Overselling infant formula: Lactivism

Maureen MinchinCommentary, HIV, Lactation, Reviews by MM

Definitely Overselling Infant Formula:                                                  Lactivism by Courtney Jung          

An overdue  review

Professor Courtney Jung’s Lactivism is sensationally subtitled: how feminists and fundamentalists, hippies and yuppies, and physicians and politicians made breastfeeding big business and bad policy. Does it deserve such widespread media attention? Is it a worthwhile contribution to scholarship in the field of infant feeding? In this review I will address some of its many deficiencies in interpretation and scholarship.

First, I note areas of agreement between the author and those she excoriates as fanatics. Subsequently some of what she gets badly wrong, and some of what she either doesn’t know, or strangely omits, is exposed. If taken seriously, I believe that what I see as her apparent ignorance of the science, and her inexcusable slanders of key players, will lead to more needless artificial feeding worldwide. I consider that her name-calling and misrepresentation of breastfeeding advocates as fanatics devoted to breastfeeding as an end, not a means, is a form of bullying that will silence some healthworkers, and most badly affect vulnerable and disadvantaged families.

And so I consider Jung irresponsible to claim that breastfeeding is not a public health issue and should not be treated as such. It may well result in the unnecessary early deaths of women and children as a consequence of needless artificial feeding, which world authorities and volunteers and healthworkers worldwide are struggling to prevent.

Introduction

Books can reveal a great deal about the author, and a reader can like the author while disliking the book (and vice versa). As well, even the most inadequate or badly written of books can contain interesting and useful material, or provoke the reader to consider issues differently, both by its contents and by its omissions. There are very few books on infant feeding that are not worth reading, even the very worst ones. This book may be the exception.

Given the persona presented in Lactivism’s Introduction, Courtney Jung is a woman I would like to have a long and robust conversation with. She initially came across to me as strong, caring, concerned about women, concerned about social inequity and racial discrimination. I came to see her as a mother who breastfed easily, and so has never really understood the process or the problems other women experienced. As I read further, I saw her as a woman who is now expiating some perhaps unconscious mother/survivor guilt[1] by writing what she intended as a helpful book; a book based on her personal experience and very little in-depth infant feeding research – by my standards, anyway. Because I credited her with good motives for writing on such a complex topic, and respected the effort of writing a book in what must be a busy life talking about other topics altogether, I was at first inclined to be as kind as I could in this review (my habitual stance in book reviewing, because I know how hard writing can be.) So I decided to highlight the positives first. Then I read the whole book. And I realised that positives could not predominate in any informed review. But that’s still where I’ll start.

Legitimate concerns

Chapters 5 and 6, Pumping on the Job and Liquid Gold, discuss (albeit inadequately) issues that many breastfeeding advocates find troubling: the way that electronic milk pumping has exploded and added to the work and cost for women, while relieving the US government and industry of responsibility to provide appropriate paid maternity leave and support; and the commodification of breastmilk as the only or most valuable aspect of breastfeeding. There is some truth in her statement that “the US government’s recent initiatives to promote breastfeeding have focussed almost exclusively[2] on breast pumping… they have radically redefined what breastfeeding is…. These much-vaunted initiatives depend on the unstated and largely unstudied premise that what is valuable about breastfeeding is the chemical composition of the milk, not the mother-child contact that goes along with feeding a baby at the breast.”

Yet strangely Jung does not seem to see the primary reason for that perception of what is important: infant formula marketing. For a century such marketing had reduced breastfeeding to the uncertain provision by fallible mothers of nutrients, which clever scientists making infant formula could reliably provide (except for a few antibodies or somesuch details dismissed as unimportant in affluent societies with access to “the perfect mix of science and love.”[3]) Although Jung rightly sees that major new industries are now growing out of exploitation of women and commodification of women’s milk – milkbanking and breastmilk sales, and the manufacture and sale of breast pumps – and that these industries are funding small amounts of infant feeding research, she does not explore the much more powerful and lucrative ways that research into infant feeding is funded and designed to benefit the now fifty billion dollar infant formula industry. That industry’s power has been such that many breastfeeding advocates have refused to emphasize the inevitably different mother-child contact involved in feeding a child from one’s own body, because they know that it is indeed possible for a determined and conscientious bottle-feeding mother to provide huge amounts of physical contact and affection while bottle-feeding.[4] Far from over-emphasizing the feeding part of the equation, breastfeeding advocates have probably often under-played its value to the mother and child, in order not to seem judgmental of other women. However, I suspect Jung would be among the first to object if the importance of the feeding process was stressed, even though of course it does make a difference to a woman’s biological state, to be lactating and holding a child skin to skin, and to a child, to be in such close physical proximity and receiving maternal hormones in milk.

