Unintended Consequences of Invoking the “Natural” in Breastfeeding Promotion

The above commentary neglects to mention the medical community's heinous cooperation in the promotion of formula over nursing following WWII. The only reason breastfeeding even needs to be "promoted" today is because of the unholy alliance of the medical field with formula companies back in the 50s to convince families across the USA that nursing is passe and that formula feeding is "more scientific" and healthier for babies. An entire generation and more of mothers lost the community wisdom regarding nursing, and we have not come close to recovering from this damage today. And formula companies like Nestle continue to forward this false marketing campaign in third world countries even today. This kind of behavior leads to a distrust of medical interventions and of science in general.

By contrast, vaccines have been strongly promoted by the same medical community that told us that nursing was not necessary, as well as many other errant campaigns, including that Benzedrine and Valium were not addictive, that regular mamograms were helpful, and that HRT was necessary for menopausal women. Much medical "science" today continues to be corrupted by financial interests, to the point that less than half of "positive" scientific studies are replicable. The use of ethyl mercury in vaccines also created concerns which were denied and minimized by the medical community instead of being honestly addressed.

All of these factors together have created a distrust in the medical community, and in some cases, in science altogether, since many of these promotion campaigns (including the suppression of nursing) were framed in terms of "science" offering "better solutions."

I am not opposed to vaccines. Definitely prefer them to polio, tetanus, and COVID. However, it is more accurate for the medical community to take responsibility for CAUSING the distrust in medicine by promoting dangerous solutions in the name of economic gain. When people have been lied to and "science" has been used to promote those lies, belief in actual science naturally declines, leading to an over-commitment to "natural" solutions. Blaming the promotion of nursing for resistance to vaccines is an absurd misassignment of responsibility. People have less trust in the medical community than they used to because the medical community has engaged in less trustworthy behavior, starting with the intentional suppression of the very human, very "natural" process of feeding our babies through nursing. The medical community should admit these errors and start trying to earn back the trust they've lost, starting by disconnecting medical research from profit-driven enterprises that lead to perverse incentives and conflicts of interest.

The vile misogyny of this article is disgusting. Why did you publish this attack on women

In developing countries exclusive breast feeding and clean water have been found to have the greatest impact on health in the under fives, see the WHO and UNICEF. Specifically UNICEF say that breastfeeding has THE most significant impact on child survival in the under 2s. In developed countries exclusive breastfeeding has been found to reduce all hospitalisation from respiratory disease, including whooping cough, and diarrhoea.

Are you aware that immune factors in milk provide protection against infections such as H influenzae, S pneumoniae, V cholerae, E coli, and rotavirus... isn't the public health aim to reduce infectious disease?

Therefore the suggestion that vaccine promotion comes with a price of potentially reducing breastfeeding is quite shocking. 'We should think twice before referencing the “natural” in breastfeeding promotion, even if it motivates women to breastfeed.' The alternative to breast feeding is formula. Can you show how formula fed fully vaccinated children are healthier than fully breast fed babies, even if they are unvaccinated please?

Are you seriously suggesting that vaccines are more important than breastfeeding in the under twos. evidence please? And in any event wouldn't it be better to find more robust evidence for vaccination instead of suggesting that the term 'natural' be censored in breastfeeding promotion?

As a Pediatrician who is a strong proponent of both breastfeeding and vaccines I find your commentary fascinating food for thought.
I do find our confidence in "man made" solutions to our problems interesting as they often turn out to be problematic in the end due to our inability to see the whole picture- eg antibiotics and the the microbiome. I also think breastfeeding and vaccines can both be seen as our attempts to manipulate the natural to our ends as opposed to imposing our own solutions but that could be argued many ways.
I do take keen interest in your idea that breastfeeding may be used to enforce stereotypical parental roles. I am not for that. We have been actually attempting to include father/family more as we promote breastfeeding- doing skin to skin with both mom and dad, going to couplet care and relying on dad/support person to care for baby too, educating both parents during their post partum stay. If we encourage dad to take a more active parenting role from the start could we not use breastfeeding promotion to break down stereotypes instead?
Thanks for a thought provoking piece.

The Academy of Breastfeeding Medicine’s (ABM’s) Comment on “Unintended Consequences of Invoking the ‘Natural’ in Breastfeeding Promotion” authored by Jessica Martucci, PhD, Anne Barnhill, PhD
Published March 4th, 2016 in Pediatrics

Food for thought: Unintended, potential, or intended consequences of invoking the “natural” in breastfeeding promotion?

On behalf of the Academy of Breastfeeding Medicine (ABM), a global organization of physicians with expertise in breastfeeding medicine, I am writing to comment on Martucci and Barnhill's recent article.

Yes, the language used to describe breastfeeding is critical for public health, especially because breastfeeding profoundly impacts the immediate and long-term health of mothers and children. It is troubling, therefore, that the authors begin their essay by asserting that "a spate of recent work" challenges the extent of breastfeeding's impact; in fact, the evidence for breastfeeding's importance has never been stronger. Even the reference the authors cite to support their assertion concludes, "It is unquestionable that breastfeeding is important for both baby and mother." The importance of breastfeeding was affirmed resoundingly in a recent systematic review, which found that scaling up breastfeeding would prevent 823,000 child deaths each year.1

Perhaps the problem with using the term “natural” to define breastfeeding is that it implies an alternative. In fact, breastfeeding is the physiologic standard and a normal human function that has no equivalent alternatives, so there are no “advantages” per se. After all, we don't talk about breathing or eating as “natural” comparisons to ventilator support or parenteral nutrition. Breast milk contains antibodies, innate immune factors, bacteria and living cells that protect infants from infection and orchestrate development of the immune system.2 Despite the extensive marketing campaigns of the formula industry, additives to formula do not replicate the myriad physiologic functions provided by breastfeeding.

