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The Literal Nanny State — Breastfeeding And Public Health Officials

Breastfeeding is great. But government limitations on other options hamper parental freedom.

For those in the healthcare profession and with children under, say, five years old, the real polarizing topic in parenting over the last few years has not been whether women can have it all, or whether working outside the home or inside the home is better. It’s about whether mothers have a duty to breastfeed at all costs. It’s about whether formula feeding is a choice, or whether it’s a medical necessity. It’s about whether outmoded healthcare practices have led uninformed women astray, away from the obvious right choice of breastfeeding and toward the evil formula companies. It’s about how beneficial breastmilk actually is, and how formula stacks up.

Don’t believe me? Just ask Suzanne Barston, the founder of a website dedicated to freedom in infant feeding choices. Her blog Fearless Formula Feeder (Tag line: Standing up for formula feeders… without being a boob about it) is about the battle to destigmatize formula feeding. When Mayor Bloomberg announced his Latch On NYC initiative in 2012, Barston went nuclear.

“Why is it being brushed off as a ‘mommy war’? Why is no one realizing that our anger has nothing to do with promoting breastfeeding – something the vast majority of us support – and everything to do with concrete, authentic fears about personal freedom?,” she wrote in her seventh post on the topic.

One could examine every claim made by breastfeeding advocates or, on the other side, claims made by formula companies on the effectiveness of their product. But the real debate is not about breastfeeders vs. formula feeders, or who faces the greater stigma. We could argue about how disingenuous statements from the Surgeon General lead to the posters on doctors’ walls making outrageous claims about how “Breastfeeding reduces obesity. Breastfeeding increases IQ,” and the resulting pressure and shame women feel if they are unable to breastfeed exclusively, for medical, mental, or lifestyle reasons. On the opposite end of the spectrum, we could kvetch all day about how the oversexualization of breasts have made breastfeeding seem indecent, or how often families and peers push supplementation even though most children do just fine on breastmilk alone.

These skirmishes in the mommy wars might be important, but there’s a more pressing political question needs to be addressed: Why has exclusive breastfeeding has suddenly become a public health issue, and should it be?

Attempting to justify the nanny state

With the continued exaggeration of the benefits of breastfeeding — and its corollary, the dangers of formula — the nanny state has taken what is essentially a private parenting decision and turned it into a crisis of national standards.

Surgeon General Regina Benjamin’s 2011 Call to Action regarding breastfeeding reflects the absurd lengths to which these activists will go to justify government involvement in infant feeding practices. The Call to Action avoids describing the valid, but possibly exaggerated, benefits to breastfeeding and instead goes one step further, demonizing formula feeding by providing very specific and also exaggerated risks.

According to the Call to Action, a 2007 study by the Agency for Healthcare Research and Quality (AHRQ) reaffirmed the health risks associated with formula feeding. In the document, formula feeding:

  • will increase the chances the baby will get sick
  • will increase the chance of diarrhea and ear infections
  • will increase the risk of acute ear infection by 100 percent
  • will increase the chance for leukemia and severe lower respiratory infections
  • will increase the risk of sudden infant death syndrome
  • will increase the risk of necrotizing enterocolitis (NEC) among premature infants
  • will increase the risk for type 2 diabetes, asthma, and childhood obesity.

The findings from the AHRQ study lead to Benjamin’s adoption of some eye-rolling-government-fixes-everything solutions favored by the left. Two classic ones are:

  • the creation of a government interagency task force to promote breastfeeding
  • paid maternity leave for government civil employees (let’s not get into the amazing amount of other leave government employees can get, including sick leave and annual leave, or the fact that the combination of the two gets one to a paid 6-week maternity leave very easily, and, if planned for correctly, a paid 12-week leave)

With such risks, breastfeeding rates in America very well may look like a public health issue. But Benjamin used the AHRQ report as her sole justification for her call to action. That was a huge mistake. The Call to Action itself repeats the AHRQ’s word of caution:

“…almost all the data in the AHRQ review were gathered from observational studies. Therefore, the associations described in the report do not necessarily represent causality. Another limitation of the systematic review was the wide variation in quality among the body of evidence across health outcomes. For future studies, clear subject selection criteria and definition of “exclusive breastfeeding”, reliable collection of feeding data, controlling for important confounders including child-specific factors, and blinded assessment of the outcome measures will help. Sibling analysis provides a method to control for hereditary and household factors that are important in certain outcomes.”