Jung is right, however, to point out that in the real world of the United States the provision of electric breast pumps often “enables women to ‘breastfeed’ by working longer hours for less pay, under conditions which are humiliating and degrading” (for many, at least) while benefitting companies, shareholders, employers, and politicians. She offends many by suggesting that somehow a woman whose life forces her to pump her milk, or who chooses to, is somehow not breastfeeding her baby. (Such a mother – or transgender partner- may be transferring her milk by bottle, but she is still certainly feeding her baby from her own body, specifically her breasts.) Jung’s desire –shared with most ‘lactivists’ – to see better maternity protection provisions is admirable. It is however, not surprising in a mother who breastfed her own children well beyond the first year of life, and practised what she calls ‘half-baked attachment parenting’, which as described was pretty full on by contemporary societal standards, and could have caused some to call her a “breastfeeding fanatic”. Her sensible support for structural change is undercut, however, by her virtual dismissal of the Affordable Care Act, which does at least recognise that breastfeeding women are in the workforce and require special consideration, even if it fails to do enough to support them in practical terms. Jung sees the supply of breastpumps as being more about profits for a growing breastmilk industry, than about helping women feed their babies. She may be right on this point; lobbyists determine much American policy, and we need to consider all such issues. But some working women do benefit from the ACA, and reform of the US political system might be needed before employers are willing to do more than the Act provides; even that may not survive. So we lactivists would agree with Jung on some things.

What Jung gets wrong

But overall, I came to see this book as really poorly researched and written. As a graduate thesis supervisor, I’d demand rewrites. Some points:

  • Jung creates straw (wo)men in order to be able to knock them down: LLLI founders are fundamentalists, not altruistic catholic mothers of their generation and culture; breastfeeding advocates are “lactivists”[5], not a wide variety of motivated people helping others in a myriad of ways to realise their desire to breastfeed, in a society which provides endless disincentives and undermines their choice at every turn. Of course every advocacy group may have an extreme fringe of highly motivated but insensitive or unintelligent supporters, but to criticise all for the dumb actions of a minority is unfair and unethical. I’m sure there are as many crass formula fantasists as there are bumptious breastfeeders.
  • Jung seems monumentally and (completely unconsciously?) biassed about infant formula, assuming its safety and adequacy, even though she herself as an infant was allergic to the standard formula, and was swapped to a soy variety.[6] Towards the end of the book there is a section that denigrates breastmilk as tainted, toxic and risky, killing babies. There is no comparable summary in relation to past and present infant formulas, although over 300 pages of my book, Milk matters: infant feeding and immune disorder is devoted to those realities. Jung seems to have no idea of the multiple pathways for contamination and defect in industrial products, and the numbers of children who die, even in Canada and Australia, because they are formula fed. (It’s possible that like many parents she is unaware that formula powder is unsterile, and that caution about soy formula is warranted because of its high levels of oestrogen analogues.)
  • Jung also seems to have little idea of the distress, psychological damage and relationship problems that formula feeding can create in babies and their families, focussing only on the distress that unsuccessful breastfeeding can cause. Yet infant formula advertisements, and the multiplication of special formulas, make it clear that many infants do not tolerate formula well. Those of us who deal with allergic families – as I have done since 1980 – know the consequences and costs of starting down the path of artificial feeding, harms that radiate into relationships and destroy parental confidence.
  • Jung evinces woeful ignorance of the many known – and emerging – biological bases for concerns about early life nutrition. The discussion of “breastfeeding benefits” (a typical error, framing breastfeeding as the deviant activity) centres on a few studies of already affected populations, rather than focuses on basic biology. For example, infant formula has been shown to produce
  • distorted gut microbiomes,
  • more chromosome breaks and DNA damage,
  • altered white matter development in the brain,
  • differences in reproductive tissue development seen by 4 months,
  • differences in metabolism and growth rates
  • smaller thymuses,
  • enlarged kidneys,
  • and other biological deviations from mostly-breastfed norms

Such facts are apparently not in Jung’s knowledge base. Some differences may be slight initially, but the concept of early-life developmental programming says that small differences may have become much more important by later childhood and adulthood; epigenetics says that some changes will persist into the next generation.

