Emily Oster on Breastfeeding - minimal benefits.

[IamOvercome]

I am pregnant with my first and am an economist so I was recommended books by fellow economist Emily Oster. The books don’t give advice. They review the statistical studies underlying pregnancy advice and whether they are any good or not.

It’s been such an eye opener. For example it is pushed pushed and pushed some more that breast is best. But when you review the evidence there is minimal evidence for benefits of breastfeeding for babies. The strongest evidence is actually for mothers that it can marginally reduce chance of breast cancer in later life.

Same with not introducing babies to bottle to confuse them when breastfeeding. Literally no concrete evidence for it.

Yet this is all pushed as clear cut facts by midwives and other health professionals.

Yes, I mean like any guidance it's a bit moot - we know babies should sleep in a freezing cold room without a blanket in the middle of a hard empty cot but it's a rare baby that will actually sleep like that, so most people break at least one guideline, even if it's only giving the baby a teddy or dressing them a bit more warmly than advised, and many people break more guidelines than that - using sleep nests, co-sleeping, putting babies on their front, in their own room etc.

Just like you'd need future-vision to be able to boil exactly a litre of water, wait 30 minutes for it to cool, make a bottle, wait for that to cool, feed the baby, and have it ready perfectly on time to feed them responsively (on demand). Somehow carry a mini kettle around to do this out and about as well, or just never leave the house. Of course it isn't practical. It was easy for us to make the bottle an hour in advance because he had one bottle a day as part of his bedtime routine, so we always knew when he would need that one and I just breastfed him the rest of the time. That wouldn't apply if we were 100% formula feeding.

In order to live life without these super-human powers, you either have to feed on a routine, make bottle(s) in advance, leave the baby crying while you make the bottle or use one of the gadgets with the result of questionable temperature water. Or fiddle around with half hot, half cold water which has a higher risk of errors in volume calculation.

But is it useful to have the information about what is best practice in terms of sleep and bottle hygiene? I think it is... because while almost everyone has to make a compromise somewhere, the specific compromise people will choose will be different. While one person might make all bottles up for the day for 24 hours, another might choose to make them immediately but with cold/warm water. If you as a government health body or advice centre or whatever decided what the acceptable compromise ought to be, you end up with a situation where people don't really understand that it's a compromise and think that it doesn't make a difference, choose one of the other compromises because it works better for their life and therefore end up doubling up on two risks when they probably would have only taken one. In reality all of this guidance is overkill, you don't need to follow every single piece of it, but it makes sense to follow as much of it as you reasonably can.

I always thought if I was going to FF full time, I'd make one bottle at a time immediately after feeding so there was always one ready to go. For nights I'd make three or however many I expected to need plus one, just in case. I'm sure that would fairly quickly stretch to making 2-3 at a time in general.

@BertieBotts it is true that people choose their compromises, yes. I’m terrified of SIDS so followed that guidance exactly to the letter from day 1. I don’t know if DD would have slept better otherwise but I wasn’t prepared to budge no matter what. Expecting number 2 now and I feel exactly the same on that.
I don’t know what I would do re formula prep because I was lucky enough that BF worked easily for us. I’m very conscious that might not be the case the second time around though.

@BertieBotts

Yes, I mean like any guidance it's a bit moot - we know babies should sleep in a freezing cold room without a blanket in the middle of a hard empty cot but it's a rare baby that will actually sleep like that, so most people break at least one guideline, even if it's only giving the baby a teddy or dressing them a bit more warmly than advised, and many people break more guidelines than that - using sleep nests, co-sleeping, putting babies on their front, in their own room etc.

Just like you'd need future-vision to be able to boil exactly a litre of water, wait 30 minutes for it to cool, make a bottle, wait for that to cool, feed the baby, and have it ready perfectly on time to feed them responsively (on demand). Somehow carry a mini kettle around to do this out and about as well, or just never leave the house. Of course it isn't practical. It was easy for us to make the bottle an hour in advance because he had one bottle a day as part of his bedtime routine, so we always knew when he would need that one and I just breastfed him the rest of the time. That wouldn't apply if we were 100% formula feeding.