So, basically, the report is one big pile of “correlation does not imply causation.”

Kudos for that part even making it into Benjamin’s document. But she neglected other cautions in the AHRQ review. The focus of the review is “on the effects of breast milk feeding, not formula feeding.” In addition, many of the studies reviewed did not separate out sick infants or premature infants from healthy term infants. Finally, the majority of the studies in the review did not distinguish between breastfeeding and partial breastfeeding and expressed breastmilk in a bottle.

The AHRQ concludes the section with this histrionic statement (emphasis mine):

“…well-performed RCT [randomized controlled trial] with proper randomization, allocation concealment, clear definitions of breastfeeding exposure compared with non-breastfeeding, and blinded assessment of outcomes will yield the best evidence in supporting the causality of breast milk in affecting health outcomes. But with the recognized benefits of breast milk, this approach is ethically not feasible.”

In other words, it’s like not giving medicine to a sick baby.

I jest, but the extent to which the tone in the Call to Action mimics the die-hard breastfeeding interest group is far from amusing.  For example, one premise is the increased risk of starting solids before six months — an amalgamation of the American Academy of Pediatrics’ (AAP) recommendation to breastfeed exclusively for the first six months and its studies on the risks of early solid feeding.  However, the AAP, although recommending exclusive breastfeeding for six months, also states on most sections of its site that solids should not begin until “after 4 months of age, preferably at 6 months of age.” And all its studies on the risks of starting solids too early considers “too early” to be before four months, at a time infants physically cannot digest food or do proper swallowing motions. Of course there are risks there. It has nothing to do with breastfeeding.

The Call to Action also criticizes the supplementation of breastfeeding with formula. Whether or not mothers are correct when they believe they are not producing sufficient milk, this attack on formula ends up demonizing combination feeding and supplementation as well — a vilification not factually supported by the AHRQ report.

The consequences of overstating the case have significant policy implications, including calls to implement portions of the World Health Organization (WHO)’s International Code of Marketing of Breastmilk Substitutes.  The Baby Friendly Hospital Initiative is the WHO’s implementation of the Code’s proposed restrictions on health care facilities. On its face, it is fairly innocuous, and perhaps even welcome, including allowing mothers and infants to remain together 24 hours a day while in the hospital after delivery and encouraging breastfeeding on demand. Certainly scores of anecdotes exist regarding outdated practices — such as giving infants formula without a mother’s permission or taking a baby away for hours a time — that hinder breastfeeding success.

Formula Fearmongering

But when the government comes in and tries to join the fray, even the best of intentions usually become draconian. Case in point: Mayor Bloomberg’s version of the Initiative.

The fault isn’t Bloomberg’s alone. The WHO Code itself restricts hospital use of free formula or other infant care aids. It also states “formula feeding should be demonstrated only to those mothers or family members who need to use it and the information given should include a clear explanation of the risks of formula feeding and hazards of improper use of products.” Maryland now has a similar Baby Friendly Hospital program.

Bloomberg may have gotten more most attention for his other forays into nanny-statism. However, his breastfeeding initiative received such a backlash that the policy’s website introduced a “Myths and Facts” document, asserting most of the hysteria over the policy was unfounded. For instance, it is a myth that the city is requiring hospitals to put formula under lock and key, or that mothers who want formula will have to convince a nurse to sign it out by giving a medical reason.  The initiative instead, according to the site, takes only the relatively benign measures of ending the practice of giving every new mother a free promotional bag of formula and instead providing mothers with accurate information on the benefits of breastfeeding.

Luckily, those silly mommy bloggers took screenshots of the original FAQ, which the Myths and Facts document replaced. What was originally in the initiative? Let’s review.

