- PREAMBLE FOR ANY SPECTATORS
It is because infant feeding is such a powerful issue, and so important to global health, that I agreed to spend the time on this question set by Amy Tuteur, and to create a time-stamped secure permanent record on a dedicated website for future reference by historians of the “the Mommy Wars”, in which Amy has been a key protagonist.
I agree with the infant formula industry that “What we feed them now matters forever.” Today’s children are affected by how their parents were fed as babies, and so it goes…
I have elsewhere posted some materials that I may refer to:
- an outline, omitting much inflammatory detail of how this debate came about, and my conditions for debate: see my website https://infantfeedingmatters.com/the-minchin-tuteur-debate/ and https://infantfeedingmatters.com/tuteur-debate-update-progress/
- my review of Tuteur’s book will be online on my website asap. My reviews of Jung’s Lactivism(a similar but better book), and Rand Oakley’s The Bottle, the Breast and the State(an excellent book with a few of the same assumptions) are already on the website; those books I thought worth reviewing.
- a copy of the first part of my book, Milk Matters: infant feeding and immune disorder. Available to download free of charge: click on https://www.researchgate.net/publication/333717900_Milk_Matters_Book_One_by_Maureen_Minchin
Referring you to relevant pages of my book will not only save me time, it also allow for you to have greater understanding of complex issues. I cannnot condense five years of evidence-based research and writing and referencing into a couple of hours worth of posts! Read what you can. Every one of you will influence others, and so you are important in the work of global health; your own descendants will benefit too.
I hope to keep strictly to the debate we are to be engaged in, from June 19 until 12.00am AEST on June 22, 2019. But other related materials may be posted on my website from time to time. Generally I also advise of these on my Facebook pages, which are usually open to all but the seriously ill-mannered… though I may close them at times avoid distraction or reduce harassment.
(Amy Tuteur asked Maureen Minchin to debate this question)
“Are the benefits of breastfeeding real and clinically relevant or merely theoretical and not reproducible in large populations?”
BENEFITS? AND THE QUESTION
Let’s start with what the world’s largest food giant and infant formula manufacturer says, as they have no reason to exaggerate. The Nestlé Nutrition Institute website says in 2019… (my emphases) “Human milk provides unparalleled nutrition to infants in the early stages of life. … Breast milk is a comprehensive source of energy and macronutrients, as well as bioactive micronutrients essential for the growth and development of an infant. Infants fed human milk have different gut microflora, exhibit different growth patterns, and even face a lower long-term risk of chronic diseases, such as obesity, types 1 and 2 diabetes, and cardiovascular disease. https://www.nestlenutrition-institute.org/world-breastfeeding-week
There is clear global consensus that early postnatal nutrition is a hugely significant factor for human development, especially the first weeks and months when breastmilk should be the sole diet. From the ultra-cautious and conservative World Health Organisation, subject to heavy political pressure by large vested interests, all the way down to industry-supported bodies such as the American Academy of Pediatrics, which in a 1984 Special issue shared what now is Amy Tuteur’s perspective, but as long ago as 1997 had drastically changed their policy statements. https://pediatrics.aappublications.org/content/100/6/1035 The latest 2019 statement (excerpt below) can be found at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Breastfeeding/Pages/Benefits-of-Breastfeeding.aspx
WHAT THE AAP SAYS IN 2019
Most health professionals are familiar with the benefits of breastfeeding. The AAP continues to support the unequivocal evidence that breastfeeding protects against a variety of diseases and conditions in the infant such as:
- respiratory tract infection
- necrotizing enterocolitis
- otitis media
- urinary tract infection
- late-onset sepsis in preterm infants
- type 1 and type 2 diabetes
- lymphoma, leukemia, and Hodgkins disease
- childhood overweight and obesity
- There are also maternal health benefits to breastfeeding such as: decreased postpartum bleeding and more rapid uterine involution, decreased menstrual blood loss and increased child spacing (lactational amenorrhea), earlier return to prepregnancy weight, decreased risk of breast and ovarian cancer
Not to mention governments world-wide, including the United States and Canada and Australia, which have all examined the evidence for risks and harms of formula feeding – oops, “benefits of breastfeeding” – and found it convincing. The 2016 Lancet Breastfeeding Series https://www.thelancet.com/series/breastfeeding was careful not to go beyond what could be safely said without contradiction about just a handful of many potential negative outcomes, and came up with an annual estimate of 823,000 child deaths and 20,000 maternal deaths. No matter how you do the stats, and what the inevitably different estimates will be, none of those bodies would agree that this morbidity and mortality, disease and death, happened only in less advantaged nations. Yes, the rates are much higher in conditions of poverty, but each child or mother death is as much of a tragedy in any country. And industrialised nations have plenty of poor people, and the United States lags badly on key health statistics like infant and maternal mortality.
