As part of their “baby-friendly” initiatives, some hospitals now require women to sign consent forms before receiving formula. These forms purport to list the “harms” associated with “a single bottle” of formula, and ask that parents signify their understanding that formula should not be given unless medically necessary.
On its face, asking parents to sign a waiver to receive formula, a long-used and widely available way of feeding babies, seems astoundingly paternalistic. But what I find most shocking are the allegedly “scientific” claims these forms make about supplementing with formula.
Let’s consider one of these consent forms recently posted by the Fed is Best Foundation.
1. “Exclusively breastfed babies have a lower risk of jaundice.”
Not only is this statement false; the opposite is true.
Exclusive breastfeeding is widely acknowledged to raise the risk of neonatal jaundice, for well-understood physiological reasons.
Jaundice, typically indicated by the yellowing of the skin and the whites of the eyes, is caused by a buildup of bilirubin. When red blood cells break down, they release bilirubin.
For most of us, the liver breaks down bilirubin before it accumulates. This is why jaundice often indicates liver damage.
For newborns, however, whose livers are immature, bilirubin can build up quickly after birth; up to two-thirds of newborns experience mild jaundice. To help out their livers, newborns excrete some of the excess bilirubin in their pee and poop (hence the staining yellow poops!).
While most newborn jaundice is mild and not harmful. Severe jaundice can cause seizures and permanent brain damage.
Fortunately, with proper diagnosis and treatment (typically phototherapy), severe jaundice is exceedingly rare.
So why are exclusively breastfed newborns at higher risk of jaundice? Because, as these babies wait for mom’s milk to come in, they tend to have greater weight loss and less fluid intake than formula fed or supplemented babies during their first few days of life. This translates to less peeing and pooping of the excess bilirubin.
For example, late preterm infants (born between 35 and 37 weeks gestation) have a higher risk of jaundice than full term babies, and their risk is twice as high if exclusively breastfed.
Rating: PANTS ON FIRE
2. “A single dose of formula before 6 months of age can trigger allergies that might otherwise have been avoided.”
I do not know how to describe this claim other than as baseless fearmongering.
The current research consensus is that in high income, developed countries like the United States, breastfeeding does not appear to protect against allergies and asthma. The PROBIT trial, the only large (17,000 mother-infant pairs) randomized trial of breastfeeding conducted to date and thus our most reliable source of information on the true benefits of breastfeeding, reports no impact on allergies.
Furthermore, I cannot locate any plausible source the “single dose of formula” claim. Exactly zero studies appear to examined the effects of a single exposure to formula.
RATING: FALSE; BELIED BY MOST AVAILABLE EVIDENCE
3. “A single dose of formula… increases the risk of diabetes.”
But putting the “single dose” nonsense aside, does formula feeding more generally raise the risk of diabetes?
Let’s start by noting that there are two kinds of diabetes, Type 1 and Type 2 Diabetes. Type 1 is an autoimmune disease that most commonly occurs in childhood and adolescence and is caused by an immune-mediated destruction of the body’s insulin producing cells. In Type 2, the body continues to produce insulin, but the cells become resistant to its effects because of a combination of genetic risk factors, weight, and a sedentary lifestyle.
Since the consent forms to specify which type of diabetes formula feeding causes, I will consider the evidence for both.
For Type 1 Diabetes, although some early studies suggested that breastfeeding was protective, a series of recent large, well-designed studies (like this one, this one, and this one) have shown no benefit.
(These studies do find an increased risk of Type 1 among babies who received fully hydrolyzed formula in their first weeks of life. Conventional and partially hydrolyzed formulas, however, had no impact.)
For Type 2 Diabetes, observational studies find that breastfeeding lowers the risk of obesity and thus Type 2 Diabetes. But sibling cohorts and cross-cultural studies, which avoid the problems of confounding that plague observational studies of breastfeeding, find no benefits.
RATING: FALSE; BELIED BY THE BEST AVAILABLE EVIDENCE
4. “A single dose of formula can cause colitis.”
Sadly, this super-precise science based consent form fails to define “colitis”, which makes this statement, like the one on diabetes, difficult to evaluate.
One possible interpretation is that colitis means necrotizing enterocolitis. This interpretation does not make much sense, but a reduction in the risk of necrotizing enterocolitis is at least a real, honest-to-goodness benefit of breastfeeding.
Very premature babies are at high risk of something called necrotizing enterocolitis, a serious and not infrequently fatal disorder involving the intestines. Breast milk lowers the risk of necrotizing enterocolitis.
This interpretation seems like a stretch, though, as necrotizing enterocolitis is essentially unheard of in late preterm and full term babies–whose parents are presumably the targets of this consent form. Parents of very preterm babies would never see such forms, because they typically have an entire care team to with whom to discuss their baby’s feeding.
Or perhaps the author meant allergic colitis. About 3% of newborns will develop colitis (inflammation of their colons) from allergies to certain proteins, most often to milk, but sometimes to eggs or soy. These allergies can be triggered by formula OR by food proteins that have passed into breast milk. There is no evidence that formula increases the chances of this allergic reaction.
Rating: FALSE
5. “Supplementation can cause nipple confusion.”
First off, can we please stop calling this nipple confusing, as that label is just… confusing. It is nipple preference. Babies sometime develop a strong, hard to break preference for either the breast or the bottle.
Regardless of what we call it, babies do not form nipple preferences in their first few days of life. They are too immature. Nipple preference only becomes a potential problem at around 8-10 weeks, when your baby’s brain starts forming associations and they become mentally and physically capable of expressing their preferences.
Rating: MISLEADING
6. “Research shows that breastfeeding…significantly decreases the risk for a large number of acute and chronic diseases that can last a life time.”
Conveniently, this form fails to state which, if any, chronic diseases, breastfeeding permanently protects against–almost certainly because nearly all of such claims about long-term health benefits are based on very low quality evidence, and are not found in high quality studies.
Rating: FALSE
The Bottom Line
Many new moms are at their most vulnerable those first few days after giving birth. Mentally and physically drained by labor and delivery, sleep-deprived, and nervous about their newfound responsibility, their natural inclination is to look to their doctors and nurses for advice and support and to trust in their expertise and experience.
These consent forms violate that trust.
Worse, these forms perpetuate false claims about supplementation and grant them the patina of credibility. This, in my opinion, makes these consent forms not just misleading but dangerously irresponsible. They could lead parent to refuse supplemental formula even when medically indicated, potentially leading to life-threatening starvation, jaundice, and dehydration.
It is time for hospitals to stop this paternalistic and groundless practice. There is nothing “baby-friendly” about it; it is unfounded, coercive, and dangerous.