Tuesday, February 16, 2016

Bias in Breastfeeding Policy and Research?

Breastfeeding got another boost this weekend in Jane E. Brody’s New York Times' article on the new breastfeeding guidelines. In case you missed it, breastfeeding is still glorious. For all mothers and children with rare exception.* More effort should be made to better accommodate breastfeeding. Such was the intended message. Got it. We all got it.

Then there was the unintended message. In case you missed it.  The bias seeping in. And I'm not just talking about this gigantic bottle of formula lurking in the nursery, the lovely graphic that accompanied Brody's article. 

Cred: Paul Rogers, New York Times
The lead author of the new guidelines, a leading breastfeeding researcher, also moonlights as a “tireless advocate” who breastfed all her kids:

In 2001, when Dr. Alison Stuebe was pregnant with her first child, breast-feeding was a personal challenge that soon morphed into a professional research interest. Her son Noah was 3 months old when she began her residency in maternal-fetal medicine at Brigham and Women’s Hospital in Boston. Determined to nurse him for a year, she arrived at the hospital carrying a breast pump and, through sheer determination, more than met her goal. Noah was 2½ before he was weaned.

In the years since, with two more breast-fed sons, Dr. Stuebe has become a leading expert in the health value of breast-feeding for both mother and baby and a tireless advocate for new mothers trying to navigate its all-too-frequent challenges.

Not uncommon, scientists get attached to certain causes, models, even hypotheses. At the same time it is incumbent on researchers to remain objective, both in the collection, interpretation and communication of empirical evidence. That is, if there is a desire for accurate, objective empirical evidence.

“Physicians should not be dogmatic,” Dr. Stuebe said. “Formula is not poison. Like antibiotics, if it’s needed, it should be used judiciously.”

Got it. If needed, used judiciously. Like antibiotics. Like pain meds. Or poison.
Ultimately, the obstetric guidelines conclude, a well-informed woman is best qualified to decide whether to breast-feed exclusively, combine breast with formula-feeding or feed only formula. New York Times
I totally agree.

A well-informed woman.

To date the public health community has not provided accurate and nuanced information about the relative size, duration and scientific rigor of empirical evidence of any breastfeeding benefits. Maybe in the privacy of their own homes but certainly not in any public, systematic manner. I don’t see many attempts to accurately portray the benefits of the breast.  

Yet it wouldn’t be difficult to clearly portray the benefits in detail, that is if researchers give enough detail in the first place. Journals should require effect sizes and researchers and officials should also put the results in real terms if they speak to the media or otherwise relay information to the public (e.g., babies who are breastfed will experience 1.5 ear infections compared to non-breastfed babies who...). Public health authorities should certainly be providing benefits and risks in these practical terms. It’s not enough to call results significant or report half as many ear infections. It certainly isn’t enough to keep calling breastfeeding “optimal” and “best” without useful details. Women deserve more information in light of the ever-tightening policies on breastfeeding. (Check out a relatively recent article, Overselling Breast-Feeding in the New York Times to see one rare instance of a breastfeeding benefit put in terms women can easily apply to their lives.)

In recent weeks there has been a public outcry over the CDCs less than nuanced and accurate recommendations regarding pregnancy and alcohol, but where is the parallel concern let alone outcry for the stringent breastfeeding recommendations? You know, the guidelines supported by a growing yet confounded, correlational body of research espousing small to moderate "effects" by researchers with a vested interest in the data.

I breastfed all of my children but the current state of breastfeeding policy needs to be closely scrutinized, including any potential conflicts of interest including a lack of objectivity that hinders nuance and even accuracy.** 

*NOTE: In case you missed it. The “few medical” conditions that excuse moms from breastfeeding. And no, these don’t include postpartum depression, other mood disorders or hormonal conditions.

Among the few medical contraindications to breast-feeding are infections in the mother – H.I.V., untreated tuberculosis, chickenpox or a herpes lesion on the nipple – and mothers being treated with cell-killing cancer drugs. Although clear-cut data are lacking on the effects of marijuana on breast-fed infants, the drug can get into breast milk and the guidelines discourage marijuana use by nursing mothers. Babies with the genetic disorder galactosemia, which impairs digestion of a sugar in milk, should not breast-feed.” New York Times

Moms with untreated tuberculosis, pot heads, please, pay attention. Galactosemia moms, all 300 of you, listen up too. Because the NY Times and breastfeeding experts are dotting all i’s and crossing all t’s – when it comes to keeping the public informed. They are making sure to provide all necessary information except for the practical details that might reduce breastfeeding (e.g., a matter of one bout of diarrhea, one ear infection). They will leave out no minor detail, no potential group of infants and mothers at risk in their quest to keep children safe and every mother informed. And to keep every mother - who isn’t suffering from certain infections and one very rare genetic disorder  - breastfeeding. 


**Note the nuance in the article’s elaboration of the contraindications (as opposed to benefits). The data on marijuana is not “clear-cut” – and apparently it is for SIDS, infection and metabolic disease. Uh huh. Clear cut. No doubt, at least if you ignore the mixed findings, the many confounding factors, the old data, etc.

Someone just asked why I omitted media from the title. It would have been redundant to add "media" to sources of potential bias in the title. I'm not giving them a pass here. 

10 comments:

Kate Amorella Proff said...

A "well-informed woman" should also be taught how to properly use formula. Instead, women have to hide in shame at the grocery store, looking over the many options and not have any guidance as to how to choose. What I would have given for someone to tell me simply how to mix formula prior to having my child. Instead, I wept at the computer, seeking any kind of guidance, fearing I was doing something wrong and would hurt my child. I can't tell you how many new moms have sheepishly asked me how "it" works. I never hid the fact that we switched to formula after 6 weeks. I don't need to explain my reasoning. It was best for my family at the time. Now I tell these women there is no shame in using formula. There's no shame in breastfeeding. There should be no shame in doing what you have to to feed your child and keep them healthy. Sure, breast is best. We got it. You know what's better? Raising a healthy child who has a healthy mother.

