Breast Feeding, Formula and Risk Analysis

The choice between formula and starvation is a no-brainer. I had an inadequate milk supply. I did. Yes, I tried that. I tried that, too. With my first baby, I saw, oh… something like 17 doctors, lactation consultants, and midwives, including Dr. Jack Newman (the guru of Canadian breastfeeding). There were herbs, and pumps, and supplementing at the breast, and speed pumping, and breast compressions until I had repetitive stress in my hand… trust me. I didn’t have enough milk. It got better with each one, but it was never enough to exclusively breastfeed.

I did nurse my three babies for 12, 16, and 21 months, but they got an awful lot of their calories from formula over the first 6-8 months of their lives. That is what is available in Canada. We have good access to clean water, sterilization equipment, and I had enough resources at my disposal to provide fully mixed powder formula. All in all, they weren’t at great risk. Formula is an adequate source of calories for human babies. Adequate. Not good, not great. Just adequate. Artificial human milk was never intended to be a first line of defence. It was designed to be used as a supplement, or in place of milk when nothing else is possible. Using formula to feed is the final step in the WHO’s guidelines for feeding, coming after donated milk from a healthy mother. And although the choice between formula and starvation is a no-brainer, the choice between formula and donated breast milk is more subtle.

I have three children who were all partially breastfed, and partially supplemented with formula. They are fine… but that is not science, that is anecdotal. The odds are pretty good that most of the kids who are fed some formula some of the time will be OK at the end of it all. In fact, in the developed world with access to clean water and basic sanitation the odds are good that kids who are fed nothing but formula will be basically OK. But that doesn’t mean that formula is safe. It means that it is safe enough.

The Canadian Paediatric Society’s response is pretty cut-and-dried: [paraphrased – feel free to correct me if there is a misinterpretation here.] Formula is safe. Informal breastmilk sharing is not. You should only ever use milk from a bank, or use formula. Period. End of discussion.

This is an understandable position, given our past experiences with transmitted diseases from human fluids. It is not, however, subtle, or complete.

There is no way that a person like me would have had access to a milk bank. Even where they exist, they are (must be) extremely tightly regulated. The milk in them is distributed to hospitals to feed to infants whose lives are in immediate danger because of a lack of access to human milk. That is as it should be; the costs of $2 – $3 an ounce for pasteurized, screened milk are far beyond what can be borne by our society, or any family for the long term, except under the most dire of medical needs. My kids were never in immediate danger. They tolerated the cheapest formula well, didn’t require any additional interventions or any of the fractionated versions. It was OK. Basically.

But that is not true in all cases, for all people. And we can’t proceed with a risk analysis that starts from the premise that all things that might happen with shared milk are real, and all things that might happen with formula are a non-issue. The Cambridge Health Alliance study that was released last April indicated 911 excess deaths in U.S. infants due to “non-compliance” with exclusive breastfeeding recommendations. (I’ll probably have something to say about blaming individuals for the nasty structures they find themselves immersed in, but some other time.) This is only the deaths; the widespread use of formula also results in additional illnesses and hospitalizations. It is fair to say that formula is relatively safe, compared to alternatives, but to state categorically that it “is safe” (as Sharon Unger did on The Current this morning) overstates the science. It is particularly troubling when it is combined with a resort to anecdotal “What if’s” regarding breastmilk sharing. Dr. Unger posed the following question: “What if a woman with a cold sore donates breastmilk when she has open lesions on her breasts???” Well, yes. Clearly that would be a problem. But is there any chance that it could be prevented by telling women that it isn’t safe to breastfeed or pump (even for their own children) when they have open herpes lesions, rather than by declaring a blanket ban on milk sharing?

This type of position is very common in our public health discussions at the moment. It is common to this issue, food processing, and to medicalized births, as well as other subjects. It treats any risk associated with informal, local, and personal solutions as if it were very high, and then compares it to an imagined zero harm for the default (industrial) process. Ever more remote possibilities are imagined, and then treated as real risks, without any numbers applied to the risk analysis. Informal sharing is presumed to be dangerous, because something might go wrong. Formula is treated as safe because we have checks and balances, and thus accept the consequences as unavoidable. This is intellectually incoherent. We are willing to accept risk and harm mitigation in industrial systems, but we distrust individuals to take the same precautions with their own health, and especially with that of their children.