That free universal stem cell transplants are provided by a mother’s milk is apparently not known to her. These cells travel beyond the gut, and have been shown in animal studies to be incredibly powerful. Professor Peter Hartmann said recently that just one stem cell placed in situ created a lactating mammary gland in a mouse where that tissue was totally absent. Such facts make it clear that no one has to prove breastfeeding to be better than formula: formula advocates like Jung need to prove that it is safe in both the short and long term. Looking at a child’s exterior tells you nothing about its chromosomes or organs or immune function.

As a way to establish physiological reference norms, documenting populations of children affected by generations of infant feeding may be misleading, as work on child growth has shown. American norms of health and behaviour have been affected by generations of artificial feeding, and all but the latest versions of infant formula are now considered unsuitable (as current ones will be in another ten or twenty years). It is no coincidence that America led the world into morbid obesity. And yes, this and other harms of formula are supported by good research. A former Chief of the Nutrition Branch at the US Centre for Disease Control and Prevention (CDC), now Technical Officer at the World Health Organization (WHO) Geneva, has written an editorial which strongly supports the idea that breastfeeding is important for health.[7] I guess he knows a bit more than Courtney Jung…. Or is he a fanatic too?

Of research, researchers and media reports

As I see it, Jung cherry-picks and misrepresents research in order to reject – not refute – it. Jung, like many other formula fantasists, relies on outcome studies where the breast and bottle, breastmilk and formula, populations are totally confused, and have been over generations. Milk Matters discusses in detail just how problematic such studies are, and how readily some studies are spread by the media, as if there were some vested interests assisting their dissemination, and others largely ignored. (Surely Jung might have noticed, given her concern about breastfeeding-related vested interests? It seems to have escaped her that at least those interests do want women to lactate and breastfeed, while other massive forces conspire to undermine women’s breastfeeding choices by encouraging formula supplementation and early weaning for absurd reasons.)

Jung’s treatment of two researchers deserves special mention.

  • Having built him up as a giant, the world leader in breastfeeding research, (which I doubt he would claim to be), she misrepresents paediatric epidemiologist Professor Michael Kramer’s research and beliefs about the importance of breastfeeding. Says he about her work: “I think she chose to ignore some of the science. I don’t think it’s a balanced summary of the evidence, and I do think it sends the wrong message.”[8] Amen to that. And Kramer is furious about media misrepresentation of what he has said and the use of his credibility to suggest that breastfeeding is not important.[9] Jung says she sent him her manuscript, he says she didn’t take notice of his criticisms of it, she says she changed some things… I can’t imagine what! If you intend to quote someone, it is imperative to show them the exact final text and get them to approve what you say they are saying – before publication. You might have misheard or misunderstood, after all. It seems Jung did. Ignore her Chapter 3: it isn’t worth the paper it’s written on, in my considered opinion.
  • And Jung has absolutely no idea about the global importance of Emeritus Professor Peter Hartmann’s Human Lactation Research Group, world leaders in trying to understand how lactation works in order to be able to educate health professionals about appropriate treatment of breastfeeding problems, and to help women succeed at breastfeeding. Peter Hartmann is a man loved and revered for his work with volunteer groups of Australian women, creator of an academic research team using ground-breaking technologies invented long before they received any substantial funding from Medela. Hartmann[10] has refused grants of up to a million dollars from formula companies in the past. A recent substantial Medela grant to support this established centre of excellence is completely untied and independently administered by the University of Western Australia. How does Jung depict him? as a dairy physiologist “who now writes about human lactation which is what Medela pays him for.” Medela does not pay him. He has been a senior salaried academic of great distinction at the University of Western Australia for decades, now Emeritus Professor. His integrity is unquestioned by anyone who knows the man. Jung’s selective account seems to me to verge on defamation, and can only have arisen from ignorance: another proof of the poor quality of the research underlying Lactivism. She seemingly does not even realise that “a recent article about piglets” might be relevant to human lactation; but anyone who checks Prof Hartmann’s publications, say on Researchgate, will find that for decades they have centred on human lactation, even if using animal models, as is often necessary. (Perhaps Jung is also unaware that much of the basic research on infant formula has been done on rodents and piglets – as well as unwitting babies, often in a less litigious country than the USA.)

Her treatment of Dr. Richard Schanler and some other named people I consider similarly shabby. If any such misrepresentation or misquoting of either professional or community volunteer could be located in my work (we can all make mistakes!), I would be quick to apologise.

