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Formula for disaster
Many new parents think infant formula is the next best thing to Mom, but nothing could be further from the truth. by Katie Allison Granju When Tabitha Walrond's 7-week-old infant died of starvation last year, the fact that this young New York mother had attempted to breast-feed her baby -albeit with obvious lack of success - was widely blamed for the complex and haunting tragedy. The national headlines regarding the Walrond case were ongoing and sensational. "Nursed to Death" read one. "Breast-feeding can kill?" inquired another.During the same period, the similar death of the 6-week-old breast-fed baby of another New York mother, Tatiana Cheeks, raised further breast-feeding concerns in the press and with the public. This time one headline read "Nursing Death?" In 1995, a widely-circulated Wall Street Journal article detailing dehydration in several middle-class breast-fed babies whose mothers had experienced breast-feeding difficulties led to a surge in phone calls to pediatricians and hospital hotlines across the country from new parents worried that breast-feeding itself could somehow harm their infants. Given this environment, many conscientious new parents may conclude that formula-feeding represents a safer alternative to the potential "dangers" of breast-feeding. In fact, nothing could be further from the truth.In virtually all of the reported cases each year in which a breast-fed baby becomes seriously ill as a result of her mother's feeding choice, the problem is actually one of not breast-feeding -meaning that, as in the Walrond and Cheeks cases, some uninformed and unsupported nursing mothers are not aware that they aren't effectively transferring milk from their breasts to their babies. In sharp contrast, however, routine formula feeding -even when done properly by parents -is itself a contributor to overall rates of infant morbidity and mortality in the United States. This is because - despite what manufacturers' advertising would have parents believe -today's commercial infant formulas, while a marked improvement over the homemade concoctions of years past, still represent a flawed and highly inferior imitation of our own, species-specific milk. According to the American Academy of Pediatrics' most recent member survey, a majority of baby doctors see slightly more formula-fed babies than breast-fed babies admitted to the hospital for instances of malnutrition and failure to thrive. But this represents only the tip of the iceberg when it comes to the differences in rates of morbidity and mortality between formula-fed and breast-fed infants in this country. When the overall health of formula-fed infants in the U.S. is compared to that of breast-fed infants -even after controlling for variables such as parents' socioeconomic backgrounds - it becomes clear that formula-fed babies are sicker, sick more often, and are more likely to die in infancy or childhood. However, parents often lack access to this information, and in fact, are often the recipients of misinformation, thus denied the ability to make truly informed choices regarding how they will feed their babies. Although the phrase "breast-feeding is best" is tossed around so liberally as to have been rendered almost meaningless, many Americans are under the mistaken impression that today's commercial infant formulas are nearly identical to human milk. And because of this, parents who routinely approach other important infant health and safety issues in a thoughtful, deliberate way are largely unaware that in epidemiological terms, the decision to formula-feed when breast-feeding is an option places their child at demonstrably higher risk for a wide variety of ailments."Parents are not adequately informed regarding the real risks of artificial milks [infant formula]," says Nancy Wight, MD, FAAP, IBCLC, and a neonatologist at Children's Hospital in San Diego. She says that she considers it part of her job to strongly encourage the parents of her patients to breast-feed. "Doctors never worry about making parents feel guilty when we discuss childhood immunizations, car seats, seatbelts, bicycle helmets or fencing around pools. I have an obligation to my patients to give them correct information - not formula marketing slogans - and let them make the choice."Dr. Lawrence Gartner, MD, FAAP is a respected medical authority on infant feeding who has played a role in drafting policy statements for the AAP regarding this issue. He agrees that parents today aren't fully aware that the breast-or-bottle decision is more than just another neutral lifestyle choice. "Compared to other equally important child safety issues like car seat use or babies' sleep position, parents should understand that the decision whether to breast- or bottle-feed ranks right up on top when it comes to protecting babies. The AAP certainly puts it in that category."In fact, the AAP explicitly states that encouraging breast-feeding among parents is "as important to preventive pediatric health care as promoting immunizations, car seat use, and proper infant sleep position." Katherine Dettwyler, Ph.D., associate professor of anthropology at Texas A&M University and an internationally recognized expert on infant nutrition, agrees with Gartner's assessment of the relative risks of "artificial feeding" for American children. "I would rank the decision of how to feed your baby as the No. 1 infant safety issue in this country," says Dettwyler.Despite the widespread misperception that aggressive promotion of breast-feeding has had a major impact on how we feed our babies, more than 70% of infants in the United States are fed infant formula as their primary source of nutrition for most of their critical first year of life. According to a recent report in the Washington Post, although a federal survey in 1995 found that 58% of American mothers start off breast-feeding their babies -- the same percentage as a decade earlier - 20% fewer mothers today are still breast-feeding after three months. While it is certainly true that many individual formula-fed infants will do "just fine" (as will most unvaccinated individuals in the United States), the research clearly indicates that, as a population, America's formula-fed babies are not "fine" at allParents may reasonably ask why, with research demonstrating the many and serious potential health hazards of routine bottle-feeding, do so many otherwise competent doctors continue to take a neutral or even pro-formula stance with their patients? As pediatrician and author Dr. Jay Gordon noted in the book "So That's What They're For: Breastfeeding Basics," by Janet Tamaro-Natt: "This [infant feeding] seems to be the one area where you can practice medicine in the 1990s -with 1960s know-how - and not get sued."
