Lactation wars
Christopher Martyn, associate editor, BMJ
[email protected]
An internet storm sparked by a recent BMJ paper shows that there?s no substitute for prepublication peer review
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?A common mistake people make when trying to design something completely foolproof is to underestimate the ingenuity of complete fools? was a witty bit of advice from Douglas Adams, author of The Hitchhiker?s Guide to the Galaxy. Adapted for authors of medical papers it might read: ?A common mistake when trying to reach a provisional and nuanced conclusion is to underestimate the ability of readers to find an unintended meaning.?
Mary Fewtrell and her colleagues probably thought that they had been careful in the way that they phrased their analysis article published in the BMJ a fortnight ago (BMJ 2011;342:c5955, doi:10.1136/bmj.c5955). They had reviewed recent evidence on infant nutrition and asked whether it might be better to abandon the current recommendation to breast feed exclusively for six months in favour of introducing solids earlier. They reckoned that, among other things, there might be benefits in reducing the risk of iron deficiency and food allergies. In the hope of forestalling any misunderstanding they had put in a sentence saying that the evidence for breast feeding itself was extensive and that it wasn?t their intention to question it.
The article attracted media attention. The Sun ran the misleading headline ?Breast is not Best? (www.thesun.co.uk/sol/homepage/woman/health/health/3351004/Breast-milk-can-put-babies-off-food-cause-allergy-says-study.html) but redeemed itself with what followed, which was a brief but faithful précis of the original article. Indeed, apart from the headlines, all the newspaper stories I saw, whether in upmarket dailies or popular tabloids, gave a fair account of Fewtrell?s argument.
But that didn?t prevent the inhabitants of planet Blog seizing the wrong end of the stick and then complaining that their hands were dirty. Breastfeeding websites vary from the twee (boobiemunchkins.blogspot.com) to the overexplicit (theleakyboob.com). Many are vehicles for groups of people with a fundamentalist conviction about the virtue of breast feeding, and these worked up a sense of outrage over the study. Lactivist.net called on its readers to email the editor of the BMJ demanding another press release (www.lactivist.net/?p=2449). A blog called Dispelling Breastfeeding Myths worried that ?fragile nursing relationships have been undermined by these reports? (mythnomore.blogspot.com/2011/01/bemad.html). The Analytical Armadillo guessed that ?many people with a young infant coming up to solids age will now be absolutely bewildered about when they should be thinking about solids!? (www.analyticalarmadillo.co.uk/2011/01/starting-solids-facts-behind-todays.html). It also quoted the author of a book, Baby-Led Weaning, whose view was that ?this is pure speculation and scare-mongering.? A woman from the Yummy Mummy Club, Canada, heard about the article from her mother, tweeted about it, and reported that most people were ?up in arms? (www.yummymummyclub.ca/breast_feeding_study).
It almost seemed that some of the people contributing to these websites were looking for a fight. Gurgle.com posted a calm and balanced piece, explaining the BMJ article well, only to receive complaints that it had been irresponsible (www.gurgle.com/articles/News/37671/Could_weaning_earlier_help_breastfed_babies_.aspx and ?Related chat? pages). More justifiably, others showed their exasperation with a profession overeager to give definite advice on a basis of observational evidence. ?Why do people not trust their own judgement a bit more rather than listen to health professionals who can?t make up their own mind from one year to the next??
Many people confided their own experiences??I fed my babies potatoes and gravy and they turned out fine??as if these somehow implied that further efforts to improve infant nutrition were a waste of time. Comments that actually focused on the issues raised in the article were rare.
There have been suggestions recently that Twitter and other social networking sites might do a better job of quality control on scientific publication than the current system of prepublication peer review. An article in Nature described how two recent papers in Science had rapidly had their flawed methods exposed this way (www.nature.com/news/2011/110119/pdf/469286a.pdf), and the former BMJ editor Richard Smith took up the theme in a recent BMJ blog (blogs.bmj.com/bmj/2011/01/26/richard-smith-twitter-to-replace-peer-review/). I can see that this may be right for, say, particle physics or molecular biology, where well informed researchers are mostly talking to each other. But, having read this stuff, I?m not convinced that it is going to work for clinical research, where the constituency is much larger and people who haven?t read the paper feel no inhibition about expressing a view.
The websites and blogs that I?ve been writing about may do all sorts of good things to support women and encourage breast feeding, but there?s no getting away from the fact that they don?t contribute much to scientific debate on infant nutrition. Reading them felt like being caught up in a demonstration march. It?s not that the protesters are bad or wicked or unable to discuss other points of view, but if you?re among them there?s just no way of going in the opposite direction.
Mind you, some of the rapid responses on bmj.com weren?t much better. I won?t give examples because they?re only a click away, and you can form your own view. The charitable explanation is that these correspondents didn?t really mean what they said, which is always a danger when the heat of the moment coincides with the availability of instant communication. I?d like to see ?rapid responses? axed and replaced with ?considered responses.? This new section wouldn?t allow comments for at least a week after the article was published, and there would be a cooling-off period between submission and publication. Anyone sending something in would have to confirm, 48 hours after they first sent it, that they really did want it posted.
Notes
Cite this as: BMJ 2011;342:d835