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.
A good friend of mine living in Scotland, who had a baby last year, mentioned to me how disappointed he has been with the U.K. National Health Service’s promotion of breastfeeding. Calling the alleged benefits overstated, he said, is itself an understatement.
I nodded in general agreement, acknowledging that many of the alleged benefits of breastfeeding have only been found in observational studies.
Observational studies on breastfeeding merit skepticism, because they all suffer from the same major problem: breastfed infants on average differ from formula-fed infants not just in how they are fed in infancy, but in practically every other possible way–maternal education, maternal IQ, poverty, neighborhood safety, exposure to environmental toxins, race, and type and quality of childcare. In scientific terms, breastfeeding is confounded, out the wazoo.
We cannot tell which benefits found in an observational study derive from breastfeeding rather than from the myriad other advantages linked with breastfeeding.
(The “good” observational studies attempt to control statistically for the other relative advantages of breastfed infants. Unfortunately, controlling for confounds only works well when (1) all the important potential confounds are known, and (2) when there is a fair amount of overlap between the groups being compared. Neither of which is true when it comes to breastfeeding.)
In an ideal world, we would settle this question by conducting several large randomized controlled trials (RCTs), in which new mothers would be randomly assigned to breastfeed. RCTs are the gold standard in medicine for determining whether a true cause and effect relationship exists. In practice, though, such trials are neither feasible nor ethical.
Fortunately, we have the next best thing: a handful of studies that have cleverly circumvented the problem of confounding. These fall into two categories:
sibling studies, which compare siblings from the same families who were breastfed for different lengths of time, or who were not both breastfed.
a large RCT of a highly successful breastfeeding intervention (PROBIT Trial).
(Is the PROBIT Trial an exception to the no-RCT rule? No. Women in the PROBIT trial were not randomly assigned to breastfed or not; they were randomly assigned to receive a breastfeeding intervention or not.)
After my friend and I spoke about his irritation with the medical organizations like the American Academy of Pediatrics (AAP) and NHS overstating the benefits of breastfeeding, I was dissatisfied with my vague sense that he was right. I wanted to know exactly which benefits had been oversold and exactly which were supported not just by observational studies but by better-designed studies.
The short answer: Nearly all the alleged long-term benefits are likely the result of confounding, not breastfeeding. Better-designed studies find only a handful of real benefits: a reduced chance of severe gastrointestinal infections and a lower risk of eczema during infancy, and perhaps a small boost in childhood IQ.
Alleged Breastfeeding Benefits According to the NHS
According to the NHS, breastfed infants are…
less likely to suffer from vomiting or diarrhea and therefore less likely to go to hospital
less likely to develop type 2 diabetes in later life
less likely to become obese in later life
less likely to suffer from heart disease in later life
less likely to suffer from constipation
less likely to get a chest or ear infection and therefore less likely to go to hospital
less likely to suffer from tooth development problems
more likely to have good communication and speech skills
more likely to have good circulation
less likely to suffer from wind, colic and constipation
less likely to develop eczema or asthma
Sounds pretty impressive, right? Until you set aside the evidence from observational studies…
Breastfeeding is a major battleground of the modern mommy wars. In her widely discussed piece in The Atlantic, Hanna Rosin called breastfeeding the “new sucking sound”–replacing vacuuming as the task that shackles women to the house, promotes the unequal distribution of childcare and household duties, and prevents women from reaching the upper echelons of professional success. The benefits of breastfeeding have been oversold, she claims, and–just as significantly–the costs to women’s sleep, time, and career progress have been downplayed.
On the other side of the debate, the American Academy of Pediatrics states that the benefits for the infant in terms of reduced risk of infection, adult obesity, allergies, and asthma are so great that breastfeeding must be viewed as an “investment in your child’s future” rather than a “lifestyle choice.” Some lactation consultants fall into this camp too, needing to be reminded to suppress their impulse to sigh when yet another mother complains of exhaustion and lack of sleep, for fear they alienate her–and thus fail to convince her to keep breastfeeding.
On both sides, well-intentioned but overzealous advocates twist the evidence on breastfeeding, cherry-picking among studies to support their preexisting views.
This is especially true when it comes to one of breastfeeding’s major downsides: Disrupted sleep.
Consider the post, 5 Cool Things No One Ever Told You About Nighttime Breastfeeding, which claims that the number 1 coolest thing about nighttime breastfeeding is “breastfeeding moms actually get MORE sleep than their formula-feeding counterparts,” and concludes with the rhetorical question: “Did you ever think, when you hear your baby rouse at 2:00am, that they are actually giving you the gift of MORE sleep…?”
To which I would like to respond: No, never, not only because it does not square with my own experience, but also because the research on this topic is clear: breastfeeding moms, on average, get less sleep, not more.
Almost without exception, studies on formula feeding, breastfeeding, and sleep find that breastfed babies wake up more often than formula fed ones at night, and breastfeeding mothers therefore get LESS uninterrupted nighttime sleep.
Nighttime Wakings in Formula-Fed Versus Breastfed Babies