The failure of many medical professionals to fully inform their patients of the impact of infant feeding choices is due in large part to their own ignorance of the facts. Most obstetricians, pediatricians and nurses graduate from their professional training having had little or no exposure to the most up-to-date literature or clinical practice in this area. In fact, a recent AAP survey revealed that 45 percent of pediatrician respondents stated that they see formula-feeding and breast-feeding as equally acceptable methods for feeding an infant. The survey further noted that "nearly equal proportions of pediatricians agree and disagree as to whether formula-fed babies are just as healthy in the long run as breast-fed babies (34 percent vs. 38 percent); 27 percent are undecided." These statistics reveal a shocking unfamiliarity with the large and growing body of current research on this topic. In many cases, health care providers' views on infant feeding are based on their own, highly personal experiences. A nurse who chose to formula-feed her own children or a doctor whose wife weaned her baby at three weeks is unlikely to be an effective advocate for breast-feeding. A large-scale study of physicians' knowledge of human lactation in a 1995 issue of the Journal of the American Medical Association reported that the most important factor influencing the effectiveness and accuracy of a doctor's breast-feeding advice to patients was whether the doctor herself, or the doctor's wife, had breast-fed her children. In a March 1999 report on breast-feeding promotion efforts by American doctors, Pediatrics magazine concluded, "A majority of pediatricians believe that breast-feeding and formula-feeding are equally acceptable methods for feeding infants. Furthermore, reasons given for not recommending breast-feeding include medical conditions such as mastitis, nipple problems, low milk supply, jaundice, and low weight gain, which have recognized therapeutic approaches that generally do not preclude breast-feeding.""Doctors need to do better in giving their patients good information and support regarding infant feeding," says Dr. Gartner, who has traveled the country offering lactation training to physicians and hospitals. "But it takes a great deal more education to do this. It's easy to explain to parents why they should put their baby in a car seat, but human lactation is much more complex. Many, if not most doctors are carrying around a lot of wrong information about breast-feeding versus bottle-feeding. In order to be effective, they have to unlearn those misconceptions."Infant formula companies have traditionally targeted health-care professionals as the quickest route to convincing mothers that formula-feeding represents a safe, nourishing option for their babies. Physicians and nurses in the U.S. routinely receive gifts, office supplies, meals, a year's supply of free infant formula for themselves or a relative and even pricey vacations from the infant-formula marketing representatives who haunt their offices. According to Dr. Dettwyler, some pediatric residency programs are largely underwritten by infant-formula manufacturers, an allegation verified by the National Association of Breastfeeding Advocacy and the International Lactation Consultants Association. Not surprisingly, more than 70 percent of surveyed pediatricians recently reported to the AAP that they recommend a particular brand of infant formula to their patients. (In contrast, Pediatrics reported that only 65 percent of pediatricians surveyed recommend exclusive breastfeeding for the first month after birth; only 37 percent recommend breastfeeding for the first year, as recommended last year by the AAP.) The 1996 annual report from Abbott Laboratories, makers of Similac infant formula, took note of this cozy tie between the medical community and infant-formula manufacturers, stating that, "Abbott's close relationship with pediatricians and other health-care providers serves as the foundation for the company's solid market position in the United States. Pediatricians are also key to the success of the consumer education programs, such as the Welcome Addition Club ...a program that provides new and expectant parents with a broad range of information, from nutrition and breast-feeding tips to basic parenting skills."In 1994, after years of stalling by Republican administrations that opposed it, the United States joined every other developed nation in the world as a signatory to the "WHO Code," an international agreement that, among other things, calls for an end to formula promotion and giveaways through the health-care system and includes a clause stating that "no financial or material inducements should be offered by [infant formula] manufacturers or distributors to health workers, or members of their families, nor should these be accepted." Despite the WHO Code, virtually all hospitals in the United States offering maternity services - as well as the majority of individual obstetricians and pediatricians - continue to provide massive free advertising from the huge pharmaceutical companies that produce and market formula in the United States. Such promotional material comes in the form of formula giveaways, patient "educational literature" produced by the formula companies and even free baby equipment such as diaper bags. Obviously, marketing and product giveaways on this scale cost infant-formula companies millions and millions of dollars each year. But it pays off. Their own market research, as well as medical literature and anecdotal observations by lactation professionals, have demonstrated that these tactics make it statistically less likely that a women will breast-feed without supplementation or breast-feed at all. And once a woman stops nursing and begins feeding infant formula, these companies know that they likely have her "hooked" on their product, since even a brief interruption in the nursing relationship can cause a woman's own milk supply to dwindle or the baby to begin refusing breast in favor of bottle. American hospitals have largely shrugged off the idea that accepting free formula and large cash "donations" in return for a particular formula company's right to market directly to its patients represents an ethical problem. Around the world, thousands of hospitals have become certified by the World Health Organization as "Baby-Friendly" by agreeing to aggressively and accurately promote breast-feeding and to end the practice of allowing infant-formula companies to offer freebies to personnel or patients. In the United States, however, fewer than 20 hospitals and birthing centers have received the Baby-Friendly designation. "Hospitals should not be accepting free infant formula from these companies. They know that if they didn't accept it, they would have a reduced sense of obligation to promote formula. Their continued acceptance of this practice says something important," notes Dr. Cunningham.Because the WHO Code hasn't been incorporated into federal law in the United States as it has in some other countries, it is impossible to enforce. And although American infant formula companies claim to voluntarily adhere to the code's provisions, including no direct marketing of infant formula to consumers, they openly flout the code and their own assurances of compliance. This can be made clear by flipping through any popular parenting magazine or watching any television program geared toward women in which appealing ads for infant formula are abundant. Nestle, the notorious maker of Carnation brand formulas, is perhaps most disingenuous when it comes to adherence to the WHO Code. On its Carnation Baby Web site, parents who live in other countries are asked to read a statement in which Nestle makes a feeble attempt to comply with the code by warning against bottle-feeding. American parents entering the site receive no such statement from Nestle. copyright, 1997, 1998, Katie Allison Granju.
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