Breastfeeding: the dogma, the evidence and the lived experience

I think I’ve written several drafts of this blog post. Each time, I gave up before editing and publishing because the topic is just too emotional for me. But today as I sit here hooked up to my Spectra pump for the umpteenth time, I think may be this is a story worth telling.

The thing about breastfeeding is that it is not just a mostly-neutral activity that you choose or don’t choose to do based on your personal circumstance. In America, it is a dogma. It is a competition. It is a political statement of sorts. It is a badge of honor. It is a symbol of commitment to motherhood. It is laden with judgment. And ultimately, my stance on it is it is way more than it needs to be, and the strong narratives around it dissuade mothers from doing what is actually best for their family. In this blog post I’ll explain why #breastisbest is nonsense and #fedisbest is the more accurate holistic way of approaching baby nutrition and your life.

The dogma

About a month ago, I was at the Lightening in a Bottle festival, at a booth of extremely alternative clothing – we’re talking mono-sunglasses that cover the whole face, furry thongs, embellished stringy leather festival attire, a place where you’d think people are open-minded and woke. After my comment that one of the bras with a lot of stringy parts would be useful for pumping (this is where my mind goes), a story ensued about a breastfeeding woman who had squirted people in the face as a greeting at the festival years ago. “No big deal. Everyone was breastfed at some point” said a woman, “Well, the ones who had good mothers were” added another one. There it was. The sentiment of the day: Good mothers breastfeed.

In Facebook communities, on Instagram, in mommy blogs, mothers show off about how long they breastfed for, or the exclusivity of it: the ‘F’ word in these communities is Formula, and you’d think it was rat poison the way they talk about it, rather than a nutritionally-complete alternative to breastmilk that has been developed over decades of scientific research. We haven’t even analyzed most women’s breastmilk and it may even be the case, as my doctor admitted, that women have different nutritional values to their breastmilk and we just don’t know or worry about it because #breastisbest #endofdiscussion for #everyoneeverywhere. She mentioned this casually after another appointment where my baby was falling weight percentiles after his #exclusivebreastfeeding following the American Academy of Pediatrics best practice guidelines (more like American Academy of Parenting Anxiety, but more on that in another blog post).

Part of the obsession with breastmilk is the overall “natural is best’ philosophical movement that has gripped our society and extends to everything from births to breastfeeding, with little regard for individual context. Nature contains so much disease, suffering, and catastrophe — these things aren’t emphasized enough when you google natural solutions on your unnatural iphone.

Now I’m not arguing that formula is better than breastmilk overall – there’s no evidence to suggest it is – but I am arguing it doesn’t deserve the taboo status it has. Formula does not contain antibodies and a host of other less well understood beneficial components that breastmilk provides, of course, but treating it like poison is extreme. Especially since as much as we may love to create the perfect, organic, natural environment for our kids, at some point (and pretty early on), they will eat pavement cheerios (a local delicacy in my local parent-kids group, even baby Ayden has participated lately) and go to daycare and catch all kinds of nasties that your breastmilk will not be able to prevent (or are there some mothers that now go to daycare before their kid, interact with all the kids to create the antibodies and then breastfeed?)…so this whole “breastmilk, absolutely no formula” thing is like being ultra-focused on trying to have perfect hair in a dust-storm. You cannot control everything in your kid’s environment so why so much energy and pain on this one thing?!

When I was pregnant and read “Sippy Cups Are Not For Chardonnay”, I was entertained by the chapter “Lactose intolerance” where Wilder-Taylor warns readers about “Lactavists”, “Tit Terrorists” and the “Breast Brigade”. But then sh*t got real when I was actually breastfeeding and joined several Facebook groups and followed a few accounts on Instagram. There’s a whole set of sub-cultures around breastfeeding and exclusive pumping. Some are deeply disturbing. In one Facebook group that I ultimately left, a mother who was desperate to exclusively breastfeed posted about her baby not having eaten in 6 hours noting “She must be hungry. I’m pretty sure she’s very hungry but she still won’t latch”, spurred on by encouraging comments that her strategy of starving her baby would probably work. I was horrified.

In one group on exclusive pumping, you have to agree to community rules to not reference breastfeeding or warn people if a photo contained a lot of pumped milk as it may trigger members. To be clear, I don’t blame these groups in most cases, but their existence and their strict rules to “protect” members go to show how sensationalized and sensitive breastfeeding has become.

In the less policed groups or on Instagram accounts, there was the unsaid competition around freezer stashes, hours pumped, and cakes that looked like pumps celebrating getting to 18 or even 24 months of pumping. The lactating parents who didn’t have freezer stashes were called “just-enoughers”, and the ones who had a whole dedicated ice-cream-shop-sized freezer were admired and looked upon as Goddesses. For Type A women, pumping was a competitive sport – now you could measure the output, label it and post about it for all to see and compare.

Here’s a message I could endorse: “Breastfeeding is very good nutrition for your baby, do it if you can or as much as is reasonable in the balance of all the things in your life, but don’t sweat it if it’s destroying your happiness or you can’t as your baby will be fine either way. And note it has diminishing marginal returns as your baby gets bigger and starts eating more foods”. The message from these groups instead was that breastfeeding was worth your life: it was worth spending all your free time on, sacrificing your sleep, carrying pumps to crazy locations for and doing all of this for as long as possible, long past even when your baby is supposed to take formula (~1 year). It was nuts. It had become dogma.