QUESTION? WHAT QUESTION?
Amy Tuteur, your ‘question’ is a statement, indeed multiple statements, that deny reality. The simple answer to your question is just “ yes, the benefits are real, relevant, reproducible – and recognised. The whole world, even the industry which benefits from breastfeeding failure, acknowledges that. And there are many efforts trying to maximise those very real, relevant, reproducible effects.” I should leave it at that, really.
But we both understand that your statement masquerading as a ‘question’ was a debating ploy, putting forward an evidence-free assertion of your belief that any beneficial effects of breastfeeding are “merely theoretical and not reproducible in large populations”. That in turn is a modified version of your more explicit claim (in your book Push Back) that the effects of breastfeeding are “trivial” In industrialised nations. I will address both.
You pretend that is the “question” you want me to answer. That is asking me to disprove your unreferenced statement. So whose is the burden of proof here? Procedurally and logically?
THE BURDEN OF PROOF
You posed your statement as a question, not backing it up with a shred of evidence. That isn’t how any debate works. The instigator of a debate proposes a thesis and argues the case for it; the opposition has to rebut it. You need now to supply your evidence for this proposition, and when you do, I will try to rebut it in a limited timeframe. And that timeframe will limit what can be done. That’s what I’ve said I’ll do. Repeatedly said. Check the record if you have forgotten the many times I’ve written that.
Obviously, I can’t rebut what I can’t imagine. I don’t know what you’ve read that I haven’t. While no human being can have read everything in print, I’ve read a lot over forty years, and yet can’t imagine what your evidence can be, given what I have read, and the families I have dealt with.
So let’s come back to the question: logically, whose is the burden of proof ? When your claims of “trivial” benefit for infants are a contradiction of what every public-health body, publicly states in writing, who needs to prove the case? Dissenters who reject the position such groups adopt need to justify their dissent, make their case. Groups including the American College of Obstetricians and Gynecologists where presumably you were a member before retiring – was it 16 years ago, in 2003? Your writing on this subject of the impact of feeding practices reminds me of the attitudes to science of vaccine-denialists, those anti-vaxxers you condemn so strongly. Perhaps you are, like them, not a sceptic at all, but a denialist. Sceptics are open to fact and reason. Denialists are not.
If I had left this reply at this point, as I could have, it would been playing games like yours in setting the ‘quatement’ (both question and statement). Wasting time. To justify the time use, this should be a serious debate that might have some value to both of us and any audience. So I went on. I re-read your book’s chapters on breastfeeding, to see if that would help me understand your case. It didn’t, as the book contains much more emotive judgmentalism and slander than scientific information. (More than half the 35 citations in one breastfeeding chapter are to pop opinion pieces by other advantaged folk, not science.)
So I must ask you directly, what evidence do you have that is so powerful that you can dismiss the considered conclusions of all those very conservative, very eminent public health authorities? Can you tell me the name of a significant global public health group that has not made a formal statement to the effect that breastfeeding is important to public health everywhere? Or that benefits are “trivial”, when babies die and so do mothers? Or that has recently disputed the fact that “What we feed them now matters forever’, as the formula cans used to say.
Perhaps the case has not been scientifically proved to your satisfaction? What would satisfy you? ‘Correlation is not causation’, you might insist, as your followers often cry. Of course it’s not. But where there Is causation, there will almost certainly be correlation, as one of my clever friends recently said. So it’s something to look for, and to look at, when found. And to look for in a multiplicity of ways, using many forms of evidence. Including many forms and modes of investigation that a meme on your site declares to be worthless – all laboratory investigations, all animal studies, all observational studies, all small trials.. Surely you don’t really believe that?!
