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A new debate on breast-feeding

One afternoon at the playground last summer, shortly after the birth of my third child, I made the mistake of idly musing about breast-feeding to a group of new mothers I'd just met. • This time around, I said, I was considering cutting it off after a month or so. At this remark, the air of insta-friendship we had established cooled into an icy politeness, and the mothers shortly wandered away to chase little Emma or Liam on to the slide. • Just to be perverse, over the next few weeks I tried this experiment again several more times. The reaction was always the same: Circles were redrawn such that I ended up in the class of mom who, in a pinch, might feed her baby mashed-up Chicken McNuggets. • In my playground set, the urban moms in their tight jeans and oversize sunglasses size each other up using a whole range of signifiers: organic content of snacks, sleekness of stroller, ratio of tasteful wooden toys to plastic. But breast-feeding is the real ticket into the club. • From the moment a new mother enters the obstetrician's waiting room, she is subjected to the upper-class parents' jingle: "Breast Is Best." Parenting magazines offer "23 Great Nursing Tips," warnings on "Nursing Roadblocks," and advice on how to find your local lactation consultant (note to the childless: yes, this is an actual profession, and it's thriving).

Many of the stories are accompanied by suggestions from the ubiquitous parenting guru Dr. William Sears, whose Web site hosts a comprehensive list of the benefits of mother's milk. "Brighter Brains" sits at the top: "IQ scores averaging seven to 10 points higher!" (Sears knows his audience well.)

The list then moves on to the dangers averted, from infancy on up: fewer ear infections, allergies, stomach illnesses; lower rates of obesity, diabetes, heart disease. Then it adds, for good measure, stool with a "buttermilk-like odor" and "nicer skin" — benefits, in short, "more far-reaching than researchers have even dared to imagine."

In the days after my first child was born, I welcomed practical advice. I remember the midwife coming to my hospital bed and shifting my arm here, and the baby's head there, and then everything falling into place. But after three children and 28 months of breast-feeding (and counting), the insistent cheerleading has begun to grate. I do have some perspective. And when I look around my daughter's second-grade class, I can't seem to pick out the unfortunate ones: "Oh, poor little Sophie, whose mother couldn't breast-feed. What dim eyes she has. What a sickly pallor. And already sprouting acne!"

I dutifully breast-fed each of my first two children for the full year that the American Academy of Pediatrics recommends. I have experienced what a Babytalk magazine story calls breast-feeding-induced "maternal nirvana." This time around, nirvana did not describe my state of mind; I was launching a new Web site and I had two other children to care for, and a husband I would occasionally like to talk to. Being stuck at home breast-feeding as he walked out the door for work just made me unreasonably furious, at him and everyone else.

In Betty Friedan's day, feminists felt shackled to domesticity by the unreasonably high bar for housework, the endless dusting and shopping and pushing the Hoover around — a vacuum cleaner being the obligatory prop for the "happy housewife heroine," as Friedan sardonically called her. When I looked at the picture on the cover of Sears' Breastfeeding Book — a lady lying down, gently smiling at her baby and still in her robe, although the sun is well up — the scales fell from my eyes: It was not the vacuum that was keeping me and my 21st-century sisters down, but another sucking sound.

Still, despite my stint as the postpartum playground crank, I could not bring myself to stop breast-feeding — too many years of Sears' conditioning, too many playground spies. So I was left feeling trapped, like many women before me, in the middle-class mother's prison of vague discontent: surly but too privileged for pity, breast-feeding with one hand while answering the cell phone with the other, and barking at my older kids to get their own organic, 100 percent juice — the modern, multitasking mother's version of Friedan's "problem that has no name."

And in this prison I would have stayed, if not for a chance sighting. One day, while nursing my baby in my pediatrician's office, I noticed a 2001 issue of the Journal of the American Medical Association open to an article about breast-feeding: "Conclusions: There are inconsistent associations among breast-feeding, its duration, and the risk of being overweight in young children." Inconsistent? There I was, sitting half-naked in public for the 10th time that day, the 100th time that month, the millionth time in my life — and the associations were inconsistent?

The seed was planted. That night, I did what any sleep-deprived, slightly paranoid mother of a newborn would do. I called my doctor friend for her password to an online medical library, and then sat up and read dozens of studies examining breast-feeding's association with allergies, obesity, leukemia, mother-infant bonding, intelligence and all the Dr. Sears highlights.

After a couple of hours, the basic pattern became obvious: The medical literature looks nothing like the popular literature. It shows that breast-feeding is probably, maybe, a little better; but it is far from the stampede of evidence that Sears describes. More like tiny, unsure baby steps: two forward, two back, with much meandering and bumping into walls. A couple of studies will show fewer allergies, and then the next one will turn up no difference. Same with mother-infant bonding, IQ, leukemia, cholesterol, diabetes.

