Breast-Feed or Else

In today's New York Times.

Breast-Feed or Else

By RONI RABIN

There is no black-box label like that affixed to cans of infant formula or tucked into the corner of magazine advertisements, at least not yet. But that is the unambiguous message of a controversial government public health campaign encouraging new mothers to breast-feed for six months to protect their babies from colds, flu, ear infections, diarrhea and even obesity. In April, the World Health Organization, setting new international bench marks for children's growth, for the first time referred to breast-feeding as the biological norm.

"Just like it's risky to smoke during pregnancy, it's risky not to breast-feed after," said Suzanne Haynes, senior scientific adviser to the Office on Women's Health in the Department of Health and Human Services. "The whole notion of talking about risk is new in this field, but it's the only field of public health, except perhaps physical activity, where there is never talk about the risk."
A two-year national breast-feeding awareness campaign that culminated this spring ran television announcements showing a pregnant woman clutching her belly as she was thrown off a mechanical bull during ladies' night at a bar — and compared the behavior to failing to breast-feed.

"You wouldn't take risks before your baby's born," the advertisement says. "Why start after?"

Senator Tom Harkin, Democrat of Iowa, has proposed requiring warning labels, on cans of infant formula and in advertisements, similar to the those on cigarettes. They would say that the Department of Health and Human services has determined that "breast-feeding is the ideal method of feeding and nurturing infants" or that "breast milk is more beneficial to infants than infant formula."

Child-rearing experts have long pointed to the benefits of breast-feeding. But critics say the new campaign has taken things too far and will make mothers who cannot breast-feed, or choose not to, feel guilty and inadequate.

"I desperately wanted to breast-feed," said Karen Petrone, an associate professor of history at University of Kentucky in Lexington.
When her two babies failed to gain weight and her pediatrician insisted that she supplement her breast milk with formula, Ms. Petrone said, "I felt so guilty."
"I thought I was doing something wrong," she added. "Nobody ever told me that some women just can't produce enough milk."

Moreover, urging women to breast-feed exclusively is a tall order in a country where more than 60 percent of mothers of very young children work, federal law requires large companies to provide only 12 weeks' unpaid maternity leave and lactation leave is unheard of. Only a third of large companies provide a private, secure area where women can express breast milk during the workday, and only 7 percent offer on-site or near-site child care, according to a 2005 national study of employers by the nonprofit Families and Work Institute.
"I'm concerned about the guilt that mothers will feel," said Ellen Galinsky, president of the center. "It's hard enough going back to work."

Public health leaders say the weight of the scientific evidence for breast-feeding has grown so overwhelming that it is appropriate to recast their message to make clear that it is risky not to breast-feed. Ample scientific evidence supports the contention that breast-fed babies are less vulnerable to acute infectious diseases, including respiratory and gastrointestinal infections, experts say. Some studies also suggest that breast-fed babies are at lower risk for sudden infant death syndrome and serious chronic diseases later in life, including asthma, diabetes, leukemia and some forms of lymphoma, according to the American Academy of Pediatrics. Research on premature babies has even found that those given breast milk scored higher on I.Q. tests than those who were bottle-fed.

The goal of a government health initiative called Healthy People 2010 is to get half of all mothers to continue at least some breast-feeding until a baby is 6 months old. Though about 70 percent of new mothers start breast-feeding right after childbirth, just over a third are breast-feeding at 6 months and fewer than 20 percent are exclusively breast-feeding by that time, according to the 2004 National Immunization Survey. Breast-feeding increases with education, income and age; black women are less likely to breast-feed, while Hispanics have higher breast-feeding rates.
For women, breast-feeding can be an emotionally charged issue, and a very personal one. Even its most ardent supporters acknowledge that they have made sacrifices.

"It's a whole lifestyle," said Kymberlie Stefanski, a 34-year-old mother of three from Villa Park, Ill., who has not been apart from her children except for one night when she gave birth. "My life revolves around my kids, basically." Ms. Stefanski quit working when her first child was born almost six years ago, nursed that child until she was 4 years old, and is nursing an infant now.
She said she wanted to reduce the risk of breast cancer for herself and for her three daughters, referring to research indicating that extended breast-feeding may reduce the risk for both mother and daughters.

Scientists who study breast milk almost all speak of it in superlatives. Even the International Formula Council, a trade association, acknowledges that breast-feeding "offers specific child and maternal health benefits" and is the "preferred" method of infant feeding. The American Academy of Pediatrics states in its breast-feeding policy that human breast milk is "uniquely superior for infant feeding."

Dr. Haynes, of the Health and Human Services Department, said, "Our message is that breast milk is the gold standard, and anything less than that is inferior."
Formula "is not equivalent," she went on, adding, "Formula is not the gold standard. It's so far from it, it's not even close."

Formula manufacturers say infant formula is modeled on breast milk and emphasize that it is the only safe alternative recommended by pediatricians for mothers who cannot, or choose not to, breast-feed.