I’m sure you understand that science is not about absolutes; it never proves anything beyond the possibility of doubt. Hypotheses arise in many ways, including from lived experience. Scientists examine hypotheses and try to prove or disprove them by testing them, repeating the study or experiment if it is ethical to do so – and increasingly, ethics committees limit those possibilities for studies on infants.
When results are not yet proved or disproved, and the result produced is the same as the result of many previous experiments, and there is basic biological evidence suggesting such an outcome is likely on the basis of established facts about how bodies work (referred to as ‘biological plausibility’), then a scientific consensus emerges that X is likely true – until something comes along that alters that perception.
Reasonable certainty is all that can be achieved sometimes. Intervention trials are not always possible or even appropriate for the task, much less ethical with infants.
Amy Tuteur, you ask, Are the benefits real and clinically relevant? How can effects not be “real”, when the effects we know about come out of epidemiological and comparative observational studies in so many different (but very real) populations? What are unreal effects? Are there unreal populations?
This you need to answer: why would effects NOT be “clinically relevant” when human babies have the same basic biology worldwide? a biology reflecting the fact that the human race has evolved over millions of years with the bioactive living tissue that is human milk? Milk interacts with genes and drives, even controls, development. Not being breastfed means more DNA damage and chromosomal breaks, and differences in gene expression. It means higher levels of free radicals, different balances of hormones, absence of vital immune cells, and much more. (more Milk Matters pp. 32-3,145. )
The more we know about breastmilk, the clearer it is that milk is an important bridge between the womb and the world, a dynamic liquid that affects gene expression, that supports metabolism, that programs physical and mental development, that provides immune support, that has lifelong effects on the child who will be a parent for the next generation, and so on that generation as well.
And that breastmilk helps the child adapt to the specific environment in which the family lives, passing on immune memory and inducing tolerance to harmless exposures, while providing some responsive protection against the potentially hazardous. And that mothers who do not or cannot breastfeed have to work harder to cope with the demands of motherhood, and are in an unnatural hormonal state which has many later ramifications for there health. Anyone wanting a recent text outlining what we now know about some aspects of breastmilk could purchase the affordable new text, Breastfeeding and Breast Milk: from biochemistry to impact; https://www.amazon.com/Breastfeeding-Breast-Milk-Biochemistry-Multidisciplinary/dp/3132204013. Any college that would like a free copy should contact the Family Larsson-Rosenquist Foundation. https://www.larsson-rosenquist.org/en/projects/reference-book/
How could all these things not be relevant to human bodies? And universally so? Does living in the parts of America where women can afford obstetricians mean bodies function differently? The rational presumption would be that it doesn’t.. But maybe it does, and you can prove that?
MIND YOUR LANGUAGE
Of course, “the benefits of breastfeeding” is a typical misleading choice of words. As James Akre, experienced former staff member in the Nutrition Unit of the World Health Organisation (1981-2004), has said, “There are no benefits to breastfeeding, only varying degrees of risk, for the health of mothers and children, of not breastfeeding. Indeed, extolling the “benefits of breastfeeding” makes as much sense as touting the “benefits of walking upright on two feet”. Both are defining features – no more and certainly no less – of what it means to be human.” https://www.huffpost.com/entry/breastfeeding-one-mans-perspective_b_57343d70e4b0ed0ca07a7cb3
“Benefits of breastfeeding” reflects the almost imperial arrogance of WEIRD (Western Educated Industrialised Rich and Democratic) nations whose people see formulafeeding as the human norm (because it is usual in their society, and they are the normative humans.). Most of the accepted “benefits of breastfeeding” are in fact proof of the risks and harms of not breastfeeding. The breastfed child or the breastfeeding mothers is the human norm, and should be the reference point. Frame the discussion in that way, and it changes the impact of the risks assessed. To say that breastfeeding for two months reduces the risk of SIDS by 50%- 73% is a lot less powerful than saying that formula feeding doubles or almost quadruples the risk of SIDS. It’s the same data, just depends on which is the norm. Both statements are true. But the public health message needs to be the latter, while in clinical practice we might choose the former. Formula feeding doubles the risk of SIDS. So does smoking in pregnancy. Compare how they are reported. (However, were the findings the opposite, it would be widely reported as “breastfeeding doubles the risk of SIDS.”) www.sciencedaily.com/releases/2017/10/171030123401.html
Similarly, we can say the risk of something (premenopausal breast cancer I think) is reduced by 33% by breastfeeding- but framing it differently, not-breastfeeding has increased the risk by 50%. And what level of increased risk in childhood cancer, pre-menopausal breastcancer, or SIDS is normal or “trivial”?
