Why we shouldn’t demonize formula feeding

Claire McCarthy, MD

Faculty Editor, Harvard Health Publishing

Follow me on Twitter @drClaire

Breast is best — we pediatricians say this all the time, because it’s true. Breast milk was uniquely designed for human babies, and many studies have shown its health benefits. In our quest to increase breastfeeding rates here in the US, which are not as high as we want them to be, we encourage new mothers not to use any formula. Hospitals are encouraged not to feed new babies with formula during those first few days before the mother’s milk comes in, and not to send mothers home with samples of formula.

This is all good, as often, if we can get mothers and babies through those first few days and weeks without formula, they can both get used to breastfeeding and make it work. But as we encourage breastfeeding, we need to be careful to keep the big picture in mind and not demonize formula feeding.

In a study recently published in the Journal of Pediatrics, researchers studied babies who had lost a significant amount of weight after birth, which, while common, can be dangerous. They randomized the babies into two groups: one got a small amount of formula after each breastfeeding until the mother’s milk was fully in, and the other group did not. They found that the babies that got the formula were less likely to be readmitted to the hospital, and were no less likely to be breastfeeding a month out.

Exclusive breastfeeding is natural, but not always easy — and when there is a glitch like a delay in the milk supply coming in, inverted nipples, or inadequate milk supply, babies can run into trouble. It’s also not always easy for mothers who don’t have a lot of support from family and health care providers, especially first-time mothers who are feeling overwhelmed, who get sore nipples, who worry that their babies aren’t getting enough to eat. Breastfeeding works best when mothers have a knowledgeable and nurturing community to help them work through the inevitable questions and problems, as well as a supportive work environment, but not every mother has this.

I am not arguing against encouraging breastfeeding. I encourage it with all of my patients, and am lucky enough to have lactation consultants readily available to my practice. I breastfed all six of my children; the last three got only breast milk, while the first three got formula as well, due to logistical and medical issues.

That’s the thing: life and parenting can be complicated. We want more mothers to breastfeed, and we have work to do to make that happen. We need paid parental leave. We need to make lactation consultants and breast pumps available to every mother. We need to educate and inform and build communities (including work communities) that support breastfeeding.

But as we do all this, we need to remember that formula isn’t evil. In fact, sometimes it can be a tool to support breastfeeding — by supplementing newborns that have lost a risky amount of weight, by supplementing the milk supply of mothers who would otherwise give up entirely, by allowing working mothers who can’t pump enough milk for all their hours of work to keep breastfeeding as long as they would like. It’s better that babies get some breast milk than none at all, but if we make it an all-or-none proposition, we may inadvertently cut breastfeeding short.

When we demonize formula we also run the risk of shaming women who, for any number of good reasons, choose not to breastfeed. There are many other ways besides breastfeeding to help babies grow and be healthy; it’s important to keep that perspective.

As valuable as breastfeeding is, there is much more to parenthood than breastfeeding. It’s important to keep the big picture in mind for each mother and baby, and help them both flourish.

Related Information: Eat, Play, and Be Healthy

Comments:

  1. Jack Newman MD, FRCPC

    Maybe I should not be surprised, but I am. People who subscribe to this Harvard website don’t know how to read and write irrelevant responses to my comment which has nothing to do with “which is better” breastfeeding or formula feeding.

  2. Anna H

    Frankly, Dr. Newman, I think it is a bit disingenuous to tout the benefits of breast milk without mentioning the plethora of highly regarded studies showing that virtually 100% of tested US & Canadian mothers had varying concentrations of PBDEs, PCBs, pesticides, and other toxins in their breast milk. Unfortunately, with the terrible track record that our country has in environmental protections, it is impossible to say with certainty what is harming our babies more: the exposure to polybrominated diphenyl ethers, polychlorinated biphenyls, polychlorinated dibenzo-p-dioxins and furans, and organochlorine pesticides via breastfeeding, or formula? Pick your poison! One last thing I want to mention is that not all formula is created equal. The formula sold in the US has different composition and much less stringent requirements concerning pesticide residue, additives, sucrose, etc. vs .European formula. That probably explains why both of my children could not tolerate any of the US formula brands we tried, while they had no digestion issues with the formula sent from Europe.