There are many more examples of inadequate research and lack of historical understanding. A few for starters:

  • While criticising Nestle – which had no formula sales in the US prior to 1987- Jung somehow fails to discuss the incredible negative postwar impact of the pioneering marketing strategies of more local American companies, which by 1981 controlled over half the world market for infant formula, then only US$2billion. These marketing machines systematically targeted hospitals and healthcare professionals and families, locking hospitals into exclusivity contracts which guaranteed that every mother went home with their infant formula. Choice is a joke if your breastfeeding is undermined by hospitals modelling artificial feeding and exposing all infants to cows milk formula, setting them up for gut disturbances post-discharge. (Jung also apparently has no conception of the intergenerational epigenetic damage done by such practices, which, as noted earlier, affects research outcomes.) Lactivism seems to me carefully to steer clear of offending powerful American infant formula interests that I see manipulating women and damaging children for profit: why, if it is so objectionable for breast pump manufacturers et al to become ‘big business’? Minnows beside the might of formula manufacturers!
  • Jung criticises the fact that the US WIC programme now gives breastfeeding mothers – who have higher caloric needs while breastfeeding – more food than it gives formula feeding mothers (who get free food plus free infant formula.) She fails to understand that in the past WIC was actively discriminating against breastfeeding women by not giving them anything like the retail value of the free infant formula lavishly provided to bottle feeding mothers, and that this new system attempts to remedy a past wrong by creating packages that incentivise breastfeeding, not punish those who don’t. (It has been reported that in the past some women presented as formula feeding in order to get the better deal.) WIC’s past role in underwriting the US infant formula market was a major reason why artificial feeding in entrenched among the disadvantaged, but Jung is not critical of those practices, only of attempts to change them.
  • What about IQ losses from formula feeding? Said Professor Michael Kramer, “There is an IQ advantage to breastfeeding by as much as three or four points. It’s not the difference between Einstein and a mental retard at an individual level, but it means having a smarter population on average, fewer children with school difficulties, and more gifted children.”[11] Yet Jung dismisses the cognitive losses created by artificial feeding as unimportant. She seems not to understand that across whole populations, small changes in mean IQ points have devastating effects, increasing the number of severely damaged children and reducing the number of extremely bright ones. Said Rutter about lead: The cognitive deficits which have been found are usually in the order of 3–5 points, and it has been argued that a 5-point difference is so trivial in its effects that it can be safely ignored. That is a totally fallacious argument. A drop of 5 points in mean IQ for any population must necessarily result in a more than two-fold increase in the percentage of individuals with an IQ below 70, that is, a doubling of the number of mentally retarded children.”

In fact, industry-linked researchers have shown that the losses created by artificial feeding can range up to 12 points in a particularly vulnerable group such as preterm infants.[12] How dare such a highly advantaged elite woman dismiss as unimportant IQ losses that might prevent a whole family escaping the poverty trap, as they did in the past, via the scholarship education of a very bright child? Or condemn them to struggling with a severely damaged child requiring help they cannot afford? (There is much more about this in Milk matters.)

  • Then there’s Jung’s absurd claim of a “stubborn refusal” (by whom, exactly?) to acknowledge medical causes of early supplementing or weaning – when community volunteers and health professionals ALL acknowledge these facts, have written the books about clincial issues; have helped mothers deal with them and resolve their grief at weaning – but also know that many problems can be resolved or worked around with skilled help if mothers are determined to breastfeed. If there are dimwits out there maintaining that breasts can never fail, I have yet to meet them. But lactation is a fundamental survival mechanism that is indeed more robust, reliable and resilient than many western women realise. Worldwide many women can testify to that! Most of the breastfeeding advocates I know are women who have conquered problems that other women have seen as reason to stop breastfeeding. Allison Dixley is right to consider it important that women accept responsibility for the decisions they make about problems they encounter, and the feelings they experience.[13]

 Lactivists and HIV

Central to Jung’s dismissal of the idea of breastfeeding as a public health issue is the idea that lactivists sacrifice mothers and babies to an unnecessary ideal of breastfeeding, others in the interest of profit, and in so doing harm women and children, even kill them via needless transmission of viral disease. Her HIV chapter is truly inflammatory. The issue is so badly dealt with that I simply can’t critique it in detail. A couple of huge blunders will do.