WHAT IS NORMAL?
Formula feeding in the 20th century became the cultural norm in nations such as the United States of America (where by 1970s fewer than 20% were ever-breastfed) formula feeding is absolutely not the physiological norm for human infants and mothers. (By the way, many of the 20% ever-breastfed/mostly short-term breastfed babies were also exposed neonatally to bovine formula, if born in hospitals that industry supplied with free powder or ready-made formula, bottles and teats. That is an exposure which has skewed much research, lessening outcome differences, until very recently. How? Many ways, not least skewing the gut microbiome through the critical period of initial colonisation. We have known since Bullen’s work in the 1970s, long before the sophisticated tests now available. Again, read more about this in the free Milk Matters.)
The fact that formula feeding had become the absolutely dominant mode of feeding in the United States by 1950 means that all generations since then have been affected to some degree, even those subsequently breastfeeding or breastfed. I have illustrated this roughly in a downloadable visual form at https://infantfeedingmatters.com/the-milk-hypothesis-visual/(copy and paste this link into a browser if it doesn’t click through)
WHAT IS RELEVANT?
Are the effects of infant feeding “clinically relevant”? Both basic logic and normal debate rules say that you need to prove to me that they are not, despite our common human biology. Amy Tuteur, how do you explain the fact that when formula feeding expands in any country, that nation develops an epidemic of inflammatory disease identical to that which characterises what are known as the WEIRD nations? Yes, there are many contributing factors, but how do you rule out the effect of distorting normal development and immune responses? why do you think companies work so hard to change their products in the hope of reducing the connections they discover? Not that any additives will work in formula fed babies the ways much more complex versions work in breastfed babies, alas.
Clinical experience suggests the clinical relevance of infant feeding, and prompts research. Four examples:
- In the period before infant formula began to replace breastmilk, a paediatrician who had worked for decades in Indonesia from the 1930s had seen only one case of juvenile diabetes, and that was the formula-fed child of an expatriate. He said that changed rapidly as formula arrived, but he still saw no breastfed child. But of course he began to see Type 2 diabetic adults: and then he began to see children gestated by diabetic mothers. Studies are now clearly vindicating his observation.
- China’s infant formula market has risen dramatically to more than $27 billion. The highest rate of type 1 diabetes increase is in the under 5s. That’s a large population, a large effect, and it is very real – and in the under 5s, it is not the result of a diet of Coca Cola and Big Macs. But there is a lot of evidence that the risk is greater in children not breastfed.
- While breastfeeding was universal, breast cancer had never been recorded in some Inuit groups except for one woman with a breast so burned as a child that she was unable to feed from it. Similarly, women from the Tanka boat people in Hong Kong developed cancer only in the breast never suckled from, as they fed only on one side. We now know some of the biological reasons, and accept that breastfeeding significantly reduces risk of breast cancer in both the mother and her children.