But while formula tastes the same way at every feeding, advocates of breast-feeding say, the smells and flavors of human breast milk change from day to day, from morning to evening, influenced by the mother's diet. Many nutritionists believe that exposing an infant to this bouquet of flavors early on may make for less fussy eaters who are more flexible about trying new foods and more likely to eat a healthy, varied diet.

"I think of human milk not just as food, but as a sophisticated and intricate infant support system that has evolved over millions of years to provide the infant with nutrition, protection and components of information," said Dr. E. Stephen Buescher, a professor of pediatrics at Eastern Virginia Medical School in Norfolk, who heads the inflammation section in the school's Center for Pediatric Research.

"It isn't just calories," Dr. Buescher said.

The protection that breast-feeding provides against acute infectious diseases — including meningitis, upper and lower respiratory infections, pneumonia, bowel infections, diarrhea and ear infections — has been among the most extensively studied of its benefits and is well documented, said Dr. Lawrence M. Gartner, chairman of the American Academy of Pediatrics' breast-feeding section.
Breast-fed babies have 50 percent to 95 percent fewer infections than other babies, Dr. Gartner said, adding, "It's pretty dramatic."

One reason for the reduction in the incidence and the severity of infections is the antibodies contained in the mother's milk. "A lot of this has to do with the mother and baby interacting," he explained. "Whatever the baby is exposed to, the mother is exposed to, and the mother will make antibodies within three to four days." The baby absorbs them through breast milk.
Breast milk also protects the baby through other mechanisms. For example, it contains agents that prevent bacteria and viruses from attaching to cells in the baby's body, so the foreign agents are expelled in the stool, Dr. Gartner said.

The protection is not ironclad, so breast-fed babies will often get a mild infection that does not make the baby sick but acts almost like a vaccine. "What we think is that human milk creates an environment where you get your immunity without the cost of an infection, the vomiting and the diarrhea," Dr. Buescher said. "That's a bargain."

Neonatologists are urging the mothers of their tiniest patients to express breast milk because premature and low-birth-weight babies are particularly vulnerable to infections. Studies have found that premature babies who get breast milk are discharged earlier from the hospital and are less likely to develop necrotizing enterocolitis, a potentially deadly disease. Breast milk has also been shown to lift the cognitive development of premature babies, presumably because it contains certain fatty acids that aid brain development.

Experts say it is possible that human breast milk produces permanent changes in the immune system, in a sense "educating" the baby's immune system, Dr. Gartner suggested. That may explain why children who were breast-fed appear to be at lower risk for autoimmune diseases like Crohn's, asthma and juvenile diabetes. Several studies also indicate that breast-fed children are at reduced risk for the cancers lymphoma and leukemia.

Officials with the International Formula Council say there is not enough evidence to prove a relationship between early feeding and serious chronic diseases.
Dr. Myron Peterson, director of medical affairs for Cato Research, a private independent research organization which reviewed the literature on breast-feeding for the council, said that studies have found a link between nursing and health benefits but that they do not prove a causal relationship. "It's like the old statement about the rooster crowing making the sun come up," he said. "If you did an observational study on that, what would you say?" An unpublished report the council commissioned from Cato says "it is not scientifically correct to conclude the lack of exclusive breast-feeding plays a causative role in the development of these diseases."

But scientists are so intrigued about the potential to protect children from juvenile diabetes that a large 10-year multinational study called Trigr (for Trial to Reduce Insulin-dependent diabetes mellitus in the Genetically at Risk) is under way to find out whether breast-feeding protects at-risk children from developing the disease.
And public health officials, excited about mounting evidence suggesting that children who were breast-fed are at lower risk of being obese, have been promoting breast-feeding as a strategy to combat alarming rates of childhood obesity.

The health benefits of breast-feeding may extend to mothers as well. According to the American College of Obstetricians and Gynecologists, extended breast-feeding reduces the risk of ovarian cancer and breast cancer. New studies have also found that women who breast-feed face a lower risk of adult-onset or Type 2 diabetes, and they seem to be at lower risk for osteoporosis later in life.

Immediately after childbirth, nursing accelerates healing by reducing the amount of bleeding and causing the uterus to contract more rapidly back to its normal size. Making milk burns up to 500 extra calories a day, so nursing mothers get help shedding extra pounds from pregnancy, experts say, especially if they nurse for an extended period.
Experts say lactation also seems to have a calming effect on the mother, which may be an adaptive mechanism to ease the transition to life with a new baby. Every time a mother nurses, she gets a spike in oxytocin, which may have an antianxiety effect and help promote bonding with the new baby, said Kathryn G. Dewey, a professor of nutrition at the University of California, Davis, and an expert on breast-feeding.

Nursing may even produce a euphoric feeling, she said.

Dr. Michael Kramer, a professor of pediatrics and of epidemiology and biostatistics at McGill University's medical school in Montreal who has been studying the health effects of breast-feeding among infants in Belarus, found a strong protective effect against gastrointestinal illnesses and a lesser protective effect against respiratory infections. Dr. Kramer is still analyzing data on obesity, I.Q., behavior and blood pressure.

"It can't do all of the things that are being claimed for it," Dr. Kramer said, injecting a note of caution into the debate. "But it probably does some of them."