Tag Archives: psychosocial

Is breastfeeding all it’s cracked up to be?

Zoe Williams wrote an intriguing article in The Guardian that challenged some widely held assumptions and beliefs about the benefits of breastfeeding (‘The backlash against breastfeeding’). It did, as you might imagine, generate strong reactions from those who vehemently espouse that “breast is best”. It was written on the back of a recent front cover of Time magazine that caused an even greater furore (‘Are you mom enough’), which championed a form of ‘attachment parenting’ that encouraged breastfeeding until the child is well over one year old.

I did feel that Zoe Williams’ article raised some interesting points, some of which I wanted to address here.

But I also had the strong suspicion that the claims made for [breastfeeding’s] benefits – the higher IQ, the protection against obesity, the superior bonding, the warding off of disease both now and for ever, both for baby and for mother – were mostly bogus. A lot of the reasoning seemed syllogistic (babies born into low-income families end up fatter; low-income mothers breastfeed less than high-income mothers; therefore breastfeeding prevents obesity) or frankly lame.

This relates to the concept I’ve written about before, that correlation does not imply causation. As she quotes Joan B Wolf later in the article: “Breastfeeding cannot be distinguished from the decision to breastfeed, which could represent a more comprehensive commitment to healthy living.”  

While this is true, that is not to say that the researchers who conduct these types of observational studies are not aware of this limitation. It is hard to do interventionist, controlled studies, as you would do in a lab or in randomised controlled trials to test a new medicine. Imagine randomly assigning new mothers to one of two groups – breastfeeding or formula-feeding – and getting them to stick to this regimen so that you can measure the outcomes of the children. Not likely, which is why such interventionist studies have been limited (1 & 2).

So researchers work with the tools available to them. They try to include appropriate comparator groups and make statistical adjustments to account for potential confounding variables. Not perfect by any stretch, but the best available methods.

I knew a lot of mothers who formula fed; they didn’t seem to love their babies less.

Ignoring the submission to anecdote, which is a mortal sin to evidence-based thinkers, a more worthwhile point to address is an argument I’ve often heard that goes approximately: “Well, they say breastfeeding is best, but I formula-fed and my child turned out alright”.

There are two key flaws in this reasoning. One is that by advocating breastfeeding, it is implying that formula-feeding is bad. No. It’s just there’s less chance that any outcomes associated with breastfeeding will also be seen with formula-feeding. The second misconception is that there’s a complete separation, or dichotomy, between the two groups. But here we’re comparing averages of large study groups – there will be huge amounts of variability around the averages and a lot of overlap, and only the right statistical analyses can reveal any true differences.

Put simply, there will be mothers of formula-fed babies who form strong attachments (to carry on the example in the article) and mothers of breastfed babies who do not.

By analogy, there will be some people that do all the ‘right’ things – not smoke, eat healthily, exercise, apply sun cream – who will get cancer and there will those who smoke 40-a-day and drink to excess who do not. It doesn’t disprove the link, it’s all about stacking the odds in your favour.

(I should clarify that the evidence I’ve seen for superior bonding associated with breastfeeding is somewhat weak, but I referred to it here to address a more general point about the common use anecdotal evidence).

This struck me as a bizarre place to have arrived at; where even to talk about the evidence behind the benefits of one type of infant feeding over another is heretical.

Absolutely correct. We should constantly gather and scrutinise data, and if strong enough evidence emerges that contradicts our prior assertions, then we should be prepared to change our minds. I applaud the fact that this article was written, even if there are bits I wouldn’t necessarily or wholeheartedly go along with, as we should always be ‘talking about the evidence’.

The questioning of the orthodoxy is taken as a direct attack on babies.

[Charlotte Faircloth, sociologist]: “… Everything has got very heated, and very moralised. How you feed your kids is no longer a personal decision. There’s this idea that you can breastfeed your way out of poverty, or if you don’t breastfeed your kid’s going to be fat or have a low IQ…” She pauses. “It’s all got a bit out of hand.”

Williams is right that some breastfeeding advocates are evangelical and overly ideological about breast milk, to the point that some mothers feel over-bearing pressure to breastfeed. As Charlotte Fairclough is quoted, it’s a personal decision. Fairclough also touches on my earlier point that there’s no binary distinction in the outcomes of children who are breastfed and those who are not – breastfeeding doesn’t determine the outcome but may make it more probable (and, if it does, it will certainly still only be one factor amongst many).