That's exactly why the AAP 2012 Policy Statement on breastfeeding does not use the word “natural.” 3 Instead, breastfeeding is described as the "normative standard for infant feeding”; the statement emphasizes that breastfeeding is a health issue and not a lifestyle choice.

Martucci and Barnhill's argument rests on the assertion that referring to breastfeeding as "natural" will inevitably lead families to reject vaccines as "unnatural." Using “natural” and “unnatural” to compare breastfeeding and formula feeding is simply not the same context as the discussion around food, vaccines, medicine / herbal products and the implications of their benefits or harm.

The authors provide no evidence to link promoting breastfeeding with avoiding vaccines. And their argument is a slippery slope that presumes families will develop a zombie-like allegiance to the word "natural," lacking the capacity to differentiate evidence-based public health recommendations from pseudoscience. We feel the term “natural” is best conceptualized as a marketing issue, not one of science, ethics or anything to do with any controversy regarding vaccinations or one's feminist perspective.

According to Webster Dictionary, natural means “existing in nature and not made or caused by people.” The word is persuasive, but perhaps in a positive and not a negative way. Note the successful “It’s Only Natural” breastfeeding campaign which was grounded in extensive focus group research .4

More important than the unintended, potential, or intended consequences of using the word “natural” to promote breastfeeding, physicians and parents should understand that there is extensive evidence to show that both breastfeeding and vaccines are healthy choices for families.

Julie Taylor, MD, MSc
President, Academy of Breastfeeding Medicine

The AAP Section on Breastfeeding Leadership read with interest the Perspectives in Pediatrics article, “Unintended Consequences of Invoking the ‘Natural’ in Breastfeeding Promotion” by Martucci and Barnhill. While we agree that the words we choose to encourage healthy behaviors certainly matter, equating breastfeeding as “natural” with the supposed “natural” of the anti-vaccine movement is neither logical, nor appropriate. Furthermore, this direct link is not substantiated in the literature.

Breastfeeding is the normative standard for infant feeding, and the standard by which all other feeding methods should be compared. Infant formulas are inferior to this standard, as documented in multiple evidenced-based studies, including the recent Lancet series on breastfeeding, which concludes that the evidence supporting breastfeeding benefits for mothers and babies is now “stronger than ever.” Accordingly, we disagree that higher risks of formula feeding to mothers and babies are being oversold.

The Nuffield Council on Bioethics Analysis Paper states that public agencies, governments and organizations “should avoid using the terms natural, unnatural and nature” unless they make transparent the “values or beliefs that underlie them.” The US DHHS Office on Women’s Health 2013 campaign entitled “It’s only natural, mother’s love, mother’s milk” specifically targets African American families, the demographic least likely to breastfeed, yet facing the greatest burden of adverse health outcomes. Among mothers giving birth in 2012, 83.0% of white women (non-Hispanic) and 82.4% of Hispanic women initiated breastfeeding, while only 66.4% of non-Hispanic black women initiated breastfeeding, a concerning disparity. For the targeted population of the “It’s only natural” campaign, breastfeeding initiation is not “natural.” The language of the campaign was chosen to convey that breastfeeding is achievable when African American mothers receive culturally sensitive education, help and support, using a multi-pronged approach.

AAP policy states that infant feeding should be considered a public health issue and not a lifestyle choice.2 Breastfeeding is indeed at the core of public health promotion and primary prevention. Additional important preventive measures advocated by the AAP and other health organizations include routine immunizations, which protect against preventable childhood diseases, based on centuries of proven benefits. The ideal way to connect breastfeeding with vaccinations is to highlight breastfeeding as the “first immunization” recognizing the abundant immune protective factors present in breastmilk, and especially in colostrum.

Choosing our words carefully in health promotion is important, but even more important is the effect our words have on the desired health outcomes. Just as the authors are concerned about a theoretical effect of breastfeeding promotion on vaccine rates, we are concerned about the effect of their article, and other similar articles, on breastfeeding promotion and rates. Let us state clearly that breastfeeding is the normative standard for infant feeding, and other feeding methods put mothers and children at risk for both short and long-term adverse health outcomes. It is our responsibility, as pediatricians and children’s advocates, to inform parents of these facts, just as we explain the importance of immunizations.

Acknowledgements

Thank you to the Leadership Team of the American Academy of Pediatrics Section on Breastfeeding for their contributions and review of this comment.

References

1. Eidelman AI, Schanler RJ, American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129:e827–e841
2. Victora CG, Bahl R, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387:475-490
3. Nuffield Center on Bioethics. Ideas about naturalness in public and political debates about science, technology and medicine. November 2015. Available at http://nuffieldbioethics.org/wp-content/uploads/NCOB_naturalness-analysi.... Accessed March 8, 2016
4. U.S. Department of Health and Human Services, Office on Women’s Health. It’s only natural, mother’s milk, mother’s love. April 2013. Available at http://womenshealth.gov/itsonlynatural/. Accessed March 8, 2016
5. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2012 National Immunization Survey. July 2015. Available at http://www.cdc.gov/breastfeeding/data/nis_data/index.htm. Accessed March 8, 2016