Is Breast Best: The Wrong Conversation

Guest post by Jessica Lang Kosa, IBCLC

My 4-year-old was thrilled about her new big-girl bike, and the pink helmet she’d picked out to go with it.  But the salesman helping us at the bike shop told me that the helmet was a little large for her, and pointed us towards the smaller ones.  Which were not pink.  For a child at the height of her princess phase, getting a primary-colored baby-patterned helmet with her birthday present was a non-starter.  Envisioning a mindwarping soulsucking struggle to get her to wear the damn thing, I decided to go with the pink one.  I figured it would fit perfectly in a few months anyway.

The salesman was disturbed – he explained that the helmet couldn’t fully protect her if it didn’t fit properly, and that “all of us who work here, we’ve all had a time when the helmet saved us from a serious injury.”  I assured him that my daughter would be riding only on a playground, not on the street, but he wasn’t calmed.  Finally, I stated clearly that I understood his point, but was more concerned with establishing the helmet habit than with perfect fit, and wanted the pink one, please.  He walked off, another salesman rang it up, and I left feeling a little annoyed – I am the mom, I had made my decision. Enough with the lecture, thank you very much.

    So I understand where Michelle Gerdes is coming from when she writes, “Of all the decisions a new mom makes perhaps none is more personal than whether or not to breastfeed.  So why is it that everyone from nurses to doctors to mothers-in-law feel free to press their agenda on the matter?”

    Her blog post describes an unfortunately common scenario – she intended to breastfeed, but a combination of factors got in the way early on.  Eventually, she decided enough was enough, stopped nursing, and wanted others to respect her decision and butt out.  Reasonable enough.  All parents make judgement calls, all parents compromise.  Kibitzing and Monday-morning quarterbacking are uncalled for.

   But her blog post raises some other questions.  At two days postpartum, Gerdes was exhausted, overwhelmed with her struggles to breastfeed, and desperate for a break.

I asked the nurse to take my daughter to the nursery and give her some formula.  The way the nurse reacted, I might as well have asked her to take my daughter to the dungeon and feed her eye of newt.

The nurse ran through her list of tsk-tsks: breast is best, nipple confusion, milk supply, bonding, the end of human civilization as we know it. Then she explained it was hospital policy to deny the mother’s first request for formula and grant the second request only after reviewing everything they thought the baby would miss out on given formula over breast milk.

    OK, wait a minute.  A healthcare provider, faced with a mother at the end of her rope, responded by lecturing her.  Now, I’m the first to say that mothers should have plenty of info about the baby’s need for breastmilk before making a choice to feed formula. Informed consent requires it.  But at a moment like that, how does spouting facts help?  Gerdes makes a striking comment: “And nobody seemed concerned with the well-being of me.”  She felt she was regarded as just a pair of breasts, a vehicle for her child’s nutrition.  No woman should be treated that way.  That is as wrong as it gets.

    But suppose the nurse had responded by comforting her, praising her persistence, and assuring her it would get easier?  Suppose she had offered suggestions for other ways she could get a much needed rest without artificial feeding?   If this nurse had the time and skills to do that, Gerdes might have had much better care, regardless of how her breastfeeding turned out.

    Another part of the blog jumps out at me: “ . . . studies haven’t shown definitively that breast-feeding results in health improvements.”  From a medical standpoint, that statement makes no sense.  The burden of proof is not on the biological system, but on the artificial replacement.  Try inventing an artificial knee joint and telling the FDA that studies haven’t clearly proven that the knees we are born with are any better.  From a scientific standpoint, it’s also bogus.  Epidemiology is really hard to do.  Humans can’t be randomized and controlled for studies of breastfeeding.  So for each study, each outcome, each population, there is controversy.  But the overall picture is this: the evidence is overwhelming that no formula supports infant health and development as effectively as breastmilk.  Check with the World Health Organization, the American Academy of Pediatrics, and the HHS.  The scientific and medical consensus on this is just as clear as the consensus that smoking is bad for you, and exercise is good for you.

