than potential avoidance of harm.  This really is the kind of thing that gets taught in introductory psychology classes.  Which, of course, is why you don't see advertising campaigns framed around the idea that the reason you should buy product X will enable you to avoid the harms caused by going for an alternative – they're framed around the many benefits product X can offer you over the alternatives.  

Oddly enough, Wiessinger herself touches on this when she writes that the phrasing of lactation consultants pushing breastfeeding 'could just as easily have come from a commercial baby milk pamphlet'… and then comes to the rather bizarre conclusion that '[w]hen our phrasing and that of the baby milk industry are interchangeable, one of us is going about it wrong'.  Logically, if two groups of people are going about something the same way, they're either both right or both wrong.  If companies with millions to spend on employing the best advertisers are taking the approach of advertising their product's benefits, shouldn't we be considering the likelihood that they're doing this because they know it to be the most effective way of convincing people?

Yet Wiessinger shows an astonishing disregard for what the evidence in psychological research has to say.  And, given that she gives nothing to back up her opinions on this point, isn't the most likely conclusion that the psychologists all have it right and Wiessinger has it wrong?

Most people aren't that masochistic.  People generally just aren't that keen to listen to criticism.  Think for a minute about how Wiessinger's words might sound to a woman who's happily formula-fed her first child and is now expecting another.  Talk to her about the benefits of breastfeeding, and maybe she'll be open to listening and perhaps having a shot at another way of doing things.  Tell her how deficient, incomplete, and inferior her way of feeding her first child was – letting her know, while you're at it, that you think her precious adorable first baby actually stank – and something tells me that she's not going to be all that thrilled about listening to anything else you have to say.   Harshness only alienates those whom we're hoping to reach.

Of course, I'm guessing (and hoping) that most advocates of Wiessinger's approach would have enough tact to temper their words in that kind of face-to-face situation.  But the words and actions of one part of a movement reflect on the whole, especially when the words come from those speaking on behalf of the breastfeeding movement.  If the voice of breastfeeding advocacy is telling women how awful formula-feeding is, a lot of women are going to expect – and fear – the same thing from individual breastfeeding counsellors.  And that's going to put off that woman who's formula-fed a previous child or children, or the woman who's currently struggling to breastfeed but has found herself giving a few bottles of formula to get through the difficulties and is scared of what reaction she might get if she tries asking a breastfeeding counsellor for help (and, anecdotally, I've read stories from women who were put off asking for help with breastfeeding for precisely this reason), or even the woman with no previous experience who might have been willing to give breastfeeding a go but is too scared of how she might get harangued if it doesn't work out.  Adopting Wiessinger's attitude to formula will make us look horribly unapproachable to a large segment of the women we most want to have approach us.

It fails to connect with people.  When Wiessinger talks about breastfeeding being the biological norm, she ignores the fact that, for many women, it isn't the social norm.  Talking to these women as if breastfeeding was the norm isn't starting where they are.   When you start by ignoring someone's own reality and life experiences in favour of focusing on where you want them to be, or think they really ought to be, you're setting your advocacy attempt up for failure.  If you're not starting where they are, you're making it far harder to form the connection you need to form with them in order for advocacy to be effective.

The stress it causes may be counterproductive.  This is actually a point that hadn't occurred to me, but that another blogger pointed out when we were discussing this online once.  She felt that Wiessinger's approach would have been more stressful to her when trying to get lactation established, and that that stress itself might have done more harm than good by interfering with her milk production.  It's a fair point – we do know that stress can affect milk production.  While there's no way to eliminate all stress from breastfeeding initiation in all cases, we can at least do our best to avoid making matters worse by not making women who need to give some formula while getting breastfeeding going feel attacked for doing so.

It encourages an all-or-nothing attitude.  And this can also be counterproductive, by putting off women who might be willing to consider short-term feeding or mixed feeding or even breastfeeding with the occasional bottle given now and again, but who just can't see themselves wanting to aim for the current gold standard of 'breastfeed for at least a year with nothing but breastfeeding for at least six months'.  How often do you hear 'Because I wanted someone else to be able to give a bottle sometimes when I went out' given by a mother as a reason for her choice not to breastfeed?  How many more of these women might actually end up giving breastfeeding a try if they knew that it is perfectly possible to breastfeed and yet have somebody else give your baby a bottle when you go out?  Or that, if full breastfeeding is not an option, mixed feeding carries most of the same benefits as breastfeeding and is still worth considering?  It's easy enough to introduce those ideas in a context of discussing the benefits of breastfeeding.  But how do we reconcile descriptions of formula as harmful and risky with the explanation that, in fact, it doesn't appear to be a problem (despite some lactivist claims) to give a bottle of it to a fully breastfed baby now and again?  We probably don't, is the answer – and that means yet another group of women we've barred ourselves from reaching.

So, with all these problems, why has Wiessinger's approach been so popular?

When I told my husband about the article, he nodded gravely and commented 'Some people just aren't happy unless they're being unkind to other people.'  Sadly, I think there's some truth to that – there's a nasty little satisfaction that comes from believing you've got a really good excuse to say unpleasant things to people, and I think that, on that subconscious level we don't like to admit to, that may be part of the attraction for at least some of the people who espouse this philosophy.  However, I really don't think that's the whole story, and my guess would be that most of the people who believe this actually have much kinder motivations. 

I think that a bigger reason is that, when you're faced with a thorny and seemingly insoluble problem and someone who gives every indication of knowing what they're talking about comes along and tells you, in authoritative tones, that XYZ is the answer, it's pretty natural to believe them – especially when some of what they say is demonstrably true.  And, of course, Wiessinger makes a few good points in amongst the frighteningly bad ones.  Promoting breastfeeding by talking in the kind of fluffy superlatives better suited to cloud-cuckoo land isn't that great a way of reaching women, either, and it's easy for Wiessinger to convince people that the issue with that approach is the positive framing.  It's true that making breastfeeding sound like something special makes it feel out of many women's reach. (Although, oddly, by the end of the article Wiessinger seems to be taking the same approach herself.  Apparently, we should be advising women that they shouldn't merely breastfeed, but 'mother at the breast' and form a 'breastfeeding relationship'.  But, hey, no pressure to make it Really Special.)

But the use of positive language isn't the problem with the 'best possible start in life, special bond of breastfeeding, blah blah' approach.  The problem is partly that that way of describing is too overblown to be taken seriously (most people, quite rightly, are just not going to be convinced by the implication that the most important choice you can possibly make to get your children well launched into a fruitful life is that of how to feed them at the beginning of it), and partly that it doesn't connect with people any more than Wiessinger does.  The hypothetical lactation consultant Wiessinger quotes isn't finding out where each individual woman is and dealing with her particular concerns and beliefs.  She isn't giving women information about the differences between breast and bottle in any sort of practical, easily comprehensible way that can be used as a foundation for sound decision-making.  She isn't having a genuine discussion.  She isn't starting from where women are.  She isn't connecting.  And the answer to those flaws is not to adopt an approach that keeps those flaws and combines them with several more.  The answer is to put right those flaws.

