Journalist and infant health advocate Kimberly Seals Allers breaks breastfeeding out of the realm of "personal choice" and shows our broader connection to an industrialized food system that begins at birth, the fallout of feminist ideals, and the federal policies that are far from family friendly. The Big Letdown uncovers the multibillion-dollar forces battling to replace mothers' milk and the failure of the medical establishment to protect infant health. Weaving together research and personal stories with original reporting on medicine, big pharma, and hospitals, Kimberly Seals Allers shows how mothers and babies have been abandoned by all the forces that should be supporting families from the startand what we can do to help.
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The Big Letdown
How Medicine, Big Business and Feminism Undermine Breastfeeding
By Kimberly Seals Allers
St. Martin's PressCopyright © 2017 Kimberly Seals Allers
All rights reserved.
Doctor Who? The Medical Field's Influence on Mothers
We have not lost faith, but we have transferred it from God to the medical profession.
— GEORGE BERNARD SHAW
I distinctly remember my anxiousness as a new mother just before a pediatrician visit. The visit starts with the inevitable weigh-in and then the height and head circumference, followed by a breakdown of where my daughter sized up on the chart compared with other babies. In our comparison-prone world, growth charts and growth percentiles are like SAT scores for babies. This is how we judge them — by weight gain. Growth percentiles rank your child based on what percent of the reference population your child would equal or exceed. For example, on the weight-for-age growth charts, a two-month-old girl whose weight is at the twenty-fifth percentile weighs the same or more than 25 percent of the reference population of two-month-old girls, and weighs less than 75 percent of the two-month-old girls in the reference population. They are the most commonly used clinical indicator for assessing the size and growth patterns of individual children in the United States. The problem is, the comparison of baby growth becomes, by extension, a comparison of parenting success and then a competitive sport. Having a baby in a high percentile for growth becomes a mommy bragging right — "My Johnny is in the ninety-fifth percentile" — statistical proof positive that you are doing a good job.
If the anxiety of the weigh-in and the peer pressure for big percentile numbers wasn't enough, I had my own fears. From the very beginning of breastfeeding, I worried if my child was getting enough food. Yes, medical experts tell you if you count five to six wet disposable diapers per day and two to five bowel movements every twenty-four hours with the fastidiousness of a city health inspector, then all is well. But still you wonder. You worry. Not to mention that as superachiever moms raised on test scores, GPAs, performance reviews and living in a "supersize" world, we crave high numbers. We want big. Our society sees plump babies as a sign of good mothering. And, let's face it, we want to boast. As the pediatrician placed my baby on the scale, I couldn't help holding my breath and bracing myself just a little.
So you can imagine the blow to the gut when, after two months of feeling like I had finally nailed the breastfeeding thing, my pediatrician said that my daughter's weight was slightly below average and suggested that I might need to supplement with formula if things weren't ticking upward in two weeks. I was heartbroken. Exclusive breastfeeding for six months was my personal goal, and I didn't want to supplement. She said that my milk supply may be dwindling and that this was very common with women. She told me that I shouldn't feel bad if I needed to add formula and that I had "done well."
What she didn't tell me was that the chart that she was using to gauge my child's growth progress was based on an outdated sample of babies who weren't being fed the way my baby was being fed. That's because until 2006, the standard infant growth charts in the United States were based on a sample of formula-fed infants. In 1977 the National Center for Health Statistics (NCHS), which became part of the CDC in 1987, published a set of growth charts based on the Fels Longitudinal Growth Study. These charts eventually became the standard U.S. growth charts and were later used by the World Health Organization and others to develop global growth curves for infants. The U.S. growth charts became the model for the world. The Fels study, however, was based on a sample of formula-fed Caucasian babies born between 1929 and 1975 in Ohio — infants who weren't even being fed according to the globally recommended infant nutrition standard: breast milk. These babies started solid foods before four months and were being measured every three months, which researchers later realized is too long of an interval for gauging the rapid growth periods during infancy. In addition, relying on a sample of infants from one racial, socioeconomic, and geographic background over a short period of time wasn't ideal for measuring a general infant population. So while pediatricians and health officials were promoting breastfeeding as the best nutrition, they were also comparing all babies to formula-fed babies. We now know that breastfed babies and formula-fed babies grow differently. This important fact was missing from the growth charts being used all over the world prior to 2006.
This isn't a small matter. For over two decades, many governmental and United Nations agencies used the data collected from physicians based on these growth charts to measure the general health and well-being of national populations. That information, in turn, was used to set global infant health policies, determine stages for interventions, and monitor the effectiveness of the recommendations. Growth charts are the core tool of the pediatrician. They are used to determine the degree to which the physiological needs for growth and development are being met during infancy and childhood and to assess a child's nutritional status. Yet generations of mothers and babies were incorrectly subjected to the bottle-based growth charts. Many breastfed infants were misdiagnosed with a failure to thrive and given formula based on these growth charts, causing needless distress to their mothers. I know. I was one of them.