  • A Ugandan doctor says in 1998 that 85% of the formula fed babies in rural areas will die if fed formula, while in those areas only 27% of babies born to HIV-infected mothers [not then getting anti-retroviral medication, not exclusively breastfeeding, having unprotected sex with infected partners] will become infected. Omniscient Canadian academic Jung knows that “there is no place in the world, including rural Uganda, where 85% of babies die”; she tells us that the national infant mortality rate in Uganda in 1988 was 8.6%. Spot the basic statistical error there. Ugandans predominantly breastfeed; formula feeding is a new problem. When formula feeding took off in the second half of the 19th century in the UK, the national infant mortality figures rose steeply despite the improvements in sanitation that had been extending lifespans and lowering death rates. I’d believe the Ugandan doctor, who just might know what the water quality was like in his country’s rural areas, and could have seen more dead babies – 85% of those formula fed in a rural area with unclean water?- than Jung can apparently imagine.
  • Jung also says that “the best research has found that even with exclusive breastfeeding there is a 22% [- twenty-two percent-] rate of HIV transmission by six months of age.” (p. 197). She also refers to Coovadia et al as saying that the rate was just 2.2%, a tenth of that. Referencing the 2007 Lancet article, despite the work done since then, for a book published in 2015. Hmmm. Sloppy proof reading at best; seriously misleading and deserving of an immediate correction slip. None provided.

Why is this slip so important? Stunningly, the Coovadia article she cites concludes with something she didn’t find worth mentioning: that “Cumulative 3-month mortality in exclusively breastfed infants was 6.1% versus 15.1% in infants given replacement feeds.” Roughly two and half times as many children of untreated infected mothers die under 3 months of age if not exclusively breastfed. Does it matter to their mothers if the diarrhoea their babies die from is due to HIV-1 or rotavirus or some other pathogen in their feeds?

And even more importantly, a 2014 article by the same researchers found that breastfeeding is essential to reduce infant mortality because “Child survival goes beyond HIV-free survival, and safe breastfeeding prevents 13% of all deaths under 5 years of age.”[14] That’s thirteen percent of the annual 5.9 million child deaths under 5 in the world are prevented by breastfeeding, while perhaps 2.2% of infants of infected mothers (who are not all the world’s mothers) may be infected with a disease that can be controlled for long periods with anti-retrovirals. Even if that 2.2% HIV+figure can’t be lowered, or that all 2.2% are infected and die under the age of 5 years, it’s obvious why public health bodies responsible still support breastfeeding even among HIV-infected women. What’s not obvious to me is how an advantaged North American could possibly think the needless death of 13% of the children under five who died doesn’t justify seeing breastfeeding as a public health issue everywhere. Let’s not kid ourselves that in affluent nations there are no poor HIV+ mothers who lack access to clean water and the many resources needed for relatively-safe formula feeding. Has anyone noticed the homeless on the streets of America, Britain and Australia?

However, that’s not the end of this story. There are preliminary reports that the 2.2% rate has already been lowered to close to zero by women following the belated new WHO guidelines about prevention of mother to child transmission (PMCT guidelines)[15]. Jung discusses this only to dismiss as unrealistic the possibility that women could or would access and take anti-retrovirals and meet the other conditions lowering the risk of infant infection to almost zero. Hers is a counsel of despair. We absolutely need to get all infected women in Africa and everywhere else on medication to halt or slow the progress of their disease, whether or not they produce babies and breastfeed. Prevention of mother to child transmission has been a powerful means both of prioritising such women’s access to medication, and motivating them to comply with it, in societies which in most cases value babies above women. Breastfeeding advocates are about saving women as well as babies. For most humans on the planet, the conditions needed to make infant formula even tolerably safe simply do not exist. Concerns about its effects on long-term health and IQ are meaningless everywhere that its principal effect is to increase the risk of malnutrition in all members of the family. Jung’s indignation about world bodies and lactivists promoting such strategies “for no reason other than a fanatical commitment to breastfeeding” seems to me myopic, politically motivated, and puerile, as well as defamatory and dangerous to mother and child health.

If I were to choose a third example of poor scholarship about HIV, it would be Jung’s uncritical acceptance of the 1985 Ziegler case study. But then, very few people noticed that Dr Ziegler described a transfused sero-converting mother whose baby, formula fed neonatally, was fully weaned by 6 weeks; a baby who developed eczema and impetigo and iron deficiency, so that during 13 months of intimate contact with a woman unaware of her HIV+ status (and bleeding after childbirth and during menses) his damaged skin and disordered gut microbiome coped with infant formulas, before the question of HIV exposure was raised. (Mother and baby later tested positive.) The paper in fact stated that other methods of transmission than breastfeeding were possible, especially through damaged skin. It’s now clear that had the child been exclusively breastfed, there is a chance that Ziegler’s case would not have been infected at all (though the highest risk of infection is when a mother is sero-converting or in end stage AIDS – when viral titres are high and the immune system cannot respond adequately.) Conversation with Dr Ziegler in Sydney in the 1980s revealed that he was more concerned about the potential stigma that would attach to known HIV+ men if skin were to be recognised as a route of infection, than about any consequences of banning breastfeeding. That was the usual western view of things at the time, hardly surprising in a male-dominant bottle-normative and homophobic culture where gay men were the principal victims of the disease. In our conversation Dr. Ziegler naturally identified more with his own patients than with breastfeeding mothers.