I've already written about what I'd like to see in breastfeeding promotion.  Wiessinger's article is a prime example of what I don't want to see in breastfeeding promotion.  Let's please, please, please, forever put to bed the attitude that unpleasantness and scare tactics are the most effective ways of persuading anybody to do anything.  Let's go, instead, for an approach that's actually likely to work.

World Breastfeeding Week – Only Connect

It's World Breastfeeding Week, and the theme is 'Communication'.  (More accurately, the theme is the rather peculiarly worded 'Breastfeeding – A 3D Experience', with communication being the 'third dimension' we're meant to write about, and time and place of breastfeeding support being the other two.  Which makes for an odd slogan, but you get the point.)  I started writing a long and detailed post that I've now had on my 'really need to blog about this one' list for more years than I care to think about, and I'm still hoping to get that one up fairly soon, though I may or may not manage it in time for the end of the week.  But, as I wrote, I found part of it needed to be a blog post of its own.  Here it is.

It's fair to say that, despite my strong opinions on breastfeeding promotion and how it should be done, I've had minimal direct experience.  This is because I work in a healthcare system where maternity care is midwife-led, and so I don't do the routine prenatal appointments that are where, in my view, it's best discussed.   However, in sixteen years as a doctor, I've had a whole lot of experience with health promotion in other areas.  I've had to start a lot of conversations on smoking and alcohol and diet and exercise.  I've had a lot of occasions of seeing my patient's eyes glaze over as I start to speak, which has given me plenty of opportunity to think about what kinds of approaches make that happen and how to avoid it.  Over the years, I've found my experience gradually formulating into a rule in my own mind: Start from where people are. 

Start from where their minds already are on a particular topic, because, otherwise, anything I have to say won't touch them.  When I've started talking out of my own viewpoint on a topic without acknowledging the very different viewpoint of the person sitting across from me, the mental image that has come to me has been of me sitting on one side of an abyss and yelling across to the person on the other side to climb over and join me.  Why on earth should they want to?  When I've found a way to climb across, meet them where they are, and see if I can look from their perspective to find a route I can point out to them, I can feel the difference in how well the consultation is going.  Of course, they may well still choose not to take this route – but they're thinking about it.  They're tuned in.  They're listening.

A more formal term for the concept would, of course, be 'connection'.  In reading about discipline and how to reach children, I've learned the importance of forming a connection with them to get the message across – which is, of course, a subject for another post, but I've realised that it works with people of any age and that this is precisely what I've been doing in my more successful consultations.  Or, to phrase it the way it was always phrased for us as trainees, find out the patient's ideas-concerns-and-expectations (and, yes, we did indeed use that phrase so often it turned into one word).  But the wording I still find myself repeating silently to myself when I hear myself rushing in with a generic health promotion speech to someone who isn't disposed to listen to it, is 'Start from where people are.  Don't start from where people aren't – start from where they are.'

How do you do that?  You find out where they are on the subject (and it may not be where you were expecting to find them).  You acknowledge where they are, and the life experience that led them to that point.  You think about how your advice might look through their eyes.  And you see if, moving to their spot and looking at the route from their perspective, you can figure out that route from there to where you want them to be.  Or to even a little bit closer to where you want them to be.

So, let's say you're a midwife or doctor seeing a woman for one of her prenatal appointments, and it's time to start talking about breastfeeding.  You have your spiel on the benefits and the how-to of breastfeeding prepared, all ready to launch into.  Now, let's say this woman comes from an area where just about everybody formula feeds.  She herself was formula-fed, all her friends have formula-fed their babies, and she doesn't know anybody who's breastfed.  She's distantly aware of breastfeeding as something that mothers in some other group that she doesn't belong to or identify with (middle-class women, maybe, or tree-hugging hippies, or just some undefined group in the Not Us category) sometimes do, but that no more impacts on her own life plans than the knowledge that some people go off and live on boats.  What's going to happen when you launch into your generic spiel?  It won't touch her, because there isn't any point of experience in her life that it can stick on.  It'll whistle past or over her and leave her unaffected.

But if you explore her feelings with a few questions – such as "How were you planning on feeding your baby?" "How did you make that decision?" "How much do you know about breastfeeding?" or whatever else seems appropriate, then you find out where she is.  You start from there.  You acknowledge it, without judgement: "So, it sounds like you've never really thought about breastfeeding," and then see if you can find a way to move a few steps closer to where she is – "What would you think of finding out a bit more about it, seeing if it's something you might be interested in?  After all, it's a lot more convenient when it works well, and it can cut down the chances of a lot of different illnesses for baby and you."  You test the waters, you see how much she's willing to take in then, and whether she might be willing to revisit the issue.  You do all this while trying to stay where she is, moving at most a step or two ahead so that you can see whether she'll move that much too.

Maybe she's somewhere worse than that as far as breastfeeding's concerned – maybe she's had a previous lousy experience and she isn't just indifferent to breastfeeding but actively hostile.  Then, you can sympathise – "Oh, boy, that sounds awful!  I can understand you not being too thrilled with the thought of trying again" and see if you can move forward at all from there in terms of opening up the possibility that her experience with feeding a different child might be different again.  Or maybe she's someone who's potentially interested in breastfeeding, but has some specific reason for not wanting to do it.  If you take the time to find out what that reason is and to acknowledge its validity, maybe you can figure out a compromise she'll be willing to try – breastfeeding for X amount of time, mixed feeding, breastfeeding with occasional supplements.

But always, always, aim to start from where she is.  Because, if you do that… you've got a hell of a lot more chance that she'll be willing to move over to where you are.

Breastfeeding promotion – a view from a UK doctor

Welcome to the Milk Mama Diaries Carnival (July).  For this month, we join the National Nutrition Council – Department of Health in celebrating Nutrition Month with the theme "Isulong ang Breastfeeding – Tama, Sapat at EKsklusibo!" [This is Tagalog – apparently, it translates as "Push Breastfeeding Forward – Correct, Sufficient, and Exclusive." Participants will share their experiences in promoting breastfeeding or their tips on how breastfeeding should be promoted.  Please scroll down to the end of this post and check out the other carnival participants.

OK, compulsory intro over.  As you can probably deduce, this blog carnival is based in the Philippines.  Undeterred by the fact that I don't know remotely enough about the Philippines to advise on how breastfeeding promotion should best be done there, I figured, hey, no problem, I'll jump in with a post about how I think the healthcare system in the UK should promote breastfeeding.  Reading more of the ongoing discussion on how dramatically different the situation is in the Philippines has made me question the wisdom of that blithe decision.  While I think at least some of what I say is universally applicable, it's easy for me to talk about breastfeeding as just another of life's choices when I have the luxury of living in a well-off country with a clean safe water supply.  I believe there are multiple advantages to breastfeeding even when living in such a country; but they don't begin to compare to the frightening consequences of formula feeding in undeveloped countries.  I think that treating the two situations as comparable would be a terrible idea.

However.  By the time I'd reached that conclusion the post was practically written, and I do think that the basic principles behind the approach I advocate are universally applicable.  So I'm going to go ahead and post it and let other carnival members make the choice as to whether or not they wish to include it on their lists.  If any think it more appropriate not to, then I will fully understand that.  I also ask anyone from the Carnival who does read this post to bear in mind that it was not written with the Philippines or any other developing country in mind, and that some of what it says will therefore not be applicable.  One specific and important example is my belief that it's quite reasonable and low-risk for a woman to give the occasional bottle of formula – the research on which I base this opinion is based entirely in developed countries, and should not be taken as applicable to the situation in countries where safe water supplies are not universally available.  In those countries, a single bottle of formula or drink of water can indeed be extremely dangerous for a baby.