"As in the past, the new guidelines disparage an all-too-common practice of outfitting new mothers at discharge with a “gift bag” that contains samples of formula, which can suggest that the hospital endorses formula feeding. Direct-to-consumer marketing of infant formula is also disparaged."

I think this is horseshit. A well-informed woman should be given all the information. She should be given resources for both breastfeeding and formula feeding. How about we just give it a rest and simply call it feeding our children.

I'll get off my soapbox now.

Polly Palumbo, Ph.D. said...

Thanks, Kate. Don't get off your soap box yet! The more the merrier, and maybe the CDCs, the AAP and their partners will start to listen and provide nuanced, unbiased information.

Andrea Riley said...

Ugh, this is (one of the many things) what gets me. This speaks volumes. "Although clear-cut data are lacking on the effects of marijuana on breast-fed infants, the drug can get into breast milk and the guidelines discourage marijuana use by nursing mothers." Only nursing mothers are discouraged from using marijuana? How is smoking pot around a newborn not discouraged? Do they not even care about how responsive a new mom might or might not be to her infant if she's high? What about baby's respiratory or neurological development? It's *only* mom's status as potential breast milk delivery device that's called into question? Everything else about that situation is kosher, even if babies are so fragile that a sip of alcohol in pregnancy will cause lasting damage as the CDC just informed us? No one sees a problem here with marijuana using mothers, only formula feeding moms? Are we in crazy town?

Sorry that image is haunting your dreams, it haunts mine, too.

Anonymous said...

Ha-ha! My hormonal condition made sure I couldn't produce enough milk. But that's no excuse not to breastfeed!

Please don't get off of your soapboxes. We need to push back against this extreme breastfeeding push. If a mother wants to breastfeed, and is capable of doing so, she should be supported. But not at the expense of mothers who cannot, or do not want to breastfeed.

Anonymous said...

Hi Polly,

I enjoyed your article but am curious why you felt it necessary to include that you had breastfed all of your children. I've noticed the inclusion of that information in several recently written articles in support of feeding our babies however a parent has to, or chooses to. My opinion is that your choice of how you fed your babies is not pertinent to the article. That information is your business alone. It reminds me of the tiresome response so many women have about abortion--"I would never have one myself, but support those who do." Saying "I support those who do" is the important information and it's enough--including a personal moral disclaimer dilutes the support and taints it of judgment. That said, great article and thank you for writing it.

Polly Palumbo, Ph.D. said...

Thanks for commenting everybody. Anonymous (the second!), great point. I've been conflicted about sharing my breastfeeding history. You're right, it is my personal business. I hope one day I won't feel the need to share it. The current climate though, for me, tips the balance in favor of sharing it. I've been attacked and questioned in the past as anti-breastfeeding so now I often report it. Also there is power in women telling their stories, including their struggles, successes, etc. as the Fearless Formula Feeder and her readers and partners so poignantly show week after week. These real life details help illustrate the actual costs and benefits. So I'm curious, this is a hard question, and could fill a whole page - did you feel the same in reading that a breastfeeding researcher has breastfed a child for over two and half years? I like having that information. Kind of like I want to know the political leanings of the next Supreme Court Justice.

Andrea: Developing lungs? Maybe the CDCs can recommend edibles to keep pot moms breastfeeding and keep the lungs clear. Now can imagine that? If it's legal, they'll have to address it more and more.

Anonymous said...

Polly, thank you for your thoughtful reply and confirming my suspicion that you included your feeding choice to ward off accusations of being anti-breastfeeding. Whether we like it or not, our personal decisions and actions, especially in regards to child rearing, inform our biases. Whatever your reasons, and whether you like it or not, including that you breastfed subtly conveys a bias for that method. For that reason, I don't like the practice.

To answer your question, yes, I feel the same way. I don't want researchers' personal information provided along with the research. I have no doubt that a researcher's own experience somewhat colors their research (they are only human) but I prefer not to be provided with that information along with their research.

It's kind of like TV newscasters and weather people nowadays--they all have to have a "personality" and tell us what they did on the weekend. Just read me the damn news. If I wanted to know about your personal life and "get to know" you, I'll invite you for coffee. Just give me the information.

Polly Palumbo, Ph.D. said...

Anonymous, I understand the sentiment especially in this era of oversharing. The ubiquitous personal anecdotes at the start of so many parenting articles (heck, any article) sometimes aggravate me. I take comfort in journal articles. Still, people are endlessly fascinating.

Anonymous said...

Thank you! The lurking formula bottle is insulting to mothers - especially those who tried so hard to breastfeed without supplementation that they ended up almost starving their babies in the attempt. It is completely negligent that hospitals, governments, and universities pretend that feeding difficulties do not exist when babies are being hospitalized every day due to our insistence that every woman can and should breastfeed. Where are the objective lists of benefits and risks for all feeding options? Where are the campaigns that acknowledge that some moms and babies need supplementation to be safe? Parents cannot make an informed choice on a feeding method if we withhold the risks from them and only provide the benefits. If researchers did this in their IRB protocols and informed consent forms, it would be considered an ethical travesty! And yet, we do it all the time in our breastfeeding initiatives.

Polly Palumbo, Ph.D. said...

Anonymous (above!), thank you too. Do I correctly detect a hint of academic researcher? Oh ethics! Bring it on. I don't ever recall reading or hearing about the ethics of breastfeeding guidelines and communications. Where do the ethicists stand on this matter?