Williams then quotes French feminist Elisabeth Badinter:

“when it’s recommended that you breastfeed your child for one year – six months exclusively, with nothing else, day and night, on demand – there are obviously consequences for a couple.”

“There are women for whom breastfeeding is a true pleasure. It’s very good for them and it’s very good for the baby. But to breastfeed a baby if the mother herself doesn’t like it? It’s a catastrophe. The decision to breastfeed is an intimate and private decision. No one should be able to interfere.”

In my mind, this touches on something I have written about before – that to lay down a hard-and-fast prescription for parents to follow is not always straightforward or productive. A more nuanced approach is often required that takes into account the familial circumstances and considers the parents’ well-being as well. It would be no good hectoring parents to follow a particular path, if it leads to a significant worsening of their own physical or mental health, especially if the knock-on effect is a deterioration in family relationships.

It seems highly unlikely that this would allow people to be good parents nor provide a decent environment for the child (a brief look at the scientific literature suggests this assumption isn’t entirely unreasonable, e.g. thisthis and this). It also risks attaching blame to a parent for any perceived character flaw in their child, and guilt-tripping parents in this way seems a counter-productive approach.

The research about ear infections, respiratory disease and diabetes is very mixed. Neither fussiness around new foods nor constipation are classic or very salient markers of good health. The obesity studies are debatable. The weight loss of breastfeeding mothers is taken from a WHO report, based on two interventionist studies in Honduras. It’s nothing like that straightforward: it does use 500 calories a day, but if your appetite increases at the same time, it is amazing how quickly and easily you can pop 500 calories into your mouth. Meanwhile, Wolf points out, no study on maternal cancer has “distinguished the effects of breastfeeding from the behaviour of women who breastfeed”

Again, I agree, it’s not straightforward! But I would, perhaps, strike a more positive tone.

The studies aren’t perfect (Williams also quotes the American Academy of Paediatrics: ‘There are a lot of methodological problems’), but that’s no reason to just give up on evidence altogether. The best available evidence, as far as I can see, is saying that breastfeeding is likely to bring a range of benefits to the child, and possibly some to the mother. A Cochrane Review from 2009 includes many citations that support various benefits of breastfeeding, as well as a discussion of some of the uncertainties.

I also agree that the weight loss data must be taken in context, such as whether you are dealing with developed or developing countries, and some effects, such as iron status, can be achieved through supplementation. So, in some instances, there’s no need to be over-zealous about breastfeeding, as long as adequate healthcare advice is in place.

“The notion of risk [has been] transformed from a dichotomy to a continuum.” It’s no longer a case of “safe” versus “dangerous”; rather, everything carries some risk and you announce your fitness as a parent to the world by interpreting hazards in the most credulous, fervent way. The onus isn’t on the researcher to prove the point any more – the onus is on the parent, or parent-to-be, to prove that they’ll believe the researcher.

I’m not sure this is true and seems an over-generalisation. There’s a huge variety in parental attitudes and some are incredibly questioning, and whether and how this has changed in recent years is uncertain without any data. I think it misrepresents the role of a researcher, too – that the onus is on them to ‘prove a point’. Scientists don’t (or shouldn’t) undertake work to prove already held beliefs, rather they formulate hypotheses and design experiments to support or reject those theories.

There are lots of other points in and around the ones I’ve highlighted, a lot of which veer from my intention to address evidence-based decisions, but I do encourage you to read the whole article for some interesting discussion of feminism and social policy.

I’ll summarise by saying that I would still state that breastfeeding can potentially bring a range of benefits over formula-feeding, because that is where the balance of scientific evidence is, with little or no contrary evidence to dissuade me yet. And this should be reflected in the healthcare advice that is provided. I absolutely agree, though, that foisting this decision on mothers is, at best, unnecessary and, at worst, damaging. Healthcare advice must take context into account.

On a more general point, I welcome any sensible, critical look at the evidence behind claims, as Zoe Williams has done. It’s certainly made me re-evaluate – and in some instances, such as in the link to lowered risk of maternal breast cancer, made me temper – my own standpoint on the benefits of breastfeeding.

A final point, though. It was disappointing that an article that relied so heavily on rejecting or challenging some of the evidence that is used to promote the “breast is best” standpoint, did not once link to any primary research. A few quotes here and there from, no doubt, serious academics, and a link to a book, but nothing that could point the reader to the original research studies.

It is perennial complaint that evidence-based advocates level at popular journalists, so I don’t want to single out this author for special criticism. But it is something that could do with a cultural shift and, perhaps, mainstream commentators will start to follow the examples of their science colleagues.

