Tuteur Push Back: Minchin Review

Maureen MinchinAppearances elsewhere, Book Reviews, Bottle Feeding, breastmilk, Child Health, Commentary, Complementary Feeding, debate, evolution, General News, Immunology, Infant Formula, Infant Health, Lactation, Lactivism, Maternal Health, Milk Hypothesis, Milk Matters, Reviews by MM

Push Back. Guilt in the Age of Natural Parenting

  • by Amy Tuteur. (HarperCollins NY 2016)

INTRODUCTION

I find it extraordinary for any medical doctor to have written a book containing such sweeping generalisations, allegations of vile motives by other health professionals, and minimally researched, provably untrue, and defamatory, assertions.

Sadly, it is no longer rare for global publishers to print confrontational, poorly referenced, inflammatory books. In the era of fake news, vituperation sells, and so justifies the six-figure advance this book’s author has boasted about. The book’s rhetorical attacks range through pregnancy to parenting, all in the same intemperate vein. This review addresses only some of what this book  says about infant feeding and so-called ‘lactivism’.

This review began in the weeks before I debated the author, Amy Tuteur, online in the period June 19-21, 2019. I have completed this lengthy, but still truncated, review – yes, much more could be said – in the aftermath of that debate. All contributions to the debate (Tuteur’s question, my answer to that question, plus two responses from each of us, or links to timestamped versions) and related materials, can be read online at www.infantfeedingmatters.com or on a dedicated site, tuteurminchindebate.wordpress.com 

Like my debate replies, this review deliberately incorporates links, in the hope that breastfeeding sceptics (people with open minds) will wander the internet and learn more of the science absent from Tuteur’s writing.

WHERE WE AGREE – AND DON’T

When reviewing any book, such as Courtney Jung’s Lactivism, for example https://infantfeedingmatters.com/overselling-infant-formula/ , I try to find positives before making any justified criticism. So I should say first, I do agree with Tuteur on some points, not least her concern about any unnecessary commodification of breastfeeding and the explosion of related paraphernalia. Almost all that expensive gear is either unnecessary for successful breastfeeding, or made necessary by an unsupportive society that mandates the separation of mothers and babies, regardless of the mothers’ preferences.

Yet some women do find that gear extremely useful. To be able to express and store their breast milk gives them some degree of welcome flexibility. Equally of course, it’s a pity people have to pay for lactation consultant services – or obstetrician help – that should be universally available free. But all that’s capitalism, for better or worse. In America, anyway. Up-skilling midwives and general practitioners in a national health scheme, as in the UK, seems unlikely to be a solution Tuteur would approve, given her scathing criticism of midwives.

It would be unreasonable to expect any public health promotional campaign to highlight all possible negatives of the desired action, whether vaccination or breastfeeding. But I absolutely agree with Tuteur that breastfeeding can be hard, especially in the first weeks before the mother’s milk supply has been established in sync with the baby’s needs. Achieving that synchronicity is basic to longterm breastfeeding, yet how to manage milk supply is not taught adequately. https://infantfeedingmatters.com/milk-supply-regulation/ In 1985 my book Breastfeeding Matters said all that, providing a great deal of practical help, and stimulating quite a bit of change. I tell pregnant women that knowledgeable and ongoing support, ideally organised in advance, helps to establish lactation, and that all new mothers need help. So I flatly disagree with the statement that “breastfeeding advocates insist on burying or eliding” difficulties. We are, rather, the ones who identify and help with those difficulties.

Equally of course, for some mother-baby pairs, breastfeeding comes easily. That group is larger in communities where breastfeeding is the norm, taken for granted, and formula feeding and marketing is rare. Confidence can be important to perseverance, so the group includes advantaged women. Some of the latter never really value or understand other women’s breastfeeding goals; they often assume that a struggling mother should be ‘helped’ to give formula instead of helped to solve her breastfeeding problems. “Giving her permission to wean” was not my favourite phrase, as it implied the health professional saying it was a mind reader, a person who knew what the mother was really saying. And who saw it as their right and role to “give permission” for her to stop breastfeeding, along with reassurance that it didn’t matter, a variant on “formula nowadays is so close it won’t make any difference”. In so doing, that ‘mind-reader’ invalidated the mother’ s own innate sense of her body’s importance to her child. Arrogant professionals with god-like pretensions to mind-reading are really so 1960s! When a mother asks for help to succeed at breastfeeding, she is really asking for just that, not for “permission to use infant formula.”