In order to live life without these super-human powers, you either have to feed on a routine, make bottle(s) in advance, leave the baby crying while you make the bottle or use one of the gadgets with the result of questionable temperature water. Or fiddle around with half hot, half cold water which has a higher risk of errors in volume calculation.

But is it useful to have the information about what is best practice in terms of sleep and bottle hygiene? I think it is... because while almost everyone has to make a compromise somewhere, the specific compromise people will choose will be different. While one person might make all bottles up for the day for 24 hours, another might choose to make them immediately but with cold/warm water. If you as a government health body or advice centre or whatever decided what the acceptable compromise ought to be, you end up with a situation where people don't really understand that it's a compromise and think that it doesn't make a difference, choose one of the other compromises because it works better for their life and therefore end up doubling up on two risks when they probably would have only taken one. In reality all of this guidance is overkill, you don't need to follow every single piece of it, but it makes sense to follow as much of it as you reasonably can.

I always thought if I was going to FF full time, I'd make one bottle at a time immediately after feeding so there was always one ready to go. For nights I'd make three or however many I expected to need plus one, just in case. I'm sure that would fairly quickly stretch to making 2-3 at a time in general.

And I guess this ^^ is where the perception comes in that FF is a lot more faff.

I mean, it is - comparatively speaking. The alternative is simply lifting up a top.

But again, this extra ‘faff’ obviously isn’t perceived as such by the vast majority of women who choose to FF.

The issue with BF, for many, is that it can be a genuine struggle to get it established. So much of a struggle, that people find it easier just to opt out.

But once it is established, it comes into its own.

If you do something hard and feel like you've achieved something, then someone else comes along and says "why did you do that? It makes absolutely no difference anyway", you might feel a little defensive and want to justify your decisions. Why it mattered to you.

I can't say I'm one of those people that had to really fight to breastfeed. It was a bit hard at the beginning, but super easy after and I've been breastfeeding now for almost 5 years (onto baby 2 without a break). I'm not surprised at all that there isn't good quality research into breastfeeding (ethical issues notwithstanding) - there are no multinational companies that would benefit from the results! It would make no one any money! But I also don't need to read any studies to know that human milk is best for human babies. That it's impossible to recreate a live substance in the same way that it's impossible to make a blood substitute. It just biologically cannot do the same thing.

As it is, formula feeding is by far the most chosen feeding option in the UK, so obviously formula is doing it's job. Though I think the hangover from formula companies being able to advertise and say what they wanted about their products has had really lasting damaging effects which are proving difficult to undo.

I struggled a lot with my mental health and don’t think I would have coped with breast feeding at all. It is draining both mentally and physically. The fact that DH was able to do feeds was a big support for me. My daughter just turned one and she’s thriving. Nothing against breast feeding but it just wasn’t for me. There’s no right or wrong, I support women and their choice.

Anything is a faff if you're not used to it and becomes routine once you are. In reality making a bottle of formula is really not that different to making a cup of tea and most of us don't find that a faff. But everyone has those moments where you want another sip and realise it's finished, or get cross because someone has used the last of the milk without telling you, or the dishwasher hadn't been turned on so you haven't got a clean cup. Or you find a half drunk cup from a few days ago lurking somewhere from where you got distracted. There clearly is input into making formula that wouldn't exist if you were breastfeeding.

The issue really is that breastfeeding is biologically neutral and formula feeding presents some risks both in content and delivery mode
So breast IS best (by a significant and often underestimated margin) because formula is not human milk and is not as good

@fenulla

What are the risks of formula? And of delivery mode? I’ve not heard of the latter?

Though I think the hangover from formula companies being able to advertise and say what they wanted about their products has had really lasting damaging effects which are proving difficult to undo.

I think there's more to it than that personally. Breastfeeding rates immediately after birth are higher than they were decades ago (when advertising was permitted), but substantially lower after 6 months- so probably what happens between birth and 6 months is more relevant as it seems the intent is perhaps there. I think it's definitely the default for some due to how their mother's fed, pressure from relatives of which some will have believed the advertising in years gone by, but I suspect societal pressures to balance a baby with other things, lack of postnatal support, the extreme over sexualisation of breasts (I mean it's gone from being in some top shelf magazines to everywhere in the past few decades) might make some more hesitant to feed in public etc. Just my thoughts and probably completely wrong, I guess what I mean is that formula advertising is often blamed, but rates will never increase unless its stopped being used as a scapegoat of sorts and the actual reasons are taken on board and addressed. Again, it shouldn't be about finding ways to force women to or shaming them for not, but the rates here are unusually low and time and time again we hear how people didn't feel supported enough or other factors affected the way they fed.