Why didn’t Jung carefully read the original source instead of treating this case as proof positive of the first case of transmission by breastmilk? For the purposes of her chapter, such brief mixed feeding was sufficient to prove that the route of transmission was the breast. That first plausible report of breastmilk transmission, widely publicised in a free video distributed by a US infant formula company, was sufficient to damn breastfeeding by HIV+ women and to close milkbanks. Yet multiple proven cases of transmission via semen did not shut down sperm banks, the difference being that breastfeeding was/is not considered important. And so thousands of babies in NICUs would die of sepsis and necrotising enterocolitis (NEC) as infant formulas replaced breastmilk in their diet. In some countries accepted NEC rates of 5-7% of all prem babies with mortality of 20-25% meant that 1-2% of all preterm infants died as a result of the lack of breastmilk, indirect victims of 1980s AIDS phobia. Rates in some units which only used breastmilk for preterm infants were around .05%. Where is the class action lawyer?

Jung condemns as AIDS denialists those who rightly said from the 1980s onwards that more child deaths would result from widespread bans on breastfeeding on the basis of such testing. The chapter reveals her lack of understanding of the limitations of PCR testing. Along with hundreds of bacterial strains, breastmilk will always contain fragments of other microbes precisely because this is part of its immunising function. PCRs could indeed amplify these fragments without being able to determine if they were capable of infecting: the mere presence of a viral fragment proved little about the likely rate of disease from exposure in breastmilk, and even less about the relative public health costs in numbers of dead babies and ostracised and brutalised women in some communities (accused of fornication because formula feeding proclaimed that the women were diseased: why else would they not feed their babies, a fundamental female activity?)

Breastfeeding advocates implored health authorities to consider the likely costs of a premature ban on breastfeeding, but most did not deny the possibility that some babies could be infected via breastmilk. A wetnurse in endstage AIDS who cared for an orphaned child certainly transmitted the disease, probably via milk. But how many babies died because of “replacement feeding” (infant formula) trials? Some agencies providing infant formula to poor families did not even collect that data. This oversight delayed the realisation that replacement feeding was disastrous, and the necessary rethink of WHO policy. But once again, it was breastfeeding which had to be proved safe by research, while infant formula had been assumed to be safe – and wasn’t. And in 1984 I heard that Washington DC research trying to see how the virus replicated in milk kept finding that it was killed before it could be examined under a microscope: results which were not published because not of interest to the AIDS community. Then.

Enough said. I hope that Pamela Morrison will find time to critique the HIV chapter in detail. But perhaps I should point out in passing that if humanity is ever to develop natural immunity to retroviruses, as other mammals have done, it is most likely to come through breastfeeding of the next generation by healthy survivors of HIV exposure, who provide in their milk what we now know are bioactive components that can prevent infection and destroy the virus. That is basically how mammalian immune memory and response is passed on to the next generation. Breastfeeding mothers worldwide can supply powerful antibodies to new threats, and other immune factors, faster and cheaper than scientists can provide vaccines.[16]

There is a lot more that is problematic in this book. I have stayed away from some of the issues such as mentioned in two other online reviews, both of which are worth accessing online, reading and sharing:

http://chronicle.com/article/Has-Mother-s-Milk-Gone-Sour-/234060; http://www.elizabethgrattan.com/prose/oversellingbreastfeeding

Bad policy?

So is it, as Jung says, “bad policy” to consider breastfeeding a public health issue? Whether Professor Courtney Jung thinks so or not, breastfeeding is a central public health issue globally, more important than the issue of tobacco, because more universal, and more fundamental. Millions of children die for want of it. All children must be breastfed (we don’t know for what duration) to develop to their full potential. All mothers are at greater risk of serious disease if they do not breastfeed. Major paediatric authorities are beginning to talk of “the necessity of breast feeding as the first source of nutrition.”[17]

This is why so many health authorities are finally realising the need to protect, promote and support breastfeeding, against huge resistance, much of it fomented online by vested interests, and supported by advantaged women like Jung, in whose computers a little knowledge is indeed a dangerous thing. And it is why there are so many lactivists who work so hard, often for little or no monetary reward, to help women make a fully informed choice of infant feeding.