I also agree with Tuteur that for mothers to love their children is more important than how they are fed, and that successful breastfeeding is not necessary for mothers and babies to be attached emotionally. Who would disagree with that? I’ve certainly written and taught it, it will be found in every breastfeeding manual created by a mother’s group. I have even argued that mothers who bottle feed responsively deserve more credit than those who breastfeed, because they are making a huge life change without the help that lactation hormones undeniably provide for dealing with the stress of new motherhood. https://www.amazon.com/Oxytocin-Biological-Motherhood-Kerstin-Uvnäs-Moberg/dp/1939807808

But equally no one should deny the power of physical contact – to create positive emotional bonds when pleasant, to create trauma when not. So that unpleasant feeding experiences need to be resolved as fast as humanly possible, not ignored. (I must admit to being shocked that this ex-obstetrician says that she was not distressed by the crying of other people’s children; that only her own baby’s cries penetrated her heart. If anything indicates how inhuman a culture is, I think it would be the reaction of bystanders to any crying baby, not just their own.)

And there is evidence that breastfeeding does have effects on measures of attachment that researchers have created, even in a sibling study Amy Tuteur later cited. (Which by the way showed more significant benefits for breastfeeding when re-analysed.) That is not surprising since breastfeeding involves skin contact that has powerful physiological effects on both mother and child, and formula feeding need not. Formula feeding can become solitary self-feeding much more easily, especially in any culture where devices are legally sold that make adults unnecessary: variants on the old “murder bottles” outlawed in 1912. (Google “self-feeding bottle” and weep.)

There are also many more ‘motherhood statements’ I could single out to agree with: her support of feminism, her belief that women should have full control over their bodies, and should not be reduced to bodily functions, that women should fight back against anything that diminishes women’s agency, that mothers’ needs should not be ignored, that work can be fulfilling (more likely if you are an advantaged woman, not a factory worker), that it is hard to be a fulltime paid employee and breastfeeding mum, that there is no one size fits all way to parent kids, that how children turn out is not determined solely by how they are parented……yada yada yada

These, and other totally unoriginal ideas, recruit readers to identify with Tuteur (usually after a distorted opposite view is set up in exaggerated form to be emotively denounced). The tactic helps validate Tuteur personally, along with her more extreme views. Because it contains such grains of truth and commonsense, the book might convince some who are not scientifically literate. (They might not notice, for instance, that Tuteur almost always fails to reference her extreme statements to specific studies correctly interpreted, or indeed, to anything but hearsay and opinion pieces written by other advantaged women.) But in my opinion, not everything she writes is utter rubbish. So what is?

WHO TO BLAME AND SHAME? LACTIVISTS!

This book, Push Back, taps into the current culture of aggression, blame and shame. Perhaps there would have been little publisher interest in less sensationalist, more measured, more professional writing: and perhaps even a Harvard-educated US obstetrician appreciated her six figure advance, enough to help her overlook or ignore Harvard University’s strong advocacy of breastfeeding on the basis of evidence that she overlooks or dismisses. https://dash.harvard.edu/bitstream/handle/1/27320186/4882692.pdf and https://www.health.harvard.edu/blog/the-real-link-between-breastfeeding-and-preventing-obesity-2018101614998

And talk about hypocrisy! This book denounces moralising by others, yet is possibly the most judgmental tract I’ve ever had to wade through.

It blames and shames some people –

*in the name of protecting others from blame and shame –

*and while deploring the tactics of blaming and shaming!