So.  With all that in mind, this is my vision of how I, as a doctor in the UK, would like to see the healthcare system in the UK go about discussing and promoting breastfeeding.  (It is, sadly, very far from the way that it does so at present…)

At the first prenatal appointment, I think it would just be mentioned as something to be discussed at further appointments.  This is simply because there's so much else to discuss at that point that it just doesn't seem like the best time to get into such a complicated subject.  So I'm picturing it more as something that gets introduced and not gone into – "OK, your next appointment will be in a month's time.  At that point we'll check you're OK, have a further chat about what sort of things to expect from the coming months, and start talking about how you want to feed the baby and the pros and cons of the different ways.  Meanwhile, here's some information for you to look through."   The antenatal pack would contain some leaflets on the subject, introducing the kind of information I'll discuss below.

At the next consultation, the midwife (the prenatal care system in the UK is midwife-led for normal pregnancies) would bring up the topic and ask the woman what thoughts she was currently having on how she wanted to feed her baby.  Obviously, at this stage there would be some women who had made a definite decision (which might be for full breastfeeding, full formula feeding, or mixed feeding), some who were thinking more generally in terms of "I'll give breastfeeding a shot and see how it goes", and some who had no idea at all. 

This would be the starting point for discussion and information-giving that would be gradually developed as indicated over subsequent consultations from then throughout the woman's involvement with the midwifery services – so, throughout her pregnancy, she would be finding out more about the decision and having the chance to continue all options, and, after the birth, the midwives would be ensuring that things were going well and looking at what they could do to provide help and support if not. 

After a woman was discharged from midwifery services, the health visitor would take over the same role – keeping an eye on how things were going, providing support, discussing with women who had difficulties what their options were and what the best way forward would be, and troubleshooting by, for example, warning breastfeeding women about what to expect during growth spurts.  Doctors would do the same thing at the six-week check and opportunistically at other times that they happened to see the mother or baby.

During these chats, there would be a lot of points to cover:

• The pros and cons of different feeding choices – discussed as clearly and honestly as possible.  This would include both evidence-based information of breastfeeding benefits, and practical considerations.
• The practical information needed to implement whatever choice the woman made – whether this be information on how to get breastfeeding to work out well and where to seek help if needed, or on how to mix formula and sterilise bottles safely, or both.
• For women who wanted to try breastfeeding/mixed feeding, a troubleshooting discussion of the problems and booby traps that might arise, and ways of dealing with them.
• For women who wanted to try formula-feeding, a sensitive discussion of the reasons why, and of whether any kind of compromise was possible.  If she was put off by a previous bad experience or by seeing a friend's bad experience, did she know that every breastfeeding experience is different and that breastfeeding another child might not come with the same problems as breastfeeding the first one?  If she was put off by the thought of all the initial difficulties to be overcome, did she know that those difficulties don't affect every woman and would she consider it worth at least giving breastfeeding a brief try to see whether it worked out?  If she wanted to be able to hand her baby over to someone else for a bottle once in a while, did she know that this was still an option for most breastfeeding mothers (either the much-maligned occasional bottle of formula, or pumped milk)? (She might, of course, flat-out not wish to discuss it at all, in which case the midwife would respect her wishes, let her know that the subject was up for discussion any time she wished to introduce it herself, and let it drop thereafter.)
• For women who wanted to breastfeed exclusively, a discussion of whether to introduce bottles of pumped milk, and, if so, when and how to go about it.

All of this would be backed up by written information that would be available in the initial booking pack given to women, with lots of discussion on where to go for further help if needed.

Midwives would aim to keep all information both honest and easy to understand.  This means that:

• They would not try to gloss over potential difficulties.  Breastfeeding can be very easy and, when it goes well, is far more convenient than giving formula, but it doesn't always go well and, for some women, can be very difficult indeed.  While there's no need to approach the subject with an attitude of what my mother calls 'Doom, doom, on the doom drums', it also doesn't do women any favours not to at least warn them of the possibility that breastfeeding may be a miserable experience for them, and, if so, that this is not absolutely guaranteed to improve with time.
• They would be honest about both what the science shows and what it doesn't.  There is extremely good evidence that breastfeeding has a number of health advantages over formula feeding; unless there's some reason such as HIV or a non-negotiable medication regime incompatible with breastfeeding why a woman is not even able to give breastfeeding a try, a woman considering formula-feeding should know the information in favour of breastfeeding in order to be able to make a truly informed choice.  On the other side of things, breastfeeding promotion campaigns have had a regrettable tendency to leap on any study that shows any apparent benefit of breastfeeding with little regard to the quality of the research, or to flat-out confuse opinion with fact.  Where we have strong evidence for a particular benefit of breastfeeding, we should tell women this.  Where the evidence is equivocal or there just isn't much of it one way or the other, we should be honest about this too.
• The research would be presented with actual numbers where possible, rather than just a laundry list of diseases for which the risk is reduced by breastfeeding.  However, these numbers would not be presented as "Formula feeding increases your baby's risk of this disease by X per cent", but as the actual likelihood of a baby being affected by a particular disease simply as a result of the formula feeding (or, to flip it the other way, the likelihood of a breastfed baby avoiding a particular disease simply as a result of the breastfeeding).  The reason for this is that, especially for rare diseases, percentage increases/decreases can be a misleading way to present information.  For example, the worrying-sounding figure of a 36% increase in SIDS in formula-fed babies actually equates to, on average, slightly less than a one in seven thousand chance of dying of SIDS as a result of being formula-fed (and, of course, that's before accounting for the fact that you can reduce your baby's risk below average in other ways).

Throughout these discussions, mixed feeding would be on the table (so to speak) as a possible option, rather than the choices being seen as a very black-and-white breast vs. formula.  That way, women who felt overwhelmed at the thought of exclusively breastfeeding would be aware that giving breastmilk was still an option, and might feel more able to try to do so.  Again, women would of course be given honest and accurate information about the various pros and cons, including the fact that we really don't have a huge amount of data on how mixed feeding stacks up against either full breastfeeding or full formula-feeding, simply because most studies don't consider it as a separate option.

But the most important thing about these discussions would be that the ultimate goal they would be based on would not be that of getting as many women as possible to breastfeed, or to breastfeed for X amount of time, or to breastfeed exclusively.  All those goals and targets have fueled the attitude that, at its darkest, has led to health care professionals browbeating women and endangering babies in the name of breastfeeding promotion.  Instead, the main guiding principle would be "How can I best ensure that this woman has all the information and support she needs to make a genuinely informed choice with which she is going to feel comfortable?"  Because, at the end of the day, that – not breastfeeding – is what matters most.