Even where consensus is mounting, the meta studies — reviews of existing studies — consistently complain about biases, missing evidence and other major flaws in study design. "The studies do not demonstrate a universal phenomenon, in which one method is superior to another in all instances," concluded one of the first, and still one of the broadest, meta studies, in a 1984 issue of Pediatrics, "and they do not support making a mother feel that she is doing psychological harm to her child if she is unable or unwilling to breast-feed." Twenty-five years later, the picture hasn't changed all that much. So how is it that every mother I know has become a breast-feeding fascist?

Some of the magical thinking about breast-feeding stems from a common misconception. 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.

Hard to compare

Since the identification of sIgA, in 1961, labs have hunted for other marvels. Thousands of studies have been published, linking breast-feeding with healthier, happier, smarter children. But they all share one glaring flaw.

An ideal study would randomly divide a group of mothers, tell one half to breast-feed and the other not to, and then measure the outcomes. But researchers cannot ethically tell mothers what to feed their babies.

Instead they have to settle for "observational" studies. These simply look for differences in two populations, one breast-fed and one not. The problem is, breast-fed infants are typically brought up in very different families from those raised on the bottle. In the United States, breast-feeding is on the rise — 69 percent of mothers initiate the practice at the hospital, and 17 percent nurse exclusively for at least six months. But the numbers are much higher among women who are white, older and educated; a woman who attended college, for instance, is roughly twice as likely to nurse for six months.

Researchers try to factor out all these "confounding variables" that might affect the babies' health and development. But they still can't know if they've missed some critical factor. "Studies about the benefits of breast-feeding are extremely difficult and complex because of who breast-feeds and who doesn't," says Michael Kramer, a highly respected researcher at McGill University. "There have been claims that it prevents everything — cancer, diabetes. A reasonable person would be cautious about every new amazing discovery."

Nearly all the researchers I talked to pointed me to a series of studies designed by Kramer, published starting in 2001. He followed 17,000 infants born in Belarus throughout their childhoods. He came up with a clever way to randomize his study, at least somewhat, without doing anything unethical. He took mothers who had already started nursing, and then subjected half of them to an intervention strongly encouraging them to nurse exclusively for several months.

The intervention worked: Many women nursed longer as a result. And extended breast-feeding did reduce the risk of a gastrointestinal infection by 40 percent. This result seems to be consistent with the protection that sIgA provides; in real life, it adds up to about four out of 100 babies having one less incident of diarrhea or vomiting. Kramer also noted some reduction in infant rashes. Otherwise, his studies found very few significant differences: none, for instance, in weight, blood pressure, ear infections or allergies — some of the most commonly cited benefits in the breast-feeding literature.

Both the Kramer study and the sibling study did turn up one interesting finding: a bump in "cognitive ability" among breast-fed children. But intelligence is tricky to measure, because it's subjective and affected by so many factors. Other recent studies, particularly those that have factored out the mother's IQ, have found no difference at all between breast-fed and formula-fed babies. In Kramer's study, the mean scores varied widely and mysteriously from clinic to clinic. What's more, the connection he found "could be banal," he told me — simply the result of "breast-feeding mothers' interacting more with their babies, rather than of anything in the milk."

The IQ studies run into the central problem of breast-feeding research: it is impossible to separate a mother's decision to breast-feed — and everything that goes along with it — from the breast-feeding itself. Even sibling studies can't get around this problem. With her first child, for instance, a mother may be extra cautious, keeping the neighbor's germy brats away and slapping the nurse who gives out the free formula sample.

By her third child, she may no longer breast-feed — giving researchers the sibling comparison that they crave — but many other things may have changed as well. Maybe she is now using day care, exposing the baby to more illnesses. Surely she is not noticing that kid No. 2 has the baby's pacifier in his mouth, or that the cat is sleeping in the crib (trust me on this one). She is also not staring lovingly into the baby's eyes all day, singing songs, reading book after infant book, because she has to make sure that the other two kids are not drowning each other in the tub. On paper, the three siblings are equivalent, but their experiences are not.

What does all the evidence add up to? We have clear indications that breast-feeding helps prevent an extra incident of gastrointestinal illness in some kids — an unpleasant few days of diarrhea or vomiting, but rarely life-threatening in developed countries. We have murky correlations with a whole bunch of long-term conditions. The evidence on IQs is intriguing but not all that compelling, and at best suggests a small advantage, perhaps five points; an individual kid's IQ score can vary that much from test to test or day to day.

Not bad for baby

If a child is disadvantaged in other ways, this bump might make a difference. But for the kids in my playground set, the ones whose mothers obsess about breast-feeding, it gets lost in a wash of Baby Einstein videos, piano lessons and the rest. And in any case, if a breast-feeding mother is miserable, or stressed out, or alienated by nursing, as many women are, if her marriage is under stress and breast-feeding is making things worse, surely that can have a greater effect on a kid's future success than a few IQ points.