So who does this book blame and shame? anyone its author decides is a lactivist. And those she seeks to protect? women who find themselves formula-feeding for whatever reason. Who do indeed need to be protected – as do their breastfeeding sisters. But from what? and who? For me, all mothers need to be protected, inter alia, from those that I see as fomenting the Mommy Wars –  people like this author. And above all, from exploitative capitalism, the US healthcare system, ignorant healthworkers, and the destruction of community linkages. But for Tuteur, it is only bottle feeding mothers who need to be protected, from “vile lactivists”.

Who are these vile creatures? Anyone Tuteur nominates, but clearly all lactation consultants and breastfeeding advocates. (That is sadly ironic when the IBCLC credential was created because of the failure of other professions – such as her own – to become educated about the complex and longterm process of lactation and breastfeeding.) But not only lactation consultants. Everyone from the American Academy of Pediatrics (AAP) to WHO and UNICEF, who protects, promotes and supports breastfeeding as superior to formula feeding: all lactivists. (Oh yes, and me, of course. Why, I even believe that women can celebrate and feel validated by their bodily capacity to nurture their children. How vile and anti-feminist of me!)

But what defines a lactivist? Lactivism, Tuteur says,is a one-size-fits-all-policy” and “The fundamental assumptions of lactivism is (sic) that all children will do better if breastfed, that all women make enough breastmilk to satisfy the needs of all infants, that every child brain is “improved” by breastfeeding, and that all women should be more concerned with using their breasts to feed babies than with using their minds and talents to work outside the home and meet any of their own needs.”

Who thinks that? No one I know. Anyone with half a brain knows all outcome results generally spread across a bell curve of effects, though there can be clusters of advantage or disadvantage. So naturally I agree when she says, “ those assumptions are sweeping and false.” (except for her archaic notion that a woman must “work outside the home” to meet any of her own needs, but let that pass, for now.) False too, is the attribution of those assumptions to any breastfeeding advocate or mother supporter that I know. Including myself. As this MD would know, if she had read carefully anything I have written over 37 years…. [I hope soon to get Breastfeeding Matters 1985 edition up online for free download.]

Ah, but Tuteur knows that lactivists are cruel monsters, as she (p. 158) and some of her followers claim. On her Facebook page, presumably with her approval, one defines them as “absolutely vile human beings”, and posts that meme on other people’s pages. Says Tuteur, Shaming is integral to lactivists, because shaming is integral to the self-image of lactivists” and reflects “the need to boost their own self-esteem and business”. Do we have there the deity-doctor as mind-reader, or maybe a psychic?

No, what we have, I believe, is a person who reveals herself in the way that she describes others. Consider what follows. Lactivists, she says, benefit from breastfeeding promotion because it increases their incomes and employment opportunities, enhances their self-esteem through feeling superior to those they shame. And they “benefit by enjoying ugly behaviour that is usually forbidden, but actually encouraged in the case of formula feeding. There is simply no limit to the cruelty of lactivists towards women who don’t, or don’t want to breastfeed, and no limit to the delight that lactivists experience in sanctioned cruelty towards other mothers.” (p.158)

In a long life, I have often found that those prepared publicly to misrepresent others, accusing them of unworthy motives, self-righteousness, and greed, have turned out to have been projecting their own reality. Tuteur’s online behavior is full of just such ugly behavior, and she does not disclose any potential conflict of interests. Self-interest does make fools of us all.

Which is why I have made sure that as far as possible, money doesn’t determine my priorities or actions; that I criticise actions and words rather than individuals; and that I avoid attributing intentions and motives. (The latter is also necessary to avoid being guilty of defamation under Australian law, which sadly doesn’t apply in Boston Massachusetts.) Why Tuteur thinks the way she does, whether there are financial rewards for doing so, why she writes the way she does, how she arrived at her irrational conclusions about science, me, or other people, I simply can never know. And I don’t think she is any better than I at mind-reading, and so ought not impute motives to others as freely as she does in this book. But I do suspect that what she writes, and encourages others to write, reveals the self behind the MD title she makes much of. (Which I am coming to think of as Muddled Denialist after re-reading her debate posts.)