Once parents know what is at stake, there are few indeed who would choose to formula feed, and many who want society to facilitate their choice to breastfeed. Many parents are angry that they have not been told the truth about infant formula: few even realise that powders will never be sterile, or that it contains oils made by genetically engineered fungi and algae, which can come with many traces of extractive chemicals like hexane. Advantaged women can make the choice to breastfeed. Disadvantaged women often don’t have any choice but to try, suffer and fail, or to avoid breastfeeding because of the horror stories beloved of the mass media. It is a matter of extreme concern that those who have most to gain from breastfeeding, and who have the least chance of accessing needed remedial work for their children, are often those who do not hear the message that it matters not only to their child, but to mothers and future generations as well. Or who, if they hear it, are forced by circumstances beyond their control either to ignore it, or to hope they’ll be the lucky ones for whom negative effects are neither immediate nor catastrophic. (But there must be effects, and such deviations from physiological norms are usually detrimental.)

 To sum up.

Lactivism seemed to me at first, taking the author at face value, to have been written out of laudable concern, but an inadequate knowledge base. This was not Professor Jung’s area of professional expertise, and there was much more to learn than perhaps she understood when writing her book. So I cut her some slack, and tried to be positive about what she had written. But by the end of the book I was very tired of her attribution of unworthy motives and “a fanatical commitment to breastfeeding” to everyone who disagrees with her position.[18] Perhaps I should judge the book by its fruits, as the biblical injunction suggests?

When I do, the result is a resounding F for failure, for the fruits are bitter indeed. Ultimately Lactivism provides little that is productive by way of solutions to the problems of infant feeding in western societies where the bottle and infant formula has both been normalised.

I believe that it will inflame pointless debate and contribute to the polarised “mommy wars” an American infant formula company has been actively fomenting, ensuring that legislators are paralysed, do not act, and will allow multi-billion dollar formula companies to go on dominating the parenting and health professional landscape and the media as they do, habituating next generations to bottle feeding as the western societal norm.

I think the book will intimidate some healthworkers, many of whom, in my experience, are in fact afraid to tell parents what they know about the risks of infant formula because of a likely backlash from those who do not want to hear it, and who are empowered by media reports of formula advocates’ latest fantasies. Administrators seem rarely to support a health professional who has upset a paying “customer” by truth-telling.

Sadly, Jung’s media remarks and writing may well persuade some parents not to bother with a task that fits so ill into a profit-driven society, and so will benefit multi-billion dollar companies expanding into new markets to replace breastfeeding with inferior substitutes, exporting the diseases of affluence as they go.

Being prone to thinking the best of people, I have to believe that none of this would have been the author’s intention, however gratifying or useful the predictably widespread media attention may have been. So I beg Professor Jung to read my book Milk Matters: infant feeding and immune disorder, and think again. Then re-write Lactivism, or withdraw it from sale, apologising to the breastfeeding advocates and researchers that I believe she has misrepresented and slandered. I hope she might then use her undoubted talents, as breastfeeding advocates do, both to help formula feeding mothers feed more safely, and to empower more mothers to enjoy the experience of breastfeeding, a unique relationship of great value and importance not only to mothers and babies, but to the world at large. And I would be delighted to engage in discussions with her in public or in private, after she has read my book.

A thought to end with.

In 1984 the American Academy of Pediatrics said (of coffee whiteners being used by the poor to feed babies): “Popularity, extravagant claims, and special marketing practices cannot make white liquids nutritionally equivalent to infant formula.”[19] Perhaps in 2016 world authorities and the AAP might jointly say, in a massive public health campaign, and in suitable languages, that

“Popularity, extravagant claims, and special marketing practices cannot make infant formula the nutritional, immunological, microbiological, or developmental equivalent of women’s milk.”

The Global Breastfeeding Advocacy Strategy[20] will fail unless it is similarly direct and clear in its statements about infant formula, and misleading industry marketing claims are controlled worldwide. We need to realise that in every country, some babies die for want of breastmilk, and some mothers die younger than they otherwise would, because they did not breastfeed. And when we do realise that, perhaps national governments will ensure that many more mothers are supported and helped and even paid to do something important and valuable: breastfeed their own babies, and supply milk for others who might need it.

[1] In my 40 years working in the field, that guilt and desire to appease seems quite common among educated women whose breastfeeding journey was relatively uneventful in a society where this is unusual. (Do others find this, I wonder?)

[2] Would the US Breastfeeding Committee agree I wonder?

[3] Infant formula companies are not known for the modesty or accuracy of their advertising claims. That was a Wyeth, now Aspen, descriptor.