At the same time, inadequate infant growth has been one of the biggest sources of profit for the infant formula industry. One of formula makers' most consistent marketing messages has been that when mother's milk is insufficient, then infant formula is there to ensure optimum growth and wellness. That eventuality could be nearly guaranteed when breastfed babies were measured against charts contradicting their normal growth pattern. It is no wonder that infant formula companies have freely given away growth charts to physicians as promotional material for years. It is a mighty sheet of paper with the power to direct medical advice on infant nutrition and either bolster formula sales or support breastfeeding worldwide. Growth charts are a really big deal.
And for decades they were wrong. It wasn't until the early 1990s that researchers began to document the different growth patterns of breastfed babies and formula-fed babies. Studies show that breastfed babies grow faster during the first few months of life and then tend to "lean out" from month 3 to month 12 when compared with formula-fed babies. Then researchers set out to find if this should be classified as some sort of "faltering" or a normal outcome of breastfeeding even in optimal conditions. One key study by DARLING (Davis Area Research on Lactation, Infant Nutrition and Growth), published in The Journal of Pediatrics in 1991, found that the slower growth of breastfed infants did not cause negative consequences for activity level, time spent sleeping, or achievement of developmental milestones. The report concluded, "infants with slower growth velocity were just as active and were ill no more often in subsequent months than infants who were growing more rapidly." Basically, the slower-growing breastfed babies were just fine.
It wasn't until 2006 (six years after I received my supplementation recommendation) that the World Health Organization released its own growth curve charts, using breastfed babies as the standard for growth, changing our understanding of the differences of how breastfed and formula-fed babies grow. The WHO charts were created from a sample of nearly nine thousand babies who were exclusively or near exclusively breastfed for the first six months. The charts established the breastfed child as the normative model for growth and development around the world. Applying them to formula-fed babies can serve as an early warning to doctors if a formula-fed baby is experiencing excessive weight gain and is therefore at greater risk of being overweight or obesity. "Arguably, the current obesity epidemic in many developed countries would have been detectable earlier if a prescriptive international standard would have been available 20 years ago," the WHO admits, acknowledging the role of two decades of inaccurate growth charts in the course of childhood health. All over the world, babies were misclassified as underweight and given infant formula, which is more calorie-dense. The higher fat content of formula and the propensity to overfeed when using a bottle has been linked to higher rates of childhood obesity. Infant formula also contains unhealthy sugars, some of which have been banned in Europe because of their known link to childhood obesity.
But getting to the critical and yet basic point of having a valid growth chart that works for all babies and is based on the diet that public health experts unanimously agree is best has taken over twenty years. It took less time to put a man on the moon. The Panama Canal was constructed in ten years. How did this happen? Child nutrition researchers, who as a group have been heavily funded by infant formula companies, accepted formula feeding as the norm for their studies. Physicians, who have historically had a financial relationship with infant formula companies, relied on researchers for information about how breastfed babies grew. And institutions responsible for setting guidelines to ensure the health of infants around the world relied, in turn, on those two entities for data and recommendations.
* * *
Thirty-two. That's the number of seconds it took for me to encounter the infant formula marketing at a pediatrician's office on the outskirts of New York City. I walked about ten feet from the office door to the reception desk and, at the check-in window, I picked up a pen and there it was — the words ROSS LABS emblazoned on one side of the pen and a Rosco teddy bear on the other side. The clipboard matched. That day, I was on a reconnaissance mission — visiting various pediatrician and ob-gyn offices in and around New York City to see how long it would take from the moment I entered the office door before I met infant formula marketing — along with the implied message that infant formula is doctor-approved.
My expedition took me to neighborhoods like the Upper East Side, where there were very few traces of infant formula marketing in the waiting or examining rooms, to some forty miles east to the suburbs of Long Island where, infant formula marketing was even more present in ob-gyn offices than in pediatrician offices. All in all, I visited some thirty offices over the span of my "mission," and I only found one physician with absolutely no visible marketing materials in the office or examining room representing the formula brand or the pharmaceutical company that manufactures it. Only one doctor out of thirty who did not give out magazines or giveaway packs full of infant formula coupons and pamphlets to expecting mothers.
Every year Perrigo Nutritionals, makers of Store Brand Formula, conducts a nationwide "Pulse of Pediatricians" survey — conducted by SERMO, the largest online network for physicians. In their most recent findings, 59 percent of pediatricians reported distributing infant formula samples in their offices — despite the fact that the American Academy of Pediatrics adopted a resolution in 2012 advising pediatricians to stop displaying infant formula marketing materials in their offices and clinics.