Tuteur (and I) believe that it is utterly wrong to shame, malign, defame, use hate speech about formula-feeding mothers. Yet she deems it fine to malign, defame, use hate speech about, those who are trying to help mothers succeed at breastfeeding. Journalists – whom she quotes approvingly – have called these helpers breastfeeding Nazis, breastapo, breast police, and much more without compunction. Hate speech is just as ugly about the people she classifies as lactivists, as it is about the disabled or anyone else. And just as unacceptable to civilised humans.

Once again, who are these lactivists? Women who have worked hard to breastfeed successfully? people like me, who have given their time and expertise free to help other women succeed at breastfeeding; LLLI Leaders who work unpaid but must pay to be accredited as a leader; people like Professor Ruth Lawrence (and me) who have educated doctors about how to help women succeed? Groups like WHO, UNICEF, Bill and Melinda Gates Foundation, World Bank economists who – unlike Tuteur – can see clearly how the modelling of artificial feeding in affluent nations affects less affluent families and communities, and who have created programs to try to improve the care and support of all women globally? They all promote breastfeeding; so they are all vile lactivists for Tuteur’s followers.

Yet I have never met a Tuteur-defined lactivist among all the woman-centred IBCLCs and midwives and doctors I know; and I certainly would not be classified as one by anyone who has read Food for Thought, Breastfeeding Matters, or Milk Matters. Three very different books, none of which goes in for blaming and shaming (anyone other than ignorant healthworkers who refuse to learn, and who offer formula as the trouble-free solution to a breastfeeding problem). All three books have led to women thanking me for ending their guilt about what they rightly identify as negative outcomes for their children from formula exposure too young. But Tuteur didn’t read my book in advance of the debate she challenged me to; she “skimmed it”.

Perhaps that’s why the debate turned out the way it did. You can read her question, my answer, and our responses online, and judge for yourself who was shown up as an ignoramus. (Here’s a clue. Tuteur defaced my first reply to her question, failed to post any links to the second and third replies. In fact she told her followers she had read the second so ”you don’t need to”, and ignored the third altogether as far as I can tell. Odd debate technique from someone who said we should alternately post, and allow readers to decide who presented the most up to date scientific evidence! For the record, I incorporated what she wrote into my replies, so that readers could see my argument or rebuttal in context. Rebuttal is what debaters do. Well, one us did, and the other offered not one rebuttal, simply repeated assertions. See for yourself when you have reading time to spare..) But back to the book.

HEALTH PROFESSIONALS AND BREASTFEEDING PROBLEMS

Still, it’s no secret that everyone can make mistakes, even lactation consultants and doctors. And no secret that in every field there are good, bad, kindly-but-useless, and nasty-but-helpful, health professionals. Sensitive and tactless, smart and stupid, self-centred and selfless, careless and caring… health professionals are people, whether in lactation and obstetric work. It’s also no secret that when stumped for an answer, many attribute the problem to the wrong causes, find someone to blame. When I was a young mother it was, “ Unfortunately you’ve just got one of those babies,” or else “You must be finding it difficult to be at home after your university work.” In other words, either the mother or the baby was the source of the problem. Nope to both. The baby’s problem was the result of exposure to cows’ milk formula under 24 hours old; mine the result of medical ignorance about breasts. Even now, not every health professional has the knowledge, or can take the time needed, to manage lactation problems, or infant crying, as seriously or sensitively as they need to be. My initial discussion with families can take 2 hours: what business can afford that, and then unlimited access for follow-up?

All medical branches will include a minority of poorly-educated and/or insensitive health professionals, like those so-called lactation consultants mothers in this book rightly complained of (assuming the reports are accurate, of course). But judging by the in-book comments on clinical cases presenting to her, and her account of her interactions with those mothers, Tuteur seems to me to be another such health professional! Possibly that’s unfair of me. She surely must have given far better help than she describes in print. The only advice consistently offered is simply to give formula, not to be “cruel” to your breastfed baby. (What a loaded, powerful word “cruel” is! You can bet mothers did whatever she said.) Sadly, there is nothing in this book that would help mothers who are struggling to breastfeed easily and well, and who wish to achieve full breastfeeding. Tuteur seems not to realise that many women really WANT to breastfeed. Not to meet their breastfeeding goals is devastating to their sense of themselves as women and as embodied beings. Not because someone else says that to them. Because it’s how women feel when their breasts cannot nurture the child they have borne.