Breastfeeding is the natural default
It doesn't have to have evidence to prove it is better. It's how babies were designed to be fed in nature
It should be for formula companies to prove that their alternatives are safe and equally beneficial
I find it bizarre that you would feel you need a study to prove a normal biological function.
I am glad that formula exists as an alternative for those who need it and that it's a good alternative but breastfeeding is the normal natural default option. It should not be some kind of difficult choice to weigh one against the other and require lots of evidence.
Breastfeeding shouldn't need to be promoted or pushed or advertised just normalised.

As an example:

Increased risk of respiratory illnesses and allergies (respiratory and eczema)
(Both from the actual formula)
Increased risk of bacterial contamination can come from the formula itself and from the way the feed is prepared and later stored

As a bit of an aside, I follow Emily Oster online and she said something really interesting in one of her Q&A's. That boiling the water before making the bottle of formula , doesn't make a huge amount of difference in terms of bacteria, but actually thousands of children are burned across the world from parents preparing boiling water for bottles, therefore it would actually be safer for all children not to boil the water?

I breastfed my kids and never made formula, so didn't really know whether this made any sense or not. All I know is that my relatives in the US with a baby, prepare their bottles with distilled cold water that they buy by the gallon, no boiling necessary.

That seems to differ from what they do in the Uk?

[quote Qwill]@fenulla

What are the risks of formula? And of delivery mode? I’ve not heard of the latter?[/quote]
I think that poster was just (rightly) challenging commonly used language about these issues. The benefits of breastfeeding are usually spoken about, when in actual fact, as breastfeeding is the biological norm and thus the benchmark, it shouldn't be the benefits of breastfeeding that we talk about, but the risks of not doing so. Therefore, rather than saying for example, that BF babies have fewer ear infections than FF infants, the language should be flipped around to say that FF babies have more infections.

Blue there is literally an outbreak of contaminated formula in the US that has just happened and babies died.

It probably is outweighed by the risk of scalding in terms of statistical likelihood, but it's not completely pointless.

But BFing does have big risks - it made my baby seriously ill and she ended up in SCBU for four days with hypernatraemic dehydration! She only narrowly avoided brain damage. EBF doubles the risk of your baby needing to be readmitted to hospital (funny how that doesn't appear on the list of 'benefits'?!) or having to be seen as an outpatient. pubmed.ncbi.nlm.nih.gov/29191700/

Families aren't being given the info to make an informed choice about feeding their baby. I would never have chosen to EBF with my personal risk factors for low supply if I'd known those risks and that combi-feeding even existed. The tiny bit of info I was given in advance about formula was all negative. I had no idea you could combine the two. It is insane that I could attend a weekly obstetric diabetes clinic and have EBF constantly pushed there without anyone mentioning diabetes is a big risk factor for low supply.

Familiea also aren't getting full info about avoiding SIDS. I was terrified of SIDS, especially when I couldn't EBF because it had been really emphasised antenatally. Yet much bigger risk reductions are from not smoking, not bed sharing, baby sleeping on back and using a dummy. Yet EBFing gets pushed as a big one, and people even get encouraged to co-sleep so they can BF .

Also imbalance of stats presented - SIDS is about 1 in 200 babies but more likely in eg prem babies. Risk of milk delay/low supply is about 1 in 5 especially for first time mums, yet this never even gets a mention.
Same for breast cancer reduction if you BF - the risk drops from 12.5% to 12% if you're under 35 and BF for at least 6 months. There were women leaving the BFing antenatal class I did thinking they wouldn't get breast cancer if they BF. I just hope they don't turn down mammograms on that basis...

@blue12345

As a bit of an aside, I follow Emily Oster online and she said something really interesting in one of her Q&A's. That boiling the water before making the bottle of formula , doesn't make a huge amount of difference in terms of bacteria, but actually thousands of children are burned across the world from parents preparing boiling water for bottles, therefore it would actually be safer for all children not to boil the water?