  3. Anna H.

    Thank you, thank you, thank you for this article, Dr. McCarthy!! Having given birth to my first child 7 years ago at Lucile Packard hospital at Stanford, I first-hand experienced that “one size fits all” approach when it comes to breastfeeding. This experience SCARRED ME for life. My daughter screamed non-stop for the first three days in the hospital while I was told to stuff my empty, inverted, misshapen nipples into her mouth, onto which she latched with a barracuda grip. Imagine the despair of a new mother, weak and hurting, holding her screaming baby for hours on end and not being able to calm her down. And all the while the hospital staff was telling me just to keep the baby on the breast and wait. Finally, in the middle of day 3, a visiting pediatrician concluded that my child was dehydrated (the inside of her mouth was completely dry- she was not producing any saliva) and ordered formula. That night my baby finally stopped screaming and slept. Well, as it turned out my milk came on day 4 (exactly the same day as with my second child!) But by that time my nipples were so sore and painful, i could not stand even the light fabric of my night gown touching them. I cried from pain for the following 3 months every time I breastfed my daughter, but knowing how important it was to her health and development, I still continued to do it. I had to supplement with formula all along, because her appetite always outpaced my production. And despite constant pumping, special teas and supplements, and many lactation consultations, my milk supply dried up when my daughter was about 6 months. We all are made differently, some have abundance of milk and good nipples, some don’t. Shoving breastfeeding-no-matter-what down everyone’s throat is not only unethical, it is criminal in my mind, because they are harming people. I still have this irrational guilt in me that I should’ve known better; as someone with two graduate degrees, I should’ve researched this beforehand, I should’ve prepared, I should’ve spared my baby, myself, and my husband that 3-day agony. I always chuckle when male doctors lecture women on what they should do – how would YOU know what it is like??? So all those who attacked Dr McCarthy in the comment section, please step back, thank again and apologize to her!

  4. Jack Newman MD, FRCPC

    And, if I may say so, to have one of the authors having a financial arrangement with Nestle and, at the same time, being an editor of the Journal of Pediatrics is an outrageous conflict of interest. Declaring the conflict of interest does not make it okay.

  5. Jack Newman MD, FRCPC

    The comments that accuse me of demonizing formula feeding, or not knowing about breastfeeding are off the mark and it seems to me some comments were made without reading my comment. I did not demonize formula feeding. I demonized this “study” which is very very poorly done, should not have been published as such and will now take away the most important issue of all, which is mothers and babies are getting very poor help with breastfeeding starting immediately with the birth of the baby.

  6. Elizabeth

    Good article that does describe my daughter and I’s early days. Instead of “breast is best” I’m liking the saying “fed is best”. Day 3’s pediatrician visit she was put on formula supplementation via bottle. However, the thing this article doesn’t go into is how the formula is given to the infant. The best practice is not through bottles (should be via SNS, syringe, spoon feeding, or at very least paced bottle feeding) , but my pediatrician was not “up” on that. And while that didn’t turn out disaterous for us. It felt disaterous for about 50 feedings (which is about 25 hours of additional crying) while I retrained a 2 week old to breastfeed. The intermediate steps between cause and ending effect also need clarity as to what the intervening steps look like, because it seems like most doctors are just like it’ll be ‘a day or two” or “a week or so” (of hell) and it doesn’t seem like they care as long as the stat at the end turns out. That week of hell (half the baby’s life) also damages the mother/baby relationship and that takes time to rebuild as well.

    On Day 3 of my kid’s life I was going to do whatever the pediatrician said because I only had 4 hours of sleep in 3 days and no mommy sense yet. Now I know I shouldnt have trusted my pediatrician to actually have all the details about how not to have formula cause massive other repercussions and should have consulted a lactation consultant or at least done more information gathering on my own.

  7. Maria Sauzier MD

    To understand the divergence between these 2 perspectives, it is useful to look at who writes what:
    Dr McCarthy is a woman and understands the contextual complexities of a woman’s life;
    Dr Newman is a man who knows better.
    Dr McCarthy’s own body has had the experience that ‘medical and logistical issues’ can interfere with only breastfeeding.
    Dr Newman presents it as an either/or argument, which unfortunately invalidates the good points he makes about the need to offer more practical breastfeeding help to new mothers.

  8. Helene Byrne

    In the debate between breast vs. formula, one side always accuses the other of “demonizing, guilt, bad-momship, “etc. Yes, one provides better nutrition, but many women need to use formula for a variety of reasons. Time to promote both and stop screaming at each other.