[4] Though the reality is that many use devices designed to facilitate self-feeding, or delegate the task of feeding to other humans of widely varying ages, competence, and involvement with the child. Indeed, the formula-industry-promoted idea that breastfeeding prevents a father from feeding his child has been powerful, though the reality is that token paternal feeding makes no difference to paternal bonding.

[5] For Jung, a pejorative term, meaning that breastfeeding is not a means, but an end to which the needs, interests and even lives of mothers and children are sacrificed: see Lactivism p. 23 Such people may exist; in 40 years in the field of breastfeeding advocacy I have yet to meet such a person.

[6] I would be surprised if there have not been negative health and dietary consequences in her life and her children’s, but not surprised if she is unaware of them, as the consequences have become normal in formula-affected societies. For her to do the questionnaire in Milk matters might be a revelation of personal benefit to her family.

[7] Grummer‐Strawn L, Rollins N. Summarising the health effects of breastfeeding Acta Paediatrica, December 2015. DOI: 10.1111/apa.13136 http://onlinelibrary.wiley.com/doi/10.1111/apa.13136/epdf

[8] http://chronicle.com/article/Has-Mother-s-Milk-Gone-Sour-/234060;

[9] http://www.independent.co.uk/life-style/health-and-families/health-news/press-twisted-my-words-says-academic-in-breast-milk-row-1766147.html

[10] I am privileged to know Prof Hartmann via shared conference platforms, and visits to his workplace, but he has had no input into this commentary. If I were to nominate a single world leader in breastfeeding research, it would be Peter. (There are many other notables, few consulted by Jung.)

[11] http://www.independent.co.uk/life-style/health-and-families/health-news/press-twisted-my-words-says-academic-in-breast-milk-row-1766147.html

[12] This is all discussed in Milk Matters: infant feeding and immune disorder (Minchin 2015)

[13] Dixley A. Breast Intentions. (Pinter & Martin 2014)

[14] Govender T, Coovadia H. Eliminating mother to child transmission of HIV-1 and keeping mothers alive: recent progress. (PMID:24139190) J Infect 2014; 68 Suppl 1:s57-62

[15] World Health Organization. Guidelines on HIV and infant feeding. Geneva: WHO Press; 2010. http://www.who.int/child_adolescent_health/documents/9789241599535/en/index.html.

[16]Pages 446-459 of Milk Matters go into this topic at greater depth.

[17] Walker WA, Shuba Iyengar R. Breastmilk, Microbiota and Intestinal Immune Homeostasis. (PMID:25310762) Pediatr Res 2014. DOI:10.1038/pr.2014.160.

[18] Perhaps I too will be told that I have sacrificed women on the altar of Hathor the Goddess of Breastfeeding, when I have always quoted Dr Mavis Gunther’s “Breastfeeding is for the baby, not the baby for breastfeeding,” and advised mothers about suitable formulas when that was the best available option – and charged none of them for my time or resources, so no, I’m not making money out of them either.

[19] AAP Committee on Nutrition. Imitation and Substitute Milks. Pediatrics 1984; 73:6 876

[20]http://www.unicef.org/nutrition/files/Breastfeeding_Advocacy_Strategy-2015.pdf

Addendum: a possibly needless clarification

“…the needless death of 13% of the children under five who died…” that of course is not 13% of all the world’s children under five, which would be an additional 130 per 1000 deaths in every country. It is 13% of the annual 5.9million deaths, whatever the child mortality rate is. So where that rate is 10%, or 100 per thousand, with full breastfeeding as WHO mandates the rate would drop to 87 per 1000. It is possible to calculate what this would mean in every country if the under-5 mortality rate is known:  for details go to http://www.who.int/gho/child_health/mortality/mortality_under_five_text/en/

I hope none of my readers is crass enough to consider that, deaths among advantaged children in their country being much fewer than in others, this statistic, like those “few” IQ points, doesn’t matter, and means western women should not be upset by the promotion of breastfeeding over infant formula, in public health campaigns. For me, any needless child death anywhere is an outrage. And in western communities the contribution of infant formula to child deaths is considerably underrated: who defines a death from NEC as due to a lack of breastfeeding? Yet it is a hugely significant and avoidable factor in such deaths.

Thanks to Deidre Knowles for picking up on this and suggesting I clarify it.  Readers, do feel free to do so any time my writing seems problematic: many rewrites of each post means many opportunities for both  the automatic text and me to make mistakes! while no one in the world knows everything there is to know about this enormous subject of infant nutrition.