I breastfed my kids and never made formula, so didn't really know whether this made any sense or not. All I know is that my relatives in the US with a baby, prepare their bottles with distilled cold water that they buy by the gallon, no boiling necessary.

That seems to differ from what they do in the Uk?

Perfect prep machines are big sellers - a lifesaver for new parents. I buy them as presents for friends having their first baby(obviously not if they are planning on bf).

I find the connected risks fascinating when you look at them population-wise. It's also why it's important people get good access to things like formula prep info as online groups may not make it obvious advice is country-specific. Safer to use a kettle for boiling water than boiling in a pan, but not all countries routinely have kettles in homes.

Other risks - friend who was severely sleep-deprived after six months of EBF ended up crashing her car on the motorway. Fortunately her baby wasn't in the car with her at the time...

@blue12345

As a bit of an aside, I follow Emily Oster online and she said something really interesting in one of her Q&A's. That boiling the water before making the bottle of formula , doesn't make a huge amount of difference in terms of bacteria, but actually thousands of children are burned across the world from parents preparing boiling water for bottles, therefore it would actually be safer for all children not to boil the water?

I breastfed my kids and never made formula, so didn't really know whether this made any sense or not. All I know is that my relatives in the US with a baby, prepare their bottles with distilled cold water that they buy by the gallon, no boiling necessary.

That seems to differ from what they do in the Uk?

This is where better info for formula would be worthwhile postnatally- when I considered it i was told to Google it and its easy to work out and that they don't advise on artificial feeding. Continued on with breastfeeding in the end but I wasn't that impressed. Water of a min temp only needs to cover the powder and then topped up with cooled water- the whole thing doesn't have to be boiling (in fact freshly boiled water shouldn't be used as it destroys some of the nutritional profile as well as being dangerous). Personally I think well maintained perfect prep machines that are used correctly ie powder first, hot shot and topped up are fab as there's less room for error.

Also extended breastfeeding. This is of very little benefit other than comfort.

I would consider comfort to be a huge benefit

Completely anecdotally, I breastfed my DD for 4.5yrs. She is now in year 7 and has had no days off sick in nearly 8 years of schooling. Most likely nothing to do with bfing, but I like to think it helped!

@RidingMyBike they don't want you combi-feeding because they think you will just FF feed. The midwives take no account of your ethnicity even though there is research that shows that in ethnicities where it is normalised e.g. Bangladeshi there are higher bf rates regardless of economic factors.

They are also not allowed to promote formula due to the past completely unethical behaviour of manufacturers. So it normally not talked about when feeding is discussed.

My friends who have been told to combi-feed have done so on the advice of paediatricians if their babies have various difficulties. However if the mother has problems, like with birth injuries or requires certain medication, no-one gives a shit.

I agree more info on combi feeding would be great, I suspect the balance would work really well for lots of people.

But this is so variable between families @DataColour and seems to bear little relation to how the child was fed.

My EBF niece who was BF to at least two years (probably longer?) picks up loads of colds and tummy bugs, has eczema and has quite a bit of time off school etc. My DD of same age who had 50% formula for first year has had precisely 3.5 days off nursery/school in six years. She's had one tummy bug in her life, has no allergies etc.

I wish there could be info antenatally about combi-feeding and also take into account people's circumstances. For some, maybe returning to work early, having a baby who takes a bottle is a priority, so recommending they wait 6+ weeks isn't a great idea. I've seen so many women get trapped into EBFing when it wasn't what they intended.

Of course, it would mean HCP's having to provide info about formula and actually being prepared to talk about it!

@RidingMyBike, I'm sure you know that mothers of FF babies can get severely sleep deprived too? It very much depends on the sleep habits of the babies.

@DataColour

Also extended breastfeeding. This is of very little benefit other than comfort.

I would consider comfort to be a huge benefit

Completely anecdotally, I breastfed my DD for 4.5yrs. She is now in year 7 and has had no days off sick in nearly 8 years of schooling. Most likely nothing to do with bfing, but I like to think it helped!

I'm sure it did help! Those antibodies etc are still going as strong at 4 years as they are at 4 weeks or months. Kids' immune systems are still developing at that age