What does it mean to restrict access to formula? Restricting access to formula means storing formula away from where it is easily visible and accessible to staff and mothers. Access to formula is restricted by both: …Storing formula in a locked location, such as a storage room, cabinet or an automated medication system or, storing formula in a location outside, but reasonably near, the maternity unit……Limiting the number of hospital staff with access to formula by implementing a system to identify which hospital member accessed the formula supply; some examples are a log book, a code or a key system. What do we tell our staff to do when mothers (families) request infant formula? Assess if breastfeeding is going well and encourage the mother to keep trying. Provide education and support to mothers who are experiencing difficulties. If the mother still insists on receiving formula, document it in the chart along with the  reason and distribute only the amount of formula needed for the feeding.

(Emphasis mine.) Well. Perhaps the city formally backed off after the brouhaha, but most of the hospitals probably still still got the intended message loud and clear: Infant formula must be guarded and distributed with the roughly the same precautions as addictive and harmful narcotics.

Unlike the city of New York, the WHO  has valid reasons to be concerned with breastfeeding rates worldwide. After all, in less developed countries not breastfeeding may mean instead using cow’s milk for infants. When formula is used, the risks of it being prepared incorrectly and using contaminated water is rather high.

The WHO should focus being on how to educate and support women in developing countries regarding the dangers of cow’s milk, the benefits of breastfeeding, and the importance of correctly mixing formula. Unfortunately, the WHO Code saves most of its energy in marginalizing formula companies, requiring hospitals to under no circumstances allow formula advertising and requiring that product samples only be given for research at the institutional level — “In no case,” it stipulates, “should these samples be passed on to mothers.” The WHO is also requiring labels stating the superiority of breastfeeding and warning to not use the product until consulting with a health professional.

The WHO Code appears to be organized around a simple, if dubious, premise: It’s always the evil corporations’ fault.

In countries that have adopted the guidelines, companies are subject to legal sanctions for failing to abide by the Code. Eighty-four countries have laws encompassing all or many of the provisions of the Code and subsequent World Health Assembly resolutions and 14 more country’s have drafted related laws. The United States is one of very few countries who have taken “no action” on the WHO Code. However, if Benjamin has her way the U.S. will eventually “hold marketers of infant formula accountable for complying with the International Code of Marketing of Breastmilk Substitutes.”

What else does the international community support? On the UNICEF website,  it lauds the “innovative strategies” the following countries have taken in the spirit of the Code:

In Iran, Government has taken control of the import and sale of breastmilk substitutes. Formula is available only by prescription, and the tins must carry a generic label – no brand names, pictures or promotional messages are allowed. In India, legislation requires that tins of infant formula carry a conspicuous warning about the potential harm caused by artificial feeding, placed on the central panel of the label. In Papua New Guinea, the sale of feeding bottles, cups, teats and dummies is strictly controlled, and there is a ban on advertising these products as well as breastmilk substitutes.

This is madness. Many of these countries are now more permissive of the sale of tobacco than infant formula.

The question is what’s next? Custody cases exploring whether or not a mother breastfed her infant? If we’re going to focus on things nebulous studies have deemed an obvious risk, we’d try to outlaw circumcision. Or we’ll deem spanking or infant sleep training as child abuse under the law. Or we’d prosecute parents for leaving children under the age of 8 in a car. Obviously it’d be hard to legislate breastfeeding since it’s a private matter, but you better believe we’ll go as far in that direction we can.

There are, of course, many laws the government issues for our protection and those of our children. Seatbelt laws, child car seat booster requirements, bans on drop side cribs and helmet laws. Regardless of whether or not these encompass valid risks (many do, some don’t), they do not encroach on personal freedom the way laws regarding parenting methods do. And don’t get me wrong; this goes in all directions. Infant feeding, and the personal freedoms associated with it, is not a liberal or conservative issue.

The main disconnect here is the view of formula as a poor-man’s breastmilk, as opposed to another valid alternative feeding method. On its face, is breastmilk a more resilient and adaptable substance? Almost certainly. Breastmilk has properties one cannot even attempt to replicate in formula. But the reasons why women choose their particular feeding method are often complex, thoughtful, and purposeful. All of which is opposite to the rampage of overreaching government regulation. We can and will continue to have fierce debates over the best approaches to motherhood, but it appears the biggest threat to America’s children comes from their Big Brother.

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