This type of unsubtle thinking leads to distrust. People who are non-compliant with doctor’s wishes are often highly educated, skilled critical thinkers, and they can see logical flaws in such an argument, but then are at risk of rejecting it in its entirety. Here is what I would like to see: I would like to see all of the “what ifs” removed from these arguments. I would like to see numbers. Hard numbers, backed by data. I would like to see an acknowledgment that a single case of something happening in the late ’80s doesn’t constitute a trend. I would like to see a little more respect for the goals and decision making capacities of parents that included more information and fewer declarations.

Formula is not poison, but it is not a perfectly safe substitute for breastfeeding. Your neighbour who is nursing her own baby probably isn’t going to give your baby syphilis (it came up in the conversation on The Current, but the incidence in Canada is 3.5 cases per 100,000), but nursing from more than one mother will probably expose a baby to a wider range of pathogens… and immunities. To realistically weigh these options, we need a truly objective analysis, not a clear (nuance-free) statement that one is always better than the other.

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For a very good article on informal breastmilk sharing, by someone who focuses on breastfeeding (among most of the other challenging parts of young parenting) check out PhD in Parenting’s very subtle analysis.

seonaid

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16 responses to “Breast Feeding, Formula and Risk Analysis”

  2. This is a really cogent analysis; I hope it will be widely read, including by the experts delivering pronouncements about milk sharing.

    The one thing I would add to this line of thinking is that there are cultural and political reasons why the risks associated with human milk and the risks associated with infant formula get treated so completely differently in both expert and popular discourses. We live in an era in which corporate power is unsurpassed, and misogyny is far from dead. We are primed to trust commercial products and distrust women’s bodies. Evidence that contradicts either stance tends to fall on deaf ears.

    • I agree completely. In fact, there is a whole other post brewing about the distrust of our culture for the body, and the assumptions that scientific/industrial solutions are superior that is a holdover from the Modern era. (I argue that we are living in a postmodern era, whether we accept it or not.)

  3. Finally! Someone else out there tried EVERYTHING and still couldn’t EBF! I’m not a failure after all! Although you wouldn’t know it based on some of the unsolicited advise I’ve been given over the past five months! Thank you for sharing and for this very informative article.

    • One thing that I found very helpful was the support of a community called BFAR (Breastfeeding After Reduction – which is *why* I don’t make enough milk. Probably.) This is an online group founded by Diana West, all of whom need to define their own success at BF-ing, because women who have had breast surgery are at very high risk of not having adequate milk supply.

      Even if that isn’t your case, both women with detectable/predictable breast problems *AND* adoptive mothers provide very good alternative narratives for BF-ing and mothering. You’re not a failure. You’re not a failure at all.

      Hugs! Keep doing the good work. It’s hard being a Mom, especially the first time around.

      BFAR is here: http://www.bfar.org/
      There is a sister site for women with low milk supply, but who haven’t had breast surgery here: http://www.lowmilksupply.org/ (I’m not suggesting getting hung up on increasing milk supply, but it is good to have the support of other women with the same issues.)

  5. THANK YOU! When I had my first baby my mother gave me all sorts of crap about how I was giving my baby poison with formula, but I just couldn’t feed her enough! And then when I had my second baby I went to a couple of drs who told me that some of my milk ducts didn’t work like half… So I ended up giving this baby formula too! So thank you I am sharing this with my mother NOW!

  8. Thanks for sharing your personal experience, Seonaid. Every drop that your children got of your breastmilk was packed full of precious antibodies and things they needed and I’m sure they benefited from it 🙂 Isn’t Diana West wonderful? I’ve heard her speak in person.
    Just to clarify, one can breastfeed with herpes, but should cover any lesions on the breast so they don’t come in contact with baby. If lesions are on the areola or nipple, the mother should not breastfeed on that side. More info. on breastfeeding and herpes can be found at the La Leche League website: http://www.llli.org/FAQ/herpes.html

  10. I’m all for breast feeding and all, but not so much the milk banks. Sure they can be beneficial and most the time they are. My problem is that a lot of STDs don’t show up for as long as six months and so many people go on living their lives without knowing they have one. I would rather give my child formula than risk them getting HIV that could kill them. I breast fed my son for a little over a year, but I also used formula because I didn’t have enough milk and he’s just fine. The milk bank is a good idea it should just be heavily monitored.

  12. Very, very interesting. I, too, am discouraged when I look for numbers — hard data — on a particular issue but can find numbers only for the industrialized, default option (vs. the “crunchy” one). I understand the cause — that companies often finance studies, and there aren’t as many rich but crunchy companies out there to do so, but it’s discouraging. Because then I’m stuck in many cases with a guess. An educated one, but still a guess.