Lactation Narration

This week’s topic organized by Nursing Freedom is about the analogy between nursing in public and smoking in public. This reminds me of another way that I have used smoking as an analogy to formula feeding – in reference to personal choice and health care professionals’ support of that choice.

So, suppose that you are a smoker. Your doctor can accept the fact that you are a smoker without necessarily supporting your smoking. She can encourage you to quit, and tell you all the reasons why smoking is a health risk, but of course she can’t force you not to smoke – that’s still your decision. Should she just leave it be because telling you these things may make you feel “guilty” for smoking? After all, it’s your personal decision. But that personal decision has negative health effects, and should not be supported by your health care professionals.

Let’s also look at the way that your health care provider does talk to you about smoking. Would she say, “Smoking is the typical choice, but let’s look at the extra bonus benefits of not smoking”? Or would it be, “Not smoking is the healthy choice, and there are negative health effects of smoking”? You may think that your reasons for smoking are fine and you don’t care about the risks, but your doctor still doesn’t have to support that decision as though it were an equally healthy choice. The doctor is still going to have plenty of patients who choose to smoke despite knowing the risks. She will accept it and work with the effects of your decision, but that is not the same thing as endorsing that choice. She’s not going to tell you that it’s just fine as long as you are happy, or that since you didn’t smoke for the first X years of your life that’s good enough.

Now think about the way that health care providers talk about formula and breastfeeding. Health care providers should talk about the health risks of formula feeding (as opposed to the “benefits of breastfeeding” – breastfeeding is the biological norm), without having to worry about someone feeling guilty. Their role is to encourage healthy behaviors, not to equivocate on the issue for fear of offending someone. If you do choose to use formula, your doctor will accept your choice and work with you, but she doesn’t have to present it as an equivalent option or try to make you feel better about your choice.

Also, just because you are already using cigarettes anyway, it doesn’t mean that your doctor should give you free cigarette samples. And it seems obvious that if you’ve already decided to quit smoking, your doctor shouldn’t send you home with a few free cigarettes “just in case” you fail. But that is just what happens every day when doctors and hospitals distribute free formula samples.

You will also hear plenty of people who say things like, “Well I’ve smoked for X years and I am perfectly healthy” or “Great Aunt Bessie smoked 2 packs a day for her whole life and lived to age 95″. Will that anecdote convince the health care professional? Will you hear your doctor tell you, “Well, a whole generation of people were smokers not that long ago, and they seem to have survived it, so I guess it’s no big deal. Forget about all the studies showing the health risks – you have anecdotal evidence that says it’s fine.” I sure hope not. And yet that’s pretty much what my first pediatrician said regarding a generation who grew up on formula.

Of course I think that breastfeeding is a choice that each mother must make on her own, but that does not mean that I think that breastfeeding and formula feeding are equivalent choices. Just like I don’t think that smoking and not smoking are equivalent choices. I still believe it is your choice to make though, whether you tried to breastfeed unsuccessfully, or you just didn’t feel like breastfeeding, or whatever your situation. The point is, that medical professionals should try to encourage and support you to make healthier choices by presenting accurate information, and should not pretend that it’s just a simple choice between two equals just to make you feel better when you don’t (or even can’t) breastfeed.

Just a funny story…

I was getting out of the shower and my husband came up behind me, and as a joke, tried to squeeze my boob so that milk would spray out. He succeeded in getting a few drops and thought that was pretty funny. I laughed though, and told him he didn’t know how to do it. He said, “What do you mean?! It dripped!” I offered to show him what I meant, and he seemed skeptical. I gave a little pinch and three streams sprayed half-way across the room! And I said, “See, you don’t know how to do it!” He was impressed! Ha – we had a good laugh about that one…

A study was recently brought to my attention that basically advocates supplementing with formula within the first two weeks of birth in order to reduce likelihood of cow’s milk allergy. The first author of the study, in interviews by the press, stated his recommendation to breastfeed while “simply complementing it with cow’s milk early on.” He says, “Let Dad enjoy some midnight infant bonding, while he delivers a dose or two of cow’s milk protein.” He specifies in the conclusions of the study that “The data should not be interpreted as discouraging breastfeeding.”