  9. Jack Newman MD, FRCPC

    Here is my take on the recent article in the Journal of Pediatrics on early formula supplementation of newborn babies:

    The first few days after birth are critical for how easy breastfeeding will be later on, for establishing good milk supply, for preventing issues with breastfeeding and for how long a mother will breastfeed. Instead of help, many mothers encounter obstacle after obstacle:

    – It starts with unnecessary interventions during labor and birth.
    – It continues with separation of mothers and babies after birth.
    – It is further made worse by undermining the mother´s ability to breastfeed by giving them all sorts of damaging rules such as “feed only 15 minutes on one breast”, “feed only every 3 hours”, “weigh the baby before and after breastfeeding to see how much he breastmilk he got”, etc.

    This is all made worse by mothers hardly ever getting any real help with breastfeeding. There is nobody in the hospital who would show them how to latch the baby on well or how to determine whether the baby is getting enough breastmilk from the breast or not. Breastfeeding is seen as unpredictable because health professionals do not know what to look for when taking care of breastfeeding mothers and babies and only notice too late when things are going really badly at which time breastfeeding itself gets blamed.

    Not offering help with breastfeeding, not knowing how to make sure the baby drinks sufficient amounts of breastmilk from the breast starting right from birth, not knowing how to increase breastmilk intake by the baby and how to help with a range of breastfeeding issues such as sore nipples or babies who do not latch on ultimately leads to … turning to formula as a solution. It is ignorance about how breastfeeding works and refusal to acquire hands-on skills to help breastfeeding mothers succeed at breastfeeding that lead to formula feeding early on. One thing gets constantly ignored – help with breastfeeding should imply actual help with breastfeeding. Giving bottles of formula is not helping with breastfeeding. And yet, this is exactly what a recent study published in the Journal of Pediatrics (V. Flaherman et al: The Effect of Early Limited Formula on Breastfeeding, Readmission, and Intestinal Microbiota: A Randomized Clinical Trial; https://doi.org/10.1016/j.jpeds.2017.12.073) pretends to tell parents.

    So instead of looking at how mothers can be helped and supported in their wishes to breastfeed, in this study, they are giving 10 ml of formula after each feeding from the second day of life. That means that ultimately the whole milk intake of those babies becomes formula. Ten ml of formula after each feeding also means the baby will take a long time before being interested in breastfeeding again and will breastfeed less well and so the crucial time for increasing milk supply right after birth will be lost.

    No wonder only 1 in 4 mothers who were being recruited for the study agreed to participate. This alone should tell us how much mothers long to breastfeed. And if they want to breastfeed, first and foremost they should get help with breastfeeding, not be offered formula and be told that unnecessary “early limited formula” helps with breastfeeding and is harmless.

    It is also incredible that the authors of the study – one of whom is a consultant for and received funding from a formula company while being an editor for the Journal of Pediatrics as well (talk about a conflict of interest!) – would recruit exclusively breastfeeding babies for the trial and make them into formula fed babies in the first few days of life. They justify doing so by saying that it helps breastfeeding. But how do they know that? Because they telephoned the mothers in the study at 1 week and then 1 month and asked how breastfeeding was going. Working with breastfeeding mothers for over 33 years, I have come to see how unreliable and misleading telephone conversations can be in terms of assessing how well breastfeeding is going. It happens only too frequently that the mother telephones describing her situation and then on being seen in person one sees a completely different picture. Babies that are not latching on are not infrequently viewed as latching on by their mothers and babies who are not getting milk from the breast are thought of as babies getting milk. So in this study, in fact, none of the babies were observed at the breast and breastfeeding was not assessed in person at all. Yet the authors conclude that babies in both groups were breastfeeding well at 1 week and 1 month.

    They talk about the rate of re-admissions to the hospital and say that it was higher in the breastfeeding group. And yet, one of the readmissions in the breastfeeding group was for an umbilical infection and another for an unknown reason. And the 3 readmissions for jaundice? No details provided but we know that the first step for these mothers would have been to get competent help with breastfeeding.

    And the macrobiota being just fine after the babies were formula fed for the first most crucial days of their lives? We have countless studies showing how formula changing the bacterial flora of the formula fed babies and yet these authors claim that testing 8 babies of their 164 babies for a small number of parameters is sufficient to be sure that the macrobiota have not been affected.

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