 

Check out the other Carnival posts:

Three Ways I Promote Breastfeeding by Example – Dainty @ Dainty Mom

A Simple Breastfeeding Campaign – The Lazy Mama

I Am A Breastfeeding Mom – The Painter's Wife

Why I Don't Nurse in Breastfeeding Rooms – Legally Mom

The Low-Milk-Supply Mommy Did It! – The Odyssey of Dinna

Breastfeeding Promotion Tips from a Formula Feeder (Yes, you read that correctly…) – The Fearless Formula Feeder

On Promoting Breastfeeding – ImPerfectly Created

Milk Mama Diaries 3 – MimmaBenz

Breastfeeding Mama – canDIshhh

I *heart* Breastfeeding – The Mum Side

Spreading the Word on Breastfeeding – Mommy Kuwentos

Taking Breastfeeding Further – Mec

A Breastfeeding Formula-Fed Mother – Soprano Mother

Breastfeeding: Promoting It Even If I Didn't Get Lucky The First Time Around – Glamma Momma

I am your breastfeeding friend – Lyndel's Mom

Thoughts of a LactatING Counselor: Breastfeeding is More of Psychology! – Handy Mommy

More on Breastfeeding Promotion plus a Guest Post – Chronicles of a Nursing Mom

Celebrating My Magic Milk – Denise

Breastfeeding Sisters – Isis Evasco

Carnival Of Breastfeeding: The Second Time Around

The Carnival Of Breastfeeding, having apparently skipped a month (unless I missed one) is back, with the topic 'The Second Time Around'.  Or any number greater than that, if you so wish.  What's it like breastfeeding your second child?

On this note, a useful bit of research I came across some while back: A group of women had their milk production measured following the birth of their first child and then following the birth of their second child and the two compared, and, on average, milk production the second time around had increased by about a third as much again when compared to the first time.  It seems breasts, like the rest of us, get more skilled with experience.  So, if you struggled to produce enough milk the first time around and are wondering whether it's even worth trying with a second child, then I can happily reassure you that the science is on your side – barring major problems with the milk production system, you're likely to produce substantially more second time round.

On to my personal experience of the topic, which is also a positive story to report.  Longstanding readers may recall that my first breastfeeding experience was blighted by the one little piece of skin anchoring my son's tongue just that crucial bit too much.  Matters spiralled downwards into a nightmare of painful nipples, inadequate milk supply despite non-stop nursing, and trying desperately to pump and get his weight up, all of which could have been so easily avoided if only his tongue tie had been cut at the start. It was an experience that left its mark on me; I was so anxious to avoid a milk supply problem this time around that I was offering Katie the breast almost constantly.  It's supposed to be impossible to overfeed a breastfed baby, but, looking back, I do have my doubts about that – Katie would take the breast for a few sucks whenever I offered it, and then spit up.  At the time I worried she might have reflux; now I think the poor little mite was probably just being given far too much.

But, despite this… the whole experience of breastfeeding my second child was so easy, so straightforward, so much what I'd dreamed of during that first-time-around nightmare.  After an initial twenty minutes of ferocious screaming on first exiting my womb, Katie's latching-on reflex kicked in and from then on it was plain sailing.  I think there was some nipple discomfort in the early days, but I honestly don't remember clearly – it was nothing like the pain I'd had with Jamie.  I kept an eagle eye on her weight, anxious to pick any problems up as early as possible, but at every visit the little X's on the chart marched steadily up the 50th centile line.  The only problem we ever had was her refusal to take a bottle before I went back to work (she resigned herself to it when I did go back and she realised it was her only option if she wanted to get fed during the day).  Even pumping at work went far better with the benefit of the experience I'd picked up first time around – I consistently produced enough and a little to spare (looking back, I wish I'd started donating milk earlier).

One big difference between the two experiences, of course, was that Katie didn't have a tongue tie.  (And it wouldn't have mattered nearly as much if she had – ironically, between my two births we'd moved to an area of the country where frenulotomy was provided, so I'd have had somewhere reasonably close at hand to go.)  Another was that she didn't comfort-suck in the way that Jamie had, so the suckling marathons that had kept me practically housebound just didn't arise. 

But my experience also made a difference; and one of the biggest differences it made was that I was a lot more relaxed.  With Jamie, I'd read all those screeds about the importance of nursing your baby quickly when he's hungry and not making him wait, and taken them far more literally than any of the authors probably ever intended, to the point where I was scared to leave the house in case one of his feeds was briefly delayed while I was getting my coat and shoes on or, heaven forfend, while he was strapped into a car seat being driven somewhere other than the tiny village where we lived, thus leading to OH MY GOD MY MILK SUPPLY DROPPING ALL MY FAULT AAARRRRGGGGHHHH. 

With Katie, I was far more rational. If I was in the middle of doing something when Katie started fussing, I was quite happy to take a few minutes to finish up without rushing.  If I was about to head out somewhere and she looked hungry and I knew it wasn't that long since her last feed (which it never was; see obsessive anxiety about supply, above), I would go right ahead with heading off, figuring I could feed her when I got there and she wasn't likely to starve meanwhile.  And, lo and behold, she never did.  (She'd usually fall asleep on the way.)  I never did reach the stage of being totally laid back about the whole thing, but I was vastly less angst-ridden about it than I'd been the previous time, and that was such a huge relief.

I have no particular punchline to wind all this up, so I shall close by sharing with you this cartoon that I stumbled across a while ago, illustrating the difference between first-time and second-time parenting (it's about introduction of solids, as it happens, but you get the idea).  Not that I want to imply that I gave Katie pretzels at three months, you understand; but I do think it makes the point rather nicely.

 

Check out the other posts in the Carnival (this list to be updated throughout Monday as new posts appear):

CaramelChica at Ambular Logic – Breastfeeding the Second Time Around

Tanya at Motherwear – Seven Reasons Why Breastfeeding Is Usually Easier The Second Time Around

Elita at Blacktating – Second Time's the Charm

Takisha at Reporter2Mother – Lessons Learned

 Anne at Dou-la-la – Once More With Feeling: Contemplating BBAC

Blimey!

I am, in 10 – 15-minute snippets when I have time, trying to catch up on my enormous backlog of recorded programmes waiting to be watched, and thus it is that I'm watching the end of Cherry Healey's 'Is Breast Best?' over my morning toast.  She's just visited a neonatal unit to discuss milk banking with one of the nurses, and, when the nurse told her that they sometimes had to purchase milk from other milk banks if their supply ran low, Cherry asked her how much this cost.  £100 per litre, was the reply, which had Cherry's jaw dropping.

Curious, I looked up conversion sites on Google to work out how many litres I'd donated back when I was pumping my milk.  Now, I very much doubt that all of mine was worth that much – some of it had been kept for longer than their regulations allow and was only donated on the off-chance that somebody might have been able to use it for research (well, it was that or the bin), and all of the fresher stuff had been pumped when Katie was over six months old, which means the composition would have changed to the point where only small quantities at a time could be given to premature babies.  Still, even allowing for that… it looks as though I might just have benefitted the world of milk donation to the tune of over a thousand pounds' worth of milk.  Which is quite a good thought to start the day on.

Breastfeeding for longer than a year – myths, facts, and what the research really shows

Welcome to the April Carnival of Breastfeeding!  For this month, the organisers have picked a delightfully controversial topic – extended breastfeeding.  It's one on which I have plenty to say.

