This post follows on Part I, "A Recent Saudi Thesis and Book", and is followed by Part III, "Formula Feeding Without Guilt or Shame". The 3 are a response to a recent Arab News article, and a post by Susie of Arabia both featuring the book based on the thesis of Dr Modia Batterjee, and concerned about breast vs formula feeding in Saudi Arabia. Here, in Part II, I would like to address more broadly some of the issues at stake in the choices. This post emphasizes the 3 most common arguments for breastfeeding over formula feeding--immunity, bonding, and health benefits--and puts them in context for readers.
Most studies, including those conducted by the WHO, show the clearest benefits of breastfeeding up to 6 mos. That is primarily because the newborn's immunity to disease is in a weakened transitional state from the immune protection via the mother's immunoglobulins acquired in utero, and the development of the capacity to produce baby's own immune response, both in maturity of the immune system and in time for replacement. This is usually completed by about 6 mos.
Most mothers wean after 6 months, usually because of teeth, and eventually because of incorporating solids into the diet, and baby's improved abilities to hold bottle, sippy cup, etc. and feed self.
While bonding can be an obvious benefit of breastfeeding, bonding occurs with bottle feeding too. Eye contact, facial expression, touch, movement, and voice are all ways to create bonds with baby. Despite all the pictures and folk wisdom bonding isn't natural; it is an acquired tie between mother and infant, even if it is part of a survival instinct.
Mothers often feel secretly wretched, guilty, and ashamed that they don't immediately love the little stranger handed to them. Some had a great bond with the occupant of their uterus, and aren't particularly thrilled with the "reveal". Because it is kept secret, each mother wanders about rather despondently thinking they are the only one, a freak of nature, a horrible person, and will become a "mommy dearest". Not so, but it may take time to bond.
Fathers feeding babies is both a bonding experience for baby and father, and a health benefit for mother, in terms of sharing feeds and freeing mother for sleep, socialization, or personal needs.
In that sense sharing bottle feedings with others, whether using breast milk or formula is a bonding experience for a number of loving family members and caregivers, and baby.
Health Benefits to Mother and Baby
While there are good studies showing health benefits, beyond immunity--such as obesity, diabetes, and hypertension prevention for baby, and cancer prevention for mothers-- it is important to analyze exactly the scope of those studies, the impact, the generalizability of their findings, and the practicality of their recommendations. While such an analysis is beyond the scope of this post, it is also important to recognize the major role of genetic predisposition and a lifetime of health practices on childhood and adult health. Good nutritional, exercise, psychological and social habits out weigh the impact of infant feeding, based on studies of risk factors for pediatric and adult diseases.
Whether breastfeeding or bottle feeding, avoid overfeeding, using the breast/bottle as a soother, or leaving it in the mouth during sleep to avoid increased risks of obesity, deformation of palate, choking, and tooth decay. Extra formula or cereal to thinken feeds further so parents get a good night's sleep is a debatable practice (eg better to do it if it helps not throw baby out window, better not to do it excessively).
Premature infants need breast milk more than full term infants do, because of the general immaturity of their organ systems. They need the fat content, immunoglobulins, and easier digestibility because they are underweight and low in insulating fat, and will take longer to develop their own immunity and a more mature digestive system. While breast milk is particularly important, special formulas may be recommended depending on health and other needs, or naso-gastric feedings for the very young and those who lack a good suck reflex.
A baby may be allergic to milk-based formula, in which case soy milk or rice milk formulas may be better if breast feeding is not possible. Other times a baby will not be able to tolerate any formula or cost is prohibitive in which case a wet nurse or a breast milk bank, or an informal sharing among friends and family of pumped breast milk would be solutions to the baby's mother not being able to breastfeed. Rarely, a baby will be allergic to all milk proteins including those in the mother's breast milk. These babies need an alert pediatrics team, and definitely need an appropriate formula.
One of the reasons the WHO guidelines and much of the international push is towards breastfeeding is because of the dreadful consequences of formula companies running clinical trials or massive ad campaigns in third world countries, including free samples to maternity facilities and individuals. However, in many cases the family doesn't have sufficient funds to continue paying for formula, and so insufficient amounts are used in the mixture with water, or water and other liquids supplement the formula feedings, with the result that the baby gets insufficient nutrition. Another major problem is an adequate water supply: easily available, clean, free of contaminants. Formula feedings with poor quality water resulted in great problems with gastrointestinal illnesses, dehydration (infants dehydrate much more easily and faster than children or adults), and death.
So if water and cost are problems, no matter where you are living in the world, breast would be best.
Breastfeeding is a biological capacity and an acquired technique on the part of both mother and baby. There are a number of circumstances in which a mother may be biologically unable to breastfeed, or it is medically inadviseable to do so. These include hormonal abnormalities preventing lactation, abnormal breast development (whether ductal or cosmetic including severe nipple inversion) mastectomy for whatever reason (usually breast cancer), mammoplasty (breast augmentation), reduction mammoplasty (breast reduction), other breast surgery, diseases of the breast, illnesses that pass through breast milk, or necessary treatment with medications that pass through the milk and would be harmful to baby. Drug addiction, alcoholism, and serious psychiatric conditions, all of which could make mother unreliable or unavailable, or involve toxicity to the baby via the breast milk, are other contraindications. In these cases formula, not only bottle feeding would be better alternatives, for mother, for baby, and for other infant caregivers.