The participation of physicians' offices in formula marketing programs, from logo-laden growth charts to formula coupons and freebies, has a strong correlation with breastfeeding outcomes. A 2000 study published in Obstetrics and Gynecology showed that mothers who receive formula marketing at the ob-gyn's office have stunted breastfeeding experiences. The randomized, controlled trial of more than five hundred mothers looked at the impact of promotional materials on the first prenatal visit. Mothers received either a formula-company-sponsored information pack on infant feeding or a noncommercial pack. The results showed that among mothers who were uncertain about their plans to breastfeed, those who received the formula marketing packet were 1.7 times more likely to stop breastfeeding before two weeks than those who received the noncommercial information. The study concluded that this was "compelling evidence that obstetric care providers should not participate in formula marketing programs."
Obstetricians and pediatricians exert a powerful influence on women not just because they passively display waiting room materials and give away freebies but because of what they actively say about breastfeeding. In a study of obstetricians and patients at a multispecialty group practice in Massachusetts, just 8 percent of physicians felt their advice on whether and how long to breastfeed was important, but more than one-third of mothers reported that their provider's advice on these topics was very important. This study also found that patient perception of clinicians' opinions is directly correlated with breastfeeding duration. In looking at breastfeeding prevalence at six weeks postpartum, researchers found that 70 percent of women who thought their physician favored breastfeeding were still breastfeeding compared with 54 percent of those who thought their physician had no preference.
Here's what we know thus far: Doctors may not think that mothers are influenced by what they give away or which infant feeding method they support, but mothers are. Their behavior reflects it and that behavior affects infant health and maternal health. In the Store Brand Formula survey, 97 percent of pediatricians said questions about feeding are the most frequently asked category for new parents, with pooping and sleeping coming in second and third place.
If so many parents are asking about feeding, shouldn't pediatricians be the most knowledgeable on all the options, starting with the optimal nutrition as recommended by the American Academy of Pediatrics? And shouldn't the AAP, representing over 64,000 pediatricians and pediatric specialists, be leading the charge for breastfeeding? Instead of being the seemingly strongest and most natural ally, the AAP continues to be heavily supported by infant formula donations, raising questions about its own bias in the infant feeding information it provides to parents. Formula manufacturers have donated $1 million annually to the AAP in the form of a renewable grant that had already netted the AAP $8 million by 1995. The formula industry also contributed at least $3 million toward the building costs of the AAP headquarters. AAP's "Friends of Children Fund" (FCF) is a corporate donor fund used to support "high priority activities" and generate new knowledge about how to care for your children, according to AAP's Web site. In return for a donation, members receive "significant acknowledgment in several AAP publications visible to our 60,000 members," the Web site says. Yet, 89 percent of the top donors — those giving $50,000 or more annually — are infant formula or pharmaceutical companies, including Mead Johnson, Nestlé, Perrigo Nutritionals, Pfizer, and Sanofi Pasteur, one of the largest companies in the world devoted entirely to vaccines. The potential conflicts of interest for parents to receive truly unbiased information from the AAP seem hard to ignore.
Medical schools also play a part. What do doctors learn about breastfeeding in medical school? "Not much," said my current pediatrician. "There was about a day or so on the medical evidence on the benefits of breastfeeding, but nothing about medical problems related to lactation or the science of what's happening in the breast at the anatomical level," he said. Most medical schools don't have any meaningful breastfeeding curriculum that includes in-depth training on the mechanics of breastfeeding, how to identify and treat lactation problems, and how breastfed babies grow and develop. Many of those teaching at medical schools are of the generation that were trained at a time when science aimed to bring better living and the chemistry behind infant formula was thought to trump breast milk. The message at many medical schools is that understanding breastfeeding is not in a physician's job description. In fact, lactation holds the dubious distinction of being the only bodily function for which modern medicine has virtually no training or knowledge. Doctors know how to treat and prescribe for erectile dysfunction, but lactation dysfunction doesn't even exist as a diagnosis. Nevertheless, where medical schools have failed to educate, infant formula companies have been more than happy to fill the gap. In the absence of independent medical training, doctors and mothers alike have relied on the commercial industry — the one supplying and profiting from the substitute product — to provide so-called unbiased education and guidance. Every year, the Abbott Nutrition Every year, the Abbott Nutrition Institute hosts conferences to "educate" thousands of physicians and nurses on infant nutrition. This is like going to a Toyota car dealer to learn about the benefits of a Buick. Or imagine thousands of licensed dieticians being trained at a McDonald's Nutrition Institute.
Excerpted from The Big Letdown by Kimberly Seals Allers. Copyright © 2017 Kimberly Seals Allers. Excerpted by permission of St. Martin's Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
1 Doctor Who? The Medical Field's Influence on Mothers 13
2 Milk Money: The Big Business of Bodies, Breasts, and Babies 38
3 Scientific Breakthroughs or Breakdowns? 80
4 The Things Unseen: Battling Structural Barriers 120
5 Nipple-omics and the Value of Motherhood 153
6 The Feminist Fallacy 168
7 The Problem of No Problem: The Breastfeeding Movement 191
8 Boob Control: The Sexualization of Breastfeeding 226
9 Ending the Letdown: The Way Forward 251