Extended breastfeeding is the term given, in our society, to breastfeeding a child beyond the first year.  An increasing number of women are choosing to do this, and, sadly, are more often than not incurring heated disapproval for doing so. Breastfeeding toddlers or older children is believed to make them overly dependent, mothers who do so are accused of thinking only of their own needs and not of their children (that ultimate indictment for mothers), and the practice is looked on as inappropriate and downright perverse.

Fortunately, it's now being increasingly recognised that this position is not supported by either logic or evidence.  Not only is there not a shred of evidence that breastfeeding beyond a year is harmful, there is positive evidence to reassure us on this score – the world is full of societies in which it is considered normal and expected behaviour to continue breastfeeding for considerably longer than a year, and the children raised thusly seem to be doing perfectly well on the practice.  It is, of course, hugely beneficial for children in developing countries where food can be scarce and malnutrition rife, and it has some potential benefits even in our affluent society – it can be a valuable source of nutrition for otherwise faddy toddlers, and it slightly reduces a mother's risk of breast cancer or rheumatoid arthritis.

I'm delighted to see it becoming more widely recognised that there is absolutely no reason why a mother should feel obliged to wean simply because an arbitrary date on the calendar is approaching.  However, there's a twist to this; the pressure is starting to go the other way.  A small but vocal minority are pushing for breastfeeding past a year to be seen not merely as an option for women who want to do so, but as a goal for everyone to aim for.  Breastfeeding a toddler (or older child) is enthusiastically touted as having a host of physical and psychological benefits.  Lactivists are advising mothers that they should do their best to continue nursing until two years at the very least, and preferably longer (nursing until the child decides spontaneously to stop is held up as the ideal).  And the problem is that there really isn't any decent evidence to support this attempted move towards yet another blanket parenting 'should'. 

I'm not objecting, here, to an individual woman deciding that there may be particular circumstances in her child's case – deprived circumstances, an unusual health problem, or even just food faddiness – that might lead to her wanting to continue to breastfeed in hopes that it will be of some benefit.  Also, of course, I'm talking specifically about the situation in the developed world here, not about breastfeeding in developing countries where it is indeed likely to remain beneficial for long past infancy.  My objection is to the claims that extended breastfeeding has been shown to be of general benefit even in situations where other sources of nutrition are plentiful.  It hasn't.  And while this kind of pro-extended-breastfeeding advocacy has been a huge comfort to plenty of women who, having struggled with the pressure from others to wean before they wish to, now feel vindicated, it's also putting some women in the position of feeling obliged to nurse for longer than they really want to, in the belief that they'll be somehow depriving or disadvantaging their children if they don't.  That is not a trend I want to see.

That position, of course, is controversial enough in lactivist circles that it'll need some defending; to break up what's now set to be a very long post, I'm going to go for the 'Debate With Imaginary Opponent' format.

What do you mean, there's no evidence that nursing past a year is beneficial?  Are you trying to claim that a fluid so packed with nutrition, antibodies, and general goodness somehow magically loses all its benefits just because a child has passed the age of one?

Of course not.  What happens is that the child gradually grows, develops and reaches the point where breast milk just doesn't have anything much further to add.  (Just to clarify, in case anyone was forgetting how I began this post, I'm fine with children continuing to nurse after that point if they and their mothers so wish.   All I'm objecting to is the claim that they should continue to nurse, which I don't agree with any more than the claim that they should stop.)

But there's plenty of evidence that breasfeeding is beneficial to toddlers.  For starters, one study by Gulick (1) showed that breastfed toddlers between 16 and 30 months old get sick less often than non-breastfed toddlers and get better more quickly when they do…

No, it didn't.

Huh?

It didn't.  Although lactivist websites all over the Internet claim that that study shows a decreased rate of infections in breastfed toddlers between 16 and 30 months old, it actually shows nothing of the sort.  I know this because I've got hold of a copy of the study and read it for myself.  The toddlers being studied weren't breastfed toddlers – they were toddlers who'd been breastfed in the past but had stopped breastfeeding before entering the study.  What the study was actually looking at was whether longer duration of breastfeeding during infancy had any benefit in terms of reducing infection rates in toddlerhood after breastfeeding cessation.  (It didn't, in case you're interested; at least, not in that study.)  Somehow, someone has managed to utterly and crashingly misreport what the study was into and what it showed, and lactivists across the Internet have simply repeated this misinformation without question.  It's one of the biggest breastfeeding myths I've seen out there.

Well, come on – what about the other studies on the topic?  Look – Kellymom has a whole list of studies showing the immunological benefits to breastfed toddlers!

One of those is a study set in a developing country, showing benefit to children who are severely malnourished children.  As I said, breastfeeding can indeed be beneficial past infancy in such a setting, but it just isn't valid to assume that those results will be applicable to children living in our relatively privileged Western settings.  One wasn't even studying toddlers – it was a study of breastfeeding benefits in babies up to the age of 20 weeks, which is not toddlerhood by any remote stretch of the imagination.  The rest, as far as I can see, all just look at concentrations of antibodies in breastmilk of mothers of nursing toddlers, not at whether those antibodies are actually adding anything to the toddler's own antibodies when it comes to fighting off infections. 

Oh, come on.  Surely all those antibodies have to be doing something.

Not necessarily.  Bear in mind that a child's own immune system also develops rapidly during the early years, and at some point it's going to reach the stage where breast milk just doesn't have a lot else to contribute.

That surely can't be as early as a year, though.  I can't believe that breastmilk doesn't still have some benefit to children older than that.

You're welcome to believe what you like.  It's the claim that it's been proved to be beneficial that I'm objecting to.

So have you any evidence that it isn't?

In the one study I have been able to find on infection rates in breastfed vs. non-breastfed toddlers – a study in New Zealand that followed over a thousand children up to the age of two, looking at respiratory and gastrointestinal infections – breastfeeding didn't show any benefit in toddlers, or for that matter, in older babies (2).  Of course, there are flaws in every study, and I can think of several possible reasons why this one might have underestimated results enough to miss a small but genuine benefit, but it does seem to me that, if that's the case, we can't be talking about that great a benefit.  And, frankly, when the one study we have on the subject shows a complete lack of any benefit, I don't really think that the people claiming evidence of benefit are on solid ground.

But, what about the other benefits for breastfed toddlers?  Just look at the way that it helps an upset or tantrumming toddler to calm down.

I agree that that can be a wonderful convenience of breastfeeding.  However – and feel free to take this or leave it as you like, because we are temporarily stepping out of the realm of objective scientific evidence and into that of my own opinion – I do have my doubts as to whether it's a good idea to do so.  After all, what message does it send children when we regularly and repeatedly teach them to turn to a sweet-tasting food source at times when they need comfort?  I wouldn't use any other form of food or drink to distract my child from a tantrum, because that's not the message I want to be giving to my children about how food should be used; it's not encouraging healthy eating habits.  Why should I make an exception for breastfeeding?  I tried to avoid doing so, for both my children.  Just because something is the most convenient way to calm an upset child doesn't mean it's necessarily the best way in the long term.

But it has psychological benefits over and beyond just calming tantrums.  Breastfeeding for longer actually helps children become more independent!

No evidence for that claim.

Look, Jack Newman says so!  And Elizabeth Baldwin!