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Hat-tip to Mum-in-law, Jenny, for The Guardian article.

On the social environment

I was brought to thinking about child development and the influence of early parental nurturing after watching a lively exchange on BBC’s Newsnight between the clinical psychologist, Oliver James, and Dr Ellie Lee, a lecturer in social policy at the University of Kent.*

From what I could see, the intense antagonism (aside from James’ unwavering dogmatism) was partly the result of a difference between a purely clinical look at child development, by which controlled scientific studies are held up to encourage the need for early intervention, and the sociological implementation of these ideas, which can introduce many variables to successful intervention.

For instance, showing that supportive parenting behaviours can lead to improved mental and language abilities in infants is one thing (as James would point out), but how you successfully communicate that to parents and change behaviour, is another (as Lee might counter). To lay down a hard-and-fast prescription for parents to follow, without layering burden upon burden, is not always straightforward. A more nuanced approach is required, as appreciated in the Early Intervention report featured in the Newsnight item.

Oliver James, in particular, seems very disposed to attach blame to a parent for any perceived character flaw in their child, and guilt-tripping parents in this way seems an overly blunt approach. And this is the point that Dr Lee may have wished to explain more explicitly.

It seems to me, albeit speculatively, that the parent’s well-being is an important consideration when encouraging them to follow particular regimens. The current consensus of the scientific community may be that a child should be doing X, Y and Z, but it may also be the case that to achieve this, one or both of the parents would end up dangerously sleep deprived, mentally exhausted and with a strain on their relationship. This would be differentially affected by a person’s physiology, underlying immunity, predisposition to mental illness, and so on. It would also depend fairly heavily on a person’s life – their age, whether they’re a single parent, in proximity to close family, in a high pressured job, etc. All of these considerations temper any absolute assertion of an intervention based on clinical data.

The field of psychosocial research, which seeks to understand the interplay between one’s psychology and their social environment, is an important factor to consider when establishing any health initiative. It would be great to see whether there is any direct evidence related to this in the context of early intervention programmes for parents. A recent special issue in the journal Science, lays out some of the issues facing educational intervention initiatives, including the obstacles faced when moving from scientific research to public policy. The need for a holistic approach is summarised in the introduction:

Early childhood education remains peppered with both opportunities and debate. Continued progress will require new research that bridges traditional disciplines of neuroscience, psychology, sociology, economics, public policy, health, and education.

So whilst the clinical research may show that a particular intervention leads to the absolute best outcomes, it may be that a parent ends up finding a middle ground that still provides a beneficial environment for their child, but also a satisfactory outcome for themselves (a sort of cost-benefit assessment, if you like). It would be no good hectoring parents into following a specific course of action, with no amount of flexibility, if it leads to a significant worsening of their own physical or mental health, especially if the knock-on effect is a deterioration in family relationships. It seems highly unlikely that this would allow people to be good parents nor provide a decent environment for the child (a brief look at the scientific literature suggests this assumption isn’t entirely unreasonable, e.g. this, this and this).

I should emphasise that I do not wish to appear as though I am justifying or accepting of ‘bad behaviour’ of parents. There are clearly things we should all strive to do, things that are a struggle, and this will involve a series of adaptations, compromises and sacrifices.

Why, say, do one in five British adults smoke when we know categorically that is causes lung cancer, heart disease and increased risk of stroke? Worse, why do so many adults still smoke in the presence of children or during pregnancy, when passive smoking can cause the same health problems in children (and more) and parental smoking increases the chances that a child will smoke as an adult? A look at how mothers from disadvantaged backgrounds respond to tobacco control initiatives gives some clues – in short, increasing stigmatisation can be counter-productive.

I would like to think, though, that most, if not all, parents are happy to put their very best efforts in and would never be wilfully neglectful. But the point which seems to emerge is that the results of clinical research should be considered against a backdrop of social and population variances. In the case of early intervention, labelling a child as ‘at risk’ or categorically predicting their development, could be helpful in targeting the right guidance and support to the right people, but should not lead to undue and counter-productive stigmatisation.

So, appreciating that each baby, each parent, each family’s circumstance is different, is very valuable. It is critical, as always, to be guided by the scientific evidence available and make this the basis of any initiative to improve child development, but it may not be possible to then arrive at a ‘one-size-fits-all’ formula, a point similar to that made by Dr Luisa Dillner regarding sleep routine.

In short, it’s complicated. Plus ça change…

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* Better quality video embedded (05/10/2011) – thanks to Denys Andrianjafy.