- The link between not-breastfeeding/formula feeding and programming for lifelong obesity/diabetes/inflammatory disease is the same in advantaged or disadvantaged nations and population groups. One causal pathway becoming widely accepted involves the harms of infant formulae’s excessive protein. I first read about this in 1981 when Scandinavian scientists argued that both quality and quantity of protein in formula was wrong. Industry recognises this problem and its link to obesity. Though protein levels have dropped from more than 20grams per litre to (mostly) 12-18g/L, they will likely drop further. On the law of averages, some of those reading this debate will have struggled with weight issues since childhood, as a direct consequence of their infant feeding, and produced children with the same issues, worse if they did not breastfeed them for long. (Practical hint for bottle-feeding parents: always choose the from-birth formula with the lowest protein levels, not more than 12-14g/L. Read Milk Matters chapter 3.5 on protein. For interest, breastmilk contains 9-10 grams per litre and some of that is immune proteins that protect the gut and pass out undigested.) Is that said to shame parents? No, to educate them about the causes of problems not of their doing. Why should they feel shamed? Regretful, angry, yes. Guilty no.
The evidence of past and present risk to infants (and mothers) – from both the absence of breastfeeding and the presence of formula – is more than two-thirds of my 800page book – which contains 2000+ footnotes and a forty page bibliography. As I said earlier, everyone is free to download the first part of that book, a mere 192 pages. The death and disease recorded is not theoretical or imaginary, but real and produced in large human populations.
WHAT TO PROVE?
Amy, to prove your case, you need to demonstrate to a reasonable level of proof that there are no serious adverse consequences for mothers and indeed families of shorter interbirth intervals, higher rates of inflammatory disease, increased medical and household costs, and so on.. But you do know that the absence of proof of harm is not at all the same as the absence of real and serious harm. It can simply be the absence of proof, for lack of research.
But will you be able to explain away as unimportant, for example
- the studies showing differences in cognitive development, along with the magnetic resonance imaging (MRI) studies showing substantial differences in (advantaged American) brain white matter development in the first year of life? [Milk Matterspp 48-6, discussed p. 335.]
- the ultrasound studies measuring differences in reproductive tissue development obvious in just 4 month old (American) babies [less testicular tissue, more ovarian tissue – see Milk Matters p.39];
- the persistent differences in bodily microbiomes and their consequences, documented everywhere it is studied;
- the studies measuring biological differences in body mass and tissues, in organ size and function [thymus halved, heart, kidneys]
- and all the other trivial matters mentioned above?
That’s just for a start. I don’t expect you to prove that milk’s pluripotent stem cells transferred during breastfeeding serve no useful purpose. Scientists haven’t yet proved that they do, but In other mammals these cells clearly do repair work, and in infants can be traced to many bodily organs, including the brain. Does the absence of such powerful cells help explain the studies showing higher cancer rates in children not breastfed, where both dose and duration affect the degree of protection breastfeeding provides? Or is that due to the effects of things present in formula, like trans-fatty acids and other reactive pro-inflammatory oxidants? You don’t know, and can’t know, and nor can I or bottle-feeding parents) because the research hasn’t been done, though companies are trying hard to lower the levels of those free radicals in formula, the inevitable by-product of multiple heat treatment and physical processing.. But the suspicion is there, the links are plausible…and these are not trivial, but global, concerns.
There is much more that could be said, but since I do not know what you are arguing I may be wasting time. So enough for now.
To sum up: you, Amy Tuteur, retired doctor, are rejecting a massive global consensus on the importance of breastfeeding everywhere. Not just in low and middle income countries (LMIC) but also in the USA. You are saying that benefits are unreal, not clinically relevant, theoretical, not reproducible in large populations, and trivial in the industrialized world. And that you can justify these claims with scientific evidence.
Go to it! I am looking forward to seeing your detailed argument. There’s a huge amount I don’t know, and I can learn from anyone. I doubt that you can convince me that the “benefits” are trivial, or unreal in America, or somehow not universally applicable… when human biology is a constant, and milk an incredibly powerful living tissue. But I’m bound to learn something. I already have today.
Then I will do what I can to rebut whatever you have written. And I will reply under 24 hours from opening it.
I can’t email you a link to this reply as you have not supplied one as requested. But I know you will read it. Please reply anytime on the 20th, and I will analyse and rebut your case, acknowledging any valid points as I do..
Please email me at any time on June 20ththe date-stamped link of your reply – firstname.lastname@example.org.
Should you not reply on the 20th, I will add a further reply to the question on the 21st.
And I will finish and post a review of your book. I doubt the result will be positive for your sales figures, but it might be.