And they're entitled to their opinion on the matter.  However, I don't see any reason why I should automatically believe it, any more than I should automatically believe the equally unreferenced opinions of the doctors who claim that longer breastfeeding makes children more dependent.  Either way, they're opinions, which are not the same thing as evidence.

 But there is evidence!  Check out this quote on Kellymom's site – 'One study that dealt specifically with babies nursed longer than a year showed a significant link between the duration of nursing and mothers' and teachers' ratings of social adjustment in six- to eight-year-old children' (3).  Or are you trying to claim that that study's being misrepresented as well?

Oh, not with the kind of spectacular degree of inaccuracy as the study by Gulick we discussed above.  However, that quote makes the results sound far more impressive than they were.  We're not told that the differences found were very small, that they showed up in only one of the several measures of psychosocial adjustment that were tested, that adjusting for other factors eliminated practically all the difference found in the teachers' ratings, or that the researchers themselves were pretty unimpressed by their results.  To quote from their conclusion: 'In general the evidence above gives only very weak support for the view that breastfeeding makes a significant contribution to later social adjustment.  The research findings tend to be both inconsistent over time and between measurement sources and at best suggest a very small association between breastfeeding and subsequent social adjustment.  Further it is more than likely that even the small and inconsistent associations that have been reported could have arisen from factors which have not been controlled in the analysis.'  As evidence goes, I have to say that that doesn't really strike me as compelling enough to justify trying to persuade women to continue breastfeeding if they don't want to.

So what about all the other studies listed on Kellymom?  Showing that breastfed toddlers suffer from fewer allergies and have higher IQs?

I've checked all five of the papers she lists as supposedly backing up her claim about reduced allergies in breastfed toddlers (full text of four of them, the abstract of the other), and none of them are about toddlers.  They're all looking at breastfeeding in infancy.  In fact, one of them (a review rather than a study) actually mentions in passing that the existing research shows 'some suggestions' that longer breastfeeding may be related to an increase in allergy risk.

When it came to the studies on breastfeeding and intelligence, after a while I simply gave up.  The only study I did manage to find that looked at breastfeeding over a year didn't find any substantial difference in intelligence or school performance between children breastfed for that length of time and children who stopped shortly before that – longer duration of breastfeeding was initially associated with a slight increase in intelligence level, but then the effect leveled out.  (That one's not available on line, but you might be interested in checking out this one by Mortensen et al that Kellymom also links to, which also studied the association between intelligence and breastfeeding duration and reached a similar conclusion – initially the increased duration of breastfeeding was associated with slight improvement on the intelligence scales, but the effect then levelled off, with children breastfed for longer than nine months having scores no better than those breastfed for 7 – 9 months.) 

I checked several other studies on her list which, again, all turned out to be follow-ups on breastfed babies, not children breastfed past a year.  So, as I say, I gave up.  Checking all the studies she lists would have taken forever and I'm afraid there are limits to the amount of time and effort even I can put in to checking references from someone who's clearly such an unreliable source of information.  (And, before anyone gets offended at me dissing Kellymom, I do actually think she's a great source of information when it comes to dealing with breastfeeding problems; I've just found her to be appallingly bad at giving accurate information on any research dealing with any question in the general category of 'Is it possible that breastfeeding in circumstance X is anything less than incredibly beneficial?')

So, for all you know, there might be studies on her list that do show benefits of toddler breastfeeding and you just haven't seen them?

Well, if you find any, by all means let me know.  I mean that – I'd be interested to read them and happy to spread the word about them.  But, until I actually see a decent-quality study providing good evidence that breastfeeding past a year is actively beneficial for children, I'm not going to tell women it is.  And, given how many studies are being erroneously cited as showing benefits of toddler breastfeeding when they show nothing of the sort – frankly, I think my scepticism about the existence of any studies that do show benefits is completely excusable.

Well, I don't care!  I love breastfeeding my older child and I want to carry on whether or not you've found any studies proving that it's beneficial!  We're both enjoying it, and that's benefit enough!

EXACTLY!  And that's the ONLY reason you need.  You don't need to prove that it's in some way superior to what all the other mothers are doing.  You don't need to score Good Motherhood points on some imaginary scale to justify your choice to others.  You just need the confidence to believe that it's OK and that it's what works for you.  Enjoy nursing your toddler or older child, accept that mothers who have made a different choice from you are doing just as well by their child and shouldn't be conned into nursing for longer than they want to, and support every mother in the choice she makes on the matter, in the knowledge that, as far as we can see from the available evidence, nursing or not nursing a child of that age are equally good options to go for and thus we can happily leave this one in the realm of personal preference where it belongs.

 

References

1. Gulick E. The Effects of Breastfeeding on Toddler Health.  Pediatric Nursing 1986; 12(1): 51 – 4. 

2. Fergusson D.M., Horwood L.J., Shannon F.T., and Taylor B.  Breast-feeding, gastrointestinal and lower respiratory illness in the first two years.  Australian Paediatric Journal 1981; 17: 191 – 5.

3. Fergusson D.M., Horwood L.J., and Shannon F.T.  Breastfeeding and subsequent social adjustment in six- to eight-year-old children.  Journal of Child Psychology and Psychiatry 1987; 28(3): 378 – 86.

 

Do come and check out the other links in the Carnival!

Mamapoeki from Authentic Parenting: Extended Breastfeeding?

Mama Alvina of Ahava & Amara Life Foundation: Breastfeeding Journey Continues

Elita @ Blacktating: The Last Time That Never Was

Diana Cassar-Uhl, IBCLC: Old enough to ask for it

Karianna @ Caffeinated Catholic Mama: A Song for Mama’s Milk

Judy @ Mommy News Blog: My Favorite Moments

Tamara Reese @ Kveller: Extended Breastfeeding

Jenny @ Chronicles of a Nursing Mom: The Highs and Lows of Nursing a Toddler

Christina @ MFOM: Natural-Term Breastfeeding

Rebekah @ Momma’s Angel: My Sleep Breakthrough

Suzi @ Attachedattheboob: Why I love nursing a toddler

Claire @ The Adventures of Lactating Girl: My Hopes for Tandem Nursing

Elisa @ blissfulE: counter cultural: extended breastfeeding

Momma Jorje: Extended Breastfeeding, So Far!

Stephanie Precourt from Adventures in Babywearing: “Continued Breastfeeding”: straight from the mouths of babes

The Accidental Natural Mama: Nurse on, Mama

Sarah @ Reproductive Rites: Gratitude for extended breastfeeding

Nikki @ On Becoming Mommy: The Little Things

Dr. Sarah @ Good Enough Mum: Breastfeeding for longer than a year: myths, facts and what the research really shows

Amy @ WIC City: (Extended) Breastfeeding as Mothering

The Artsy Mama: Why Nurse a Toddler?