Mothers must acquire the skill of breastfeeding and of breastfeeding this particular baby. There is evidence to show that being exposed while young to other mothers breastfeeding enhances this skill. At the very least it provides a set of other mothers to consult. This isn't available to everyone, but lactation consultants, classes, nurses, videos, books, and articles, are alternatives. Still, like any other physical skill, this requires practice, modification to one's own needs, and can be met with frustration, tears, sleeplessness, pain, and even illness (like mastitis). Proper latching of baby, full feeds, alternating sides, and not using breastfeeding as a pacifier are key elements. Most, but not all, can acquire this skill. For some, recurrent cracked nipples and recurrent mastitis are unavoidable, and generally preclude a good breastfeeding experience for either mother or baby.
Babies also have biological requirements for breastfeeding, especially a good suck reflex, and a normally developed mouth, palate, and nasal passages. A poor suck reflex can be characteristic of prematurity and of developmentally delayed children, or those with neurological syndromes. Cleft lip and palate are the most common congenital birth malformations. A baby with a severe cleft lip will be unable to breast feed, as most likely will a baby with a cleft palate. Prior to adequate bottle feeding (even of breast milk) and formula (in cases where women were unable to maintain lactation), babies born with these problems used to die, whereas now they most often survive, have good surgical repair, and thrive.
Babies also have to learn how to breast feed, despite having a rooting reflex (a reflex to turn, find the breast and suckle if the cheek near the side of the mouth is stroked). Babies need help latching on, feeding sufficiently, and then digesting (burping). Some babies are better at it than others, some are faster learners, and some need more help from mom. A very few never quite get it. They may be better with bottle feeding, whether breast milk or formula.
I know a woman who was bottle fed and cared for by her brothers, ages 10 and 12,
when her mother was too ill to do so, and father out working of necessity,
she is one of the kindest people I know
she is one of the kindest people I know
Some mothers are at risk, even if not clearly medically unable to breast feed. These include those who are struggling more with postpartum medical complications, depressive symptoms (not time limited postpartum blues), requiring more sleep or more sensitive to sleep deprivation because of either of those, or who have particularly negative ideas about breastfeeding for whatever reason, even when well-informed.
A baby who is an extra challenge for medical reasons, including colicky, or difficult to feed, may exacerbate these considerations for mother. In these situations, bottle-feeding breast milk or formula may be the best solution. Ultimately, a healthy, including psychologically happy, mother is more important to the baby's well-being and development than which of these types of feedings is used, as long as proper nourishment is provided.
Pressure and criticism from family members, friends, neighbours, professionals, and society at large can put women struggling with breastfeeding, for whatever reason, at greater risk of self-recrimination, negative self-image, feelings of failure, insecurity in their abilities as a mother, and undue anxiety about the well-being of their child.
For Muslim women, a belief that breastfeeding for 2 years is a requirement may be an extra burden. In fact it is recommended, as an option, for up to 2 years, including for divorcees:
When ye divorce women, and they fulfil the term of their ('Iddat), do not prevent them from marrying their (former) husbands, if they mutually agree on equitable terms. This instruction is for all amongst you, who believe in Allah and the Last Day. That is (the course Making for) most virtue and purity amongst you and Allah knows, and ye know not.
The [divorced] mothers shall give such to their offspring for two whole years, if the father desires to complete the term. But he shall bear the cost of their food and clothing on equitable terms. No soul shall have a burden laid on it greater than it can bear. No mother shall be Treated unfairly on account of her child. Nor father on account of his child, an heir shall be chargeable in the same way. If they both decide on weaning, by mutual consent, and after due consultation, there is no blame on them. If ye decide on a foster-mother for your offspring, there is no blame on you, provided ye pay (the mother) what ye offered, on equitable terms. But fear Allah and know that Allah sees well what ye do.
Let the [divorced] women live (in 'iddat) in the same style as ye live, according to your means: Annoy them not, so as to restrict them. And if they carry (life in their wombs), then spend (your substance) on them until they deliver their burden: and if they suckle your (offspring), give them their recompense: and take mutual counsel together, according to what is just and reasonable. And if ye find yourselves in difficulties, let another woman suckle (the child) on the (father's) behalf.
The other verses of the Quran do not reference breastfeeding recommendations or times, but rather the issue of mahrems (milk siblings), and the story of Moses/Musa.
As women have said about other medical interventions which have required hospital committee approval: "Women shouldn't have to prove they are crazy to be in control of their bodies." Many fine women have chosen not to breastfeed for whatever reason and to be the best mother they can be in other ways. Their children do well and don't love them any less.
One woman I know simply wanted her body back, detached from baby, and so decided early not to breast feed, and asked for medication post-partum to halt lactation early. She did the same with all 3 daughters. Another woman I know exclusively bottle fed formula to all three of her sons, with no hesitation, and each time informed the obstetrician, pediatrician, and hospital that this was her "birthing plan". The oldest child in each of those families is in medical school, and the others are doing very well health wise, academically, socially, and athletically. None has allergies.
Some women are in jobs where breastfeeding or pumping cannot be managed easily, and a maternity leave is not an option. One example is a friend who owns a cafe, and cannot afford not to work in it herself. There is almost no privacy--the only privacy available would be a junk filled closet, a basement parking storage bin, or a small washroom. She cannot predict when her husband will have an "episode", go home to his parents', and leave her doing double shifts. She breast fed her first daughter only for the first month she was home recuperating from a difficult delivery. She didn't breast feed the second. Another category might be women who are in highly competitive positions where using the available maternity leave, or leaking through their professional attire would be too detrimental to their career, and therefore their psyche, income, marriage, home life, etc. to make breastfeeding for any length of time a reasonable trade off.
So, yes, breastfeeding is best--unless it isn't.
Please share your comments, thoughts, impressions, and experiences.
Men and women, mothers and non, are all welcome to share their opinions.
Please be sensitive to the choices of others, as I know regular commentators are, and expect all readers/commentators will be.