The evidence

Breastmilk is commonly known to be an elixir of life. It is regarded as a prevent-all. It has been linked to everything from IQ scores to obesity and diabetes and even higher earnings in later life. When you look at the research that underpins these claims, as a few journalists like Emily Oster have taken a deep dive on in her excellent article “Everybody calm down about breastfeeding“, you’ll be shocked to see how weak the evidence is for all these bold claims that are printed all over doctor’s waiting rooms, and on the freezer bag and pamphlets hospitals hand out to you after birth, which I very much appreciate, by the way, but would like more accurate slogans on them like may be: #fedisbest and #dowhatworksbestforyourfamilyholistically, but that’s not as catchy.

Oster notes that many studies of breastfed vs non-breastfed infants are “observational” studies which neglect to account for the fact that there are differences in many other conditions between who is breastfed vs non-breastfed such as education level and income of the parents – richer, more educated parents tend to breastfeed, for example, and higher income and more education has a positive impact on the infant’s health and such. When you look at truly randomized trials, there are very few trials and in those the differences between the health outcomes for breastfed and non-breastfed infants are far meeker than the street talk.

One of the largest randomized trials was done in Belarus in the 1990s with 17,000 infant-mother pairs (The “PROBIT trial”). It found that breastfeeding may slightly decrease your infant’s chance of diarrhea and eczema. But there were no significant differences between breastfed and non-breastfed infants in respiratory infections, ear infections, croup, wheezing and infant mortality. This is important because these are so often cited as benefits of breastfeeding. Furthermore:

“The researchers analyzed the impacts of breastfeeding on allergies and asthma; on cavities; and on height, blood pressure, weight and various measures of obesity. They found no evidence of nursing’s impacts on any of these outcomes. They also found no evidence of impacts on child behavior issues, emotional problems, peer issues, hyperactivity or maternal-child connection.“

— Emily Oster, “Everybody calm down about breastfeeding”

Hanna Rosin’s provocatively titled and unapologetically honest 2019 article “The Case Against Breastfeeding” is a much needed counterbalance to the swelling dogma around how holy and wondrous breastfeeding was. One of the most important myths busted in the article is that of how antibodies in breastmilk work: they coat the baby’s digestive tract, they do NOT enter a baby’s bloodstream.

Even many doctors believe that breast milk is full of maternal antibodies that get absorbed into the baby’s bloodstream, says Sydney Spiesel, a clinical professor of pediatrics at Yale University’s School of Medicine. That is how it works for most mammals. But in humans, the process is more pedestrian, and less powerful. A human baby is born with antibodies already in place, having absorbed them from the placenta. Breast milk dumps another layer of antibodies, primarily secretory IgA, directly into the baby’s gastrointestinal tract. As the baby is nursing, these extra antibodies provide some added protection against infection, but they never get into the blood.

— Hanna Rosin, in “The Case Against Breastfeeding” for the Atlantic

I agree with Rosin when she reviews all the evidence and concludes: “Given what we know so far, it seems reasonable to put breast-feeding’s health benefits on the plus side of the ledger and other things—modesty, independence, career, sanity—on the minus side, and then tally them up and make a decision. But in this risk-averse age of parenting, that’s not how it’s done.”

The lived experience

To say breastfeeding is a natural and bonding experience (for everyone) is to tell an obvious lie that is offensive to any parent who has had a frustrating time trying to breastfeed. My baby hated breastfeeding for the longest time. So much for a warm fuzzy bonding experience, he would actually cry upon seeing a breast and turn his face away. It was not an activity that helped our bonding, to the contrary, it was a stressful activity for both of us.

When he got better at it over time, mainly because his mouth got bigger, rather than because of all the contortionist poses I tried spurred by different lactation consultants, it wasn’t stressful for us in the same way any more. But one thing has been true throughout: breastfeeding has been a massive time and energy drain on my life.

The health benefits for the baby may be minor and fade over time as we’ve seen in the evidence section above, but the brain and body damage the mother incurs with exclusive breastfeeding is permanent, and not given nearly enough importance in my view. It’s all bundled into the culture of suffering we have around motherhood: suffering is a badge of honor, part of the job. The more you suffer, the better you’re doing the job. I think this is unfeminist BS. Your health, your sleep, your sanity, your relationship with your partner, your time to workout, your time to be with friends, your time to attend a wedding without constantly zipping and unzipping your bridesmaid dress and trying to locate refrigeration for pumped milk, your time to attend a career-furthering conference, and your time for doing something you enjoy every day matters. You matter. Your baby matters, but you matter too. And that’s what I think is really missing in the narrative around breastfeeding and motherhood: the mother, the owner of the breast is just overlooked. And the connection between the mother’s wellbeing and the baby’s wellbeing is overlooked — would you rather have a breastfeeding mother who is grumpy, tired, inattentive or a woman who confidently combination feeds or formula feeds and is better rested and fulfilled as a result?

*****

None of this is as straightforward as breastfeeding = a good mother. And I wrote this article because I am tired of that bullshit unfeminist narrative. I was caught in it for several months. I pumped through my nap times for months on end, I took many full night shifts as the breastfeeding parent when just one formula feed would have let me get 5-6 hours of uninterrupted sleep, and I got to points where I was so depleted and so confused and embarrassed why I was so trapped despite living in modern times with abundant solutions.

My mother formula-fed me after about a month, and she went to work as a Pediatrician about a month after I was born. She still carries guilt about some of these decisions like the early return to work (she didn’t even have a choice back then). But I feel proud that she was able to be a good doctor and serve all those children. It’s just amazing how much we shame mothers and make them feel like every thing they do is directly tied to their kid’s outcomes, overlooking the randomness of life or the fact that some of these decisions are not as long-lived as we want them to be: we have less control on outcomes than we think, but we have more control over solutions today that can make our lives easier than we think – if we’re lucky and economically privileged — neither formula feeding nor breastfeeding are cheap. Ultimately, it’s a personal choice that should be up to the parent(s), and everyone else’s job should be to support the parent(s) in having a fed baby because #fedisbest.