Christina @ The Milk Mama: The best thing about breastfeeding

TopHot @ the bee in your bonnet: From the Mouths of Babes

Beth @ Bethstedman.com: Extended Breastfeeding: To Wean Or Not To Wean

Callista @ Callista’s Ramblings:  Pressure To Stop Breastfeeding

Amanda @ Postilius: Nursing My Toddler Keeps My Baby Close

Sheryl @ Little Snowflakes: Tandem Nursing- The Good, The Bad and The Ugly

Zoie @ Touchstone Z: Breastfeeding Flavors

Lauren @ Hobo Mama: Same old, same old: Extended breastfeeding

Tanya @ Motherwear Breastfeeding Blog: Six misconceptions about extended breastfeeding

Jona (Breastfeedingtwins.org): Breastfeeding older twins

Motherlove Herbal Company: Five reasons to love nursing a toddler

Things I Believe About Parenting, And Things I Do Not

The Writing Workshop theme for this week is 'Belief', with various open-ended questions thereof, including an invitation to talk about our beliefs on a non-religious subject if we so wish; such as, for example, parenting. I'm going for that one.  This is not so much an essay as a kind of laundry list of my opinions.  If you find any of them interesting and/or ridiculous enough to request further clarification, please do so; I shall, in theory at least though admittedly possibly not in actuality, be happy to write a further post on why I hold that particular belief/lack thereof.

Things I believe

I believe that the most important part of parenting is building a strong relationship of mutual respect and enjoyment with your children.  That's the best possible foundation both for teaching them the things you'll need to teach them, and for the rest of their lives.

I believe that discipline should, as much as possible (and it is not always possible), center around teaching conflict resolutions skills and the benefit of co-operation, within the kind of relationship described above, rather than centering around figuring out how to get your child to do what you tell them.  (This approach to discipline is generally referred to as either 'gentle discipline' or 'positive discipline', although I don't feel either sums it up very well for me – I generally think of it as 'collaborative discipline'.)

I believe that my job as a parent includes being sensitive to my children's feelings, and letting them know that experiencing those feelings is all right, including the negative ones.  It does not include a requirement to shield my children from anything that might cause them to experience such feelings.

I believe that most babies will thrive perfectly well on any non-abusive and non-neglectful method of baby-raising, as long as it's practiced with affection and enjoyment.  Some babies do do better on one method rather than another, but there is no consistency in which method such babies do better with.  So, regardless of whether the particular method that happens to float your boat is Gina Ford, William Sears, Tracy Hogg, Jean Liedloff, or Wing It As We Go, as long as it suits you, your baby and the rest of the family feel free to get on with it and to ignore anyone who tells you you'd be better off with a different method.  Just don't assume that your success with it gives you the right to assume that your child will turn out superior in some ways to children raised via a different method or to tell other random parents that they should use the same method if they're clearly equally happy with what they're doing.

I believe that breastfeeding has several health and convenience advantages, so is worth trying fairly hard to do if possible.  However, in a list of priorities including breastfeeding, your physical and mental health, and your enjoyment of your baby's babyhood, breastfeeding is at the bottom, so don't sacrifice any of the others for it. 

I believe that there are some risks with taking young babies (in the early months of life) into your bed.  If all safety precautions are carefully followed then they're exceedingly low and it's highly debatable whether it's worth worrying about them if the alternative is living through a nightmare of sleep deprivation (especially given that this carries its own risks for the baby), but they do appear to exist.  (And they're MUCH higher if safety precautions are not followed – so, if you're unable to do so for whatever reason, then it really is much better to try to find another way to manage the situation.)

 

Things I Do Not Believe

I don't believe that one bottle of formula, or even the occasional bottle of formula repeated over time, is likely to have anything particularly important in the way of adverse consequences for the vast majority of babies.   (Exceptions, in case you're interested, are babies with a strong family history of Type I diabetes or of severe – as in, life-threatening – food allergies.)

I don't believe that it matters more than minimally whether you introduce solids at four months or six (though six is definitely easier in practical terms).

I don't believe it makes any great difference whether you nurse your child for a year or five years.  I don't believe that nursing past infancy has either adverse or beneficial consequences, and think it should be considered entirely a matter of personal choice.

I don't believe that carrying your baby in a sling during as many as possible of your waking minutes needs to be on any parent's list of goals, or that it makes a difference to most babies over and above the many other ways of satisfying their needs for touch, affection, and general inclusion in your life.

I don't believe that sleep training causes mental or psychological damage or is a form of neglect.

I don't believe that sleep training is the only way of ever getting children to be good sleepers.

I don't believe that wanting sleep at night automatically makes you a selfish or neglectful parent.

I don't believe that there's either long-term problem or benefit with co-sleeping with an older baby or child if your family is happy that way.  I don't believe that it will make children over-dependent or that they'll never want to leave your bed, but nor do I believe that it's some sort of magic route to making your children extra confident and well-adjusted.  (I believe that the studies that have shown this to be the case have been confounded by the other differences likely to exist in parenting styles between families happy to bedshare and families who aren't.)

I don't believe that bedsharing protects babies against SIDS or that this should be put forward as a reason for advocating bedsharing.  (Since, as stated above, I believe bedsharing can increase the risk of SIDS in some cases, I'm very much against this particular claim.)

I don't believe that sensibly-applied time-outs indicate to a child that you are withdrawing your love from him or her.  (And, yes, in case you were wondering, there are actually people who do believe this.)

 

Things On Which The Jury Is Still Out

(PLEASE NOTE: All of these are issues on which I've seen some research/commentary that has made me form an initial opinion on the subject, but on which I am aware that I have not made a comprehensive enough study of the available research to be sure that I'm not missing some crucial evidence that would change my view.  Do be aware of this when deciding whether or not to take this as advice.)

I'm not sure how much evidence there actually is for continuing breastfeeding past six months (in the Western world, that is – there's no doubt it's beneficial if you're in a country where you can't count on proper food or uncontaminated water).  It seems from one study to reduce risks of gastroenteritis for older babies living in crowded/poor conditions, and there may be some fractional benefits for mental development, but there also seem to be several studies showing no benefit.  Of course, it's still likely to be a hell of a lot more convenient than formula, but if you're living in affluent conditions and absolutely hating the experience of breastfeeding your six-plus-month-old baby then I'm not sure that there's actually compelling evidence in favour of you continuing.

I think (based on a couple of studies I have seen indicating this) that breastfeeding during the night may present a risk of tooth decay as a child grows older.  Obviously this should not be applied to babies, who need to feed during the night if they aren't to risk going short of nutrition/fluid, but, if you are nursing an older child, it's worth night-weaning them.  And, yes, I am well aware that lactivists will hotly deny a possible risk to teeth from nursing and cite studies supporting their position.  Their studies relate to age of weaning (which I agree does not, in itself, appear to present a risk) and NOT to whether or not a child is breastfed at night during this age.  It's the night-time breastfeeding that may present a risk.

I doubt that smacking a child (smacking, not using the word as a euphemism for beating with objects and not taking the opportunity to add in a heavy helping of emotional manipulation) is mentally or psychologically harmful.  I don't do it, because I think it's not the most constructive way of going about approaching discipline (see second point under 'Things I Believe' above; but I remain unconvinced by a lot of what I've read about it, which doesn't appear to take all sorts of potential confounders into consideration.

 

So there you have it.  A mish-mash of the philosophical, the practical, and the sticking out of my neck on subjects on which I don't actually have sufficient knowledge to be making definitive pronouncements.  Pretty apt for a guiding creed of parenthood, when you think about it.

The November Carnival of Breastfeeding: Breastfeeding, Circa 1950s

The Carnival of Breastfeeding is back!