So overall, yes, breast is probably best. But not so much better that formula deserves the label of "public health menace," alongside smoking. 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.

In the early '90s, a group of researchers got together to revise the American Academy of Pediatrics' policy statement on breast-feeding. They were of the generation that had fought the formula wars, and had lived through the days when maternity wards automatically gave women hormone shots to stop the flow of breast milk. The academy had long encouraged mothers to make "every effort" to nurse their newborns, but the researchers felt the medical evidence justified a stronger statement.

Released in 1997, the new policy recommended exclusive breast-feeding for six months, followed by six more months of partial breast-feeding, supplemented with other foods. The National Organization for Women complained that this would tax working mothers, but to no avail.

"The fact that the major pediatric group in the country was taking a definitive stance made all the difference," recalls Lawrence Gartner, a pediatrician and neonatologist at the University of Chicago, and the head of the committee that made the change. "After that, every major organization turned the corner, and the popular media changed radically."

Mothers these days are expected to "optimize every dimension of children's lives," writes Joan Wolf, a women's studies professor at Texas A&M University. Choices are often presented as the mother's selfish desires versus the baby's needs.

About seven years ago, I met a woman from Montreal, the sister-in-law of a friend, who was young and healthy and normal in every way, except that she refused to breast-feed her children. She wasn't working at the time. She just felt that breast-feeding would set up an unequal dynamic in her marriage — one in which the mother, who was responsible for the very sustenance of the infant, would naturally become responsible for everything else as well.

At the time, I had only one young child, so I thought she was a kooky Canadian — and selfish and irresponsible. But of course now I know she was right.

I recalled her with sisterly love a few months ago, at 3 in the morning, when I was propped up in bed for the second time that night with my new baby (note the "my"). My husband acknowledged the ripple in the nighttime peace with a grunt, and that's about it. And why should he do more? There's no use in both of us being a wreck in the morning. Nonetheless, it's hard not to seethe.

The Bitch in the House, published in 2002, reframed the Feminine Mystique for my generation of mothers. We were raised to expect that co-parenting was an attainable goal. But who were we kidding? Even in the best of marriages, the domestic burden shifts, in incremental, mostly unacknowledged ways, on to the woman.

Breast-feeding plays a central role in the shift. In my set, no husband tells his wife that it is her womanly duty to stay home and nurse the child. Instead, both parents together weigh the evidence and then make a rational, informed decision that she should do so. Then other, logical decisions follow: she alone fed the child, so she naturally knows better how to comfort the child, so she is the better judge to pick a school for the child and the better nurse when the child is sick, and so on.

Recently, my husband and I noticed that we had reached the age at which friends from high school and college now hold positions of serious power. When we went down the list, we had to work hard to find any women. Where had all our female friends strayed? Why had they disappeared during the years they'd had small children?

Behind the breast

The debate about breast-feeding takes place without any reference to its actual context in women's lives. Breast-feeding exclusively is not like taking a prenatal vitamin. It is a serious time commitment that pretty much guarantees that you will not work in any meaningful way.

Let's say a baby feeds seven times a day and then a couple more times at night. That's nine times for about a half hour each, which adds up to more than half of a working day, every day, for at least six months. This is why, when people say that breast-feeding is "free," I want to hit them with a two-by-four. It's only free if a woman's time is worth nothing.

I continue to breast-feed my new son some of the time — but I don't do it slavishly. When I am out for the day working, or out with friends at night, he can have all the formula he wants, and I won't give it a second thought.

I'm not really sure why I don't stop entirely. I know it has nothing to do with the science; I have no grandiose illusions that I'm making him lean and healthy and smart with my milk. Nursing is certainly not pure pleasure, either; often I'm tapping my foot impatiently, waiting for him to finish.

I do it partly because I can get away with breast-feeding part-time. I work at home and don't punch a clock, which is not the situation of most women. Had I been more closely tied to a workplace, I would have breast-fed during my maternity leave and then given him formula exclusively, with no guilt.

My best guess is something I can't quite articulate. Breast-feeding does not belong in the realm of facts and hard numbers; it is much too intimate and elemental. It contains all of my awe about motherhood, and also my ambivalence. Right now, even part-time, it's a strain. But I also know that this is probably my last chance to feel warm baby skin up against mine, and one day I will miss it.

Hanna Rosin is an Atlantic contributing editor and the author of God's Harvard: A Christian College on a Mission to Save America. Copyright 2009 Atlantic Media Company, as first published in The Atlantic magazine. Distributed by Tribune Media Services.

A new debate on breast-feeding 04/02/09 [Last modified: Friday, April 3, 2009 4:10pm]

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