This is not a study that I’d seen before, but I do find it interesting from an immunological perspective. The study essentially goes to tolerance. Basically, your immune cells need to learn “self” vs “non-self”, and tolerance is used to tell them not to attack “self”. Sometimes this gets messed up, and you end up with an autoimmune condition – essentially, your immune cells attacking some part of “self” that it should have had tolerance to. There are also plenty of “non-self” things though, that you don’t want the immune system to attack – food, pollen, a fetus… The body should therefore also be able to tell “danger” from “non-danger”. When the immune system mounts an attack on something that we consider “non-danger”, that’s typically what we call an allergy. It’s a tricky business for the immune system to learn what it should and should not attack, and immunologists are very interested in learning how it works, which is still not fully understood. If we could manipulate this system, it could lead to many medical breakthroughs in autoimmune disease, allergies, transplant medicine, and the like.

Unfortunately, we still don’t know exactly how it does work. This study is postulating that exposure to the allergen within the first two weeks of life, seems to result in a higher rate of tolerance to that allergen (in this case, cow’s milk protein). This study though, is purely observational and does not even begin to propose a mechanism for how and why this would work. Without a mechanism, one observational study is not going to be enough to influence the medical associations and public health boards to change their current recommendation of exclusive breastfeeding for at least 6 months – exclusive breastfeeding being defined as no water, juice, formula, cereal, or foods.

Some other thoughts on this study:

**The reported incidence of cow’s milk allergy (CMA) is 2-5%, yet this study only found it in 0.5% of their population. They either have a skewed demographic or they have different diagnostic criteria than other clinicians. In addition, 381 cases were reported to the researchers by the parents as CMA, but the researchers diagnosed only 66 of these as actually allergic using their criteria. If parents did not report CMA, the researchers assumed CMA was not present. Only those who reported CMA were tested for it. Also of note, this study did not find any correlation of rate of CMA with other factors previously shown to affect likelihood, including gender, type of delivery, and genetic background.

**The study purports to relate first exposure of cow’s milk protein with incidence of CMA, however the researchers excluded any formula that was given to newborns while still in the hospital (estimated to be ~70% of all Israeli babies) as inconsequential.

**The study also excludes babies who were not exposed to cow’s milk or cow’s milk formula at all within the first year. The general recommendation from medical and public health associations is to breastfeed exclusively for 6 months, followed by continued breastfeeding with the introduction of complementary foods until at least 12 months, with introduction of cow’s milk after 12 months. Therefore, all babies whose parents actually followed this advice were excluded from the study and there is no data on their rate of CMA. These babies were excluded presumably because babies typically outgrow a cow’s milk protein allergy after the first year anyway. Babies who were delayed introduction to cow’s milk until after this time are not at a disadvantage. Cow’s milk is not a necessary part of a human diet, particularly a human infant whose diet consists of human milk.

**The study found a 0.5% rate of CMA for introduction of cow’s milk protein at most time-points. The publicized result was that the rate was 10 times lower when introduced at less than 14 days. However, it is also worthy to note that the incidence was 3.5 times higher when cow’s milk protein was introduced between 3.5-6.5 months. And, as mentioned above, the rate for those who were not exposed to cow’s milk protein until after 12 months was not given because these infants were excluded from the study.

**The study measures the first (non-hospital) exposure to cow’s milk protein in days, but it does so through parental interview at two-month intervals. Recall rate down to the exact day for introduction of cow’s milk protein from an interview up to two months later seems prone to inaccuracy given that parents were not asked to keep a daily diary. Though the study calls itself prospective because subjects were enrolled at birth, the methodology for data collection was retrospective.

**The study did report on dairy product consumption by the mother, however less than 1% of mothers did not consume dairy. Of note, all of the mothers who did not consume dairy had babies who did not have CMA, but the numbers were very small and there was no statistical significance.

**The study was funded by the Israel Dairy Board, a potential conflict of interest. Note that the conclusions of the study are to begin supplementing breastfeeding with formula made from cow’s milk within the first two weeks of birth, which would be of financial benefit to the Dairy Board.

My personal conclusions: Benefits of introducing cow’s milk formula within the first 2 weeks may include reducing the likelihood of cow’s milk allergy by inducing early tolerance. Costs of introducing cow’s milk formula though are loss of exclusive breastfeeding (and associated health implications) and increased likelihood of earlier weaning in general. Cow’s milk allergy is typically outgrown within the first year anyway, and delay of introduction of cow’s milk or cow’s milk formula until after 12 months also reduces the likelihood of cow’s milk allergy while also avoiding the other risks inherent in formula feeding. Introduction of cow’s milk formula between 3.5-6.5 months may be the worst scenario with respect to cow’s milk allergy. Even if reduced risk of cow’s milk allergy was only to be achieved through early use of formula, I do not think that this would be worth risking the other health implications of not exclusively breastfeeding.