As longstanding readers may remember, I started participating in the Carnival of Breastfeeding at the beginning of this year, and got posts up for January, February, and March.  The reason I stopped writing posts for the Carnival after that was because the Carnival stopped.  The blog of one of the main hosts was cut off without warning (unfortunately I can't remember who the provider was that did it, or I'd name and shame them wholeheartedly) and the Carnival just didn't seem to reappear, although I did regularly check for some months after that.  In the end I gave up checking, and thus missed the first month's reappearance, although that was probably no great loss to the blogging world as I can't really think of any particularly interesting ways in which my birth experience impacted my breastfeeding experience.  However, thanks to Hobo Mama's Sunday Surf, I found that the Carnival was baaaaaaack in time to write something for November's deadline.  

(Quick note: As usual, I will be posting this on the day of the Carnival – November 22nd – but amending it once the other posts are out there to include links to them at the end.  Do check back after the end of the 22nd to see who else has submitted a post.)

Our brief for this month is to write about the history of breastfeeding through the generations in our family.  For what it's worth, here's what I know:

My mother breastfed me for six weeks before getting mastitis and becoming one of the far-too-many women of the time to be given the totally inaccurate advice that she should stop breastfeeding (we now know that the reverse is true – stopping breastfeeding actually makes mastitis worse, due to the buildup of milk in an already painful breast).  When she questioned this, the doctor said to her "Mrs _____, some women are SELFISH when it comes to thinking about what's best for their babies.  You don't want to be SELFISH, do you?"  So she stopped breastfeeding and she and my father spent a miserable day struggling to persuade me to take a bottle, something I wasn't in the least willing to do after six weeks of exclusive breastfeeding.  Thirty-four years later, the first piece of advice she would give me when I was pregnant with my first child – even before such important gems as "Don't solve the problem until it happens", and "The most important thing you can do for your kids is to enjoy them" – would be "Make sure you give your baby a bottle every day, even if it just has a little bit of water in it." 

I eventually resigned myself to taking the bottle (though apparently not before storing up some serious karmic retribution, judging by the amount of my maternity leave my daughter would someday spend stressing me out by her utter refusal to take the bottles that I had indeed tried to introduce at an early stage) and was formula-fed from then on.  But my mother's breastfeeding story did have a happy ending – later, she went on to breastfeed my younger sister for a year.  (And now our generational story has come full circle; my sister is now breastfeeding her own beautiful little boy.)

Since I know absolutely nothing whatsoever about the breastfeeding history of any of the other women of previous generations in my family and, quite honestly, can't see myself asking, that would have been that for this month's blog post.  Except that my mother saved two particularly special gifts for her two daughters.  She saved the books she used for information when breastfeeding each of us.  She saved them through decades and (in the case of mine) two international moves, so that she could give them to us when we had our own children.

I don't know what book my sister got (although I'd love to see it, someday), but mine was the second edition of the La Leche League's The Womanly Art Of Breastfeeding, published in 1963.  A thin volume in a blue hardbacked cover embellished only with the title and a simple line drawing of the LLL's logo, a woman cradling a baby (slightly different from the one used today – there's a definite 50's look to the woman's hairstyle).  On the inside of the front cover is my mother's handwritten name and the Philadelphian address where she and my father lived during my infancy, before we moved to the UK.  On the facing page, above a stamp reading 'Childbirth Education Association Of Greater Philadelphia', is a personal inscription that my mother wrote to me before presenting the book to me on the first Mother's Day after my son was born.

It's a fascinating relic from a bygone era.  While the decade might have turned to the 60s three years before that edition was published, the book was first written in 1958 and the ethos of the second edition is still wholeheartedly 50s.  Sometimes this shows up in glaringly obvious ways; an entire chapter is devoted to the father's role as protector and provider and to the assurance that, just because the authors advocate that he helps his wife out at particularly busy times (obviously, only when there are no women relatives available to step in and the family can't afford hired help), it in no way means that they aren't all in favour of men being masculine and there being a 'natural division of labour' within the family.  'La Leche League was formed for no other purpose than to help women be more womanly' the authors assure us.  Other signs of the thought patterns of that era are more subtle, assumptions dropped in casually in passing; discussing how a mother might talk to an older sibling about the need to deal with the baby first, the book suggests telling them in tones of happy reminiscence '"Mary, when you were little and hungry, I'd tell Timmy and Elizabeth and the older ones to wait a bit because I wanted to feed you…" Mary will love the idea of once having been the star.'  Yup – and I love the idea that the authors could take it for granted that a family of six or more children would be the norm among their audience.

But the biggest contrast between this relic of a bygone era and so many of the parenting books of today is in the tone of the entire book.  In her highly controversial article about the breastfeeding wars, Hannah Rosin wrote of The Womanly Art Of Breastfeeding 'The experience of reading the 1958 edition is like talking with your bossy but charming neighbor, who has some motherly advice to share. Reading the latest edition is like being trapped in the office of a doctor who’s haranguing you about the choices you make.'  I haven't read the latest edition, so can't comment on that (though it is fair to say that one reason why I haven't read it is simply because it looks so daunting – the edition my mother gave me is a delightful little guide that I read at a sitting, while my distant recollection of what I saw of the latest edition at the occasional LLL meeting that I managed to attend is that it bore more resemblance to a textbook to be dipped into for reference purposes).  But I do know that the tone of this book is a world away from the tense anxiety-ridden attitude of so much of what I read in modern breastfeeding literature in particular and childcare literature in general. 

In the books of today's parenting world (across the parenting spectrum), there are a host of possible ways to get things Wrong which must be avoided at all costs, and, oh, the pitfalls that might lead to Wrongness are many and devious and hard to spot – cling to our crucially important advice as closely as you can, dear readers, because dread disasters hover in wait for you and your baby otherwise, and won't somebody think of the chiiiiiiildreeeeeeen?  But, to the LLL founders, their role was simply to offer a small collection of pieces of friendly advice to get a mother's feet well set on a path that she would, thereafter, be fully capable of treading herself.  They genuinely believed in the ability of mothers to do the job of mothering.

For me, the book was a breath of fresh air and a joy to read.  Good grief, it even made the world of 1950s homemaking sound pleasurable – I can never leaf through the book without feeling inspired to go cook something with shortening (what the hell is shortening, anyway?). But, most of all, it's a loving gesture from a mother who has done so much for me that matters so much more than those weeks of breastfeeding or months of formula-feeding.  And one day, I hope to be able to turn that gesture into a family tradition as I write my own inscription in the space below my mother's and place the book in the hands of my own daughter, on the birth of her first baby.

 

Other posts in the Carnival include:

Elita at Blacktating: Three Generations of Breastfeeding

Christine at Christine's Contemplations: My Family History of Breastfeeding

Judy at Mommy News Blog: My Family History of Breastfeeding

Mama Mo at Attached at the Nip: How Women In My Family Feed Babies

Tanya at The Motherwear Breastfeeding Blog: An Unbroken Chain

Jona at Breastfeeding Twins: Beer & Bottles (and other motherly advice)

Alicia at Lactation Narration: Only the Hippies Were Breastfeeding

Jake Aryeh Marcus at Sustainable Mothering: Breastfeeding? Not in My Family