    Fundamentally, though, that’s the wrong conversation.  In the bike store with my daughter, I never doubted that 1) Biking carries some risk of head injury 2) Helmets reduce the risk, sometimes saving lives.  The concerned salesman and I could have bickered over statistics, but that wasn’t the point.  The point was that I had to consider the very real risks in the context of my daughter’s particular situation.  In this case, I decided that the longterm benefit (a good attitude towards the helmet) outweighed the short term risk of an imperfect fit.  Other mothers might decide differently, because reasonable people sometimes make different choices.

    An important point is that I made my helmet selection after getting objective information about bike safety from my pediatrician.  Mothers can’t always count on getting unbiased education about infant feeding, because unlike other countries, the U.S. allows hospitals and healthcare providers to benefit from and participate in formula marketing.   It often happens in subtle ways, like sponsorships, gift bags, and formula logo stickers on the plastics bassinets in the hospital.

    Sometimes it’s blatant. Once, I spoke with a pediatrician about the baby care brochure in his waiting room.  It was printed by a formula company, marked with their logo, and full of “breast is best” platitudes but stripped of any references to negative effects of formula.  Among other outdated tidbits, it suggested that mothers could get more sleep by giving formula “such as Brand X” at night, contrary to research showing that parents actually get less sleep when they formula feed.  The doctor responded, “These things are expensive to print.  If we can get someone to pay for it, we’re not going to say no.”

    The hospitals are supporting breastfeeding with one hand, while undermining it with the other.  Nobody offers them corporate money to hire enough nurses and lactation consultants, or train their staff in breastfeeding counseling.  The CDC says that less than 4% of US hospitals offer effective breastfeeding support.  Gerdes is right to complain about the tsk-tsking nurse, but let’s remember that the poor counseling skills of an overworked untrained nurse are no match for the formula advertising juggernaut. When a vulnerable and exhausted new mother is targeted by pervasive and manipulative marketing, and advised by hospitals who accept the freebies and the influence of formula companies, is this really a free choice?

    The Surgeon General’s Call to Action to Support Breastfeeding is focused on identifying “Barriers to Breastfeeding” and the actions needed to eliminate them.  Inadequate breastfeeding support in the hospital is a major one, and Gerdes’ experience shows that just flooding mothers with warnings does not make for effective support.  The Surgeon General is starting the right conversation – one about removing barriers to breastfeeding so that women who want to breastfeed get the best chance to do so. This is part of a larger conversation our society needs to have.  The question is not “Is breast best?”.   It’s “How do we stop scolding mothers and remove the barriers that make modern mothering unnecessarily tough?”

Jessica Lang Kosa is a board-certified lactation consultant in private practice in the Boston area.  You can visit her site at, find her on Facebook, and follow her on Twitter @motherfeeding.


9 thoughts on “Is Breast Best: The Wrong Conversation

  1. Wow! I’ve never heard of a nurse reacting that way! Here, in Panama City, fl, it is the opposite! They push formula. At least they informed her before giving the formula, although a little compassion never hurts.

  2. As a child with a severe lactose (in fact it turn out to be any animal protien!) allergy I couldn’t be breast fed, my mother tried for months but it made me incredibly ill and I lost a lot of weight. I know that breast is not always best, children thrive when they are fed something nutritious and they are cared for. The world isn’t black and white like statistics printed on a page.

  3. This is well said. I am a pediatrician who, for a variety of reasons, was unable to breast feed my oldest child. It was devastating in a way only another woman who has been there can really understand. I make it a point to be empathic about the challenges of breast feeding, to support any option that gives the baby adequate nutrition, and to recommend specific formulas only when medically necessary (ie due to metabolic disorder or allergy).
    I sincerely wish in America we did a better job of preparing mom’s for the challenges as well as the joys of breastfeeding.

  4. ” Try inventing an artificial knee joint and telling the FDA that studies haven’t clearly proven that the knees we are born with are any better.” Wow, I totally love this quote! I know I’m a little late to commenting for such an old post, but had to say how much I love it!

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