The basic mechanisms of breastfeeding link milk supply to infant intake. As every midwife and lactation consultant knows, formula can be necessary in extreme cases. In fact many lactation consultants, GPs and midwives, reach for formula too easily as the “solution” to a breastfeeding problem. Which it isn’t. It’s a band-aid. And like any badly applied or over-used band-aid, it can worsen the problem, and create new ones. The way supplementation is discussed in Tuteur’s book suggests that there is no problem with what will likely be the ever-increasing use of formula and premature weaning: teaching a mother to understand milk supply regulation was not mentioned. Perhaps she should read this link. https://infantfeedingmatters.com/milk-supply-regulation/

Nor does Tuteur mention the possibility that any child would not tolerate formula. Yet fatal anaphylaxis with just the first bottle of formula is on record in affluent societies where many mothers have been sensitised by their own infant nutrition, and sensitised their babies in utero. There would be no market for new formulas if every child tolerated the first one they tried. Tuteur’s book gives the impression that it’s a case of “they all live happily ever after”, once the mother shifts to formula or, as she calls it, “combo” feeding. (Positively jazzy word.) The reality for a formula-feeding mother is often shopping around for yet another brand to try that might give baby less gut pain, and parents more relief. Why else would there be so many different varieties? So many new sources of protein coming into formula? Not just cows milk and soy any more, but goat and rice and pea and camel and hydrolysed proteins of many kinds. (All discussed in the second section of Milk Matters: infant feeding and Immune Disorder, or the e-book, Infant Formula and Modern Epidemics.) But then I suppose you have to be living or working in an ordinary community, with a range of families, to appreciate the problems faced by formula-feeding women who cannot afford private obstetricians or daily help. In Australia at least, obstetricians check the postpartum mother once around six weeks after birth, and do not pretend to be expert on infant feeding. (Though some accept free formula supplies from companies, a clear indication of ongoing ignorance. Does Tuteur, I wonder?)

SUPPLEMENTATION OF BREASTFED BABIES

So is supplementation with formula a problem? Well, that depends on many things, and since it is discussed at length in the book available free online, I’ll just say: read Chapter 2.5. The age of the child, and the dose, are very significant factors to consider. https://www.researchgate.net/publication/333717900_Milk_Matters_Book_One_by_Maureen_Minchin/

The importance of early exclusive breastfeeding – or at least breastmilk feeding – has emerged along with the science of epigenetics and the microbiome, so that experts now talk of “the necessity of breastmilk as the first food.” The Flaherman et al study Tuteur cites as supporting early supplementation of breastfed babies was mis-reported in the popular media, and it is by her. pp.113-115 of Milk Matters discusses this study, often cited as proving that giving formula in the first few days of life improves breastfeeding outcomes at three months.It doesn’t show that. What it does show, clearly, is that the larger the amount of formula given in the early days of life, the smaller the likelihood of continued breastfeeding at three months of age. But you won’t see that, if you just skim the abstract and conclusions. Any formula given in the early days of life has a negative effect on breastfeeding duration. And that fact is backed up by many studies, including this one: https://www.contemporaryobgyn.net/modern-medicine-news/hospital-formula-cuts-likelihood-breastfeeding

SUFFERING

Perhaps reflecting her own experience, Tuteur talks a lot about suffering while breastfeeding, and never about joy. As someone who suffered through three months of unbelievable nipple pain thanks to the ignorance of doctors like herself, I would never make light of any woman’s pain during breastfeeding. But I was fortunate to have a mother who empathised, and kept saying “but when you get past this, and you will, there’s nothing like it. It’s like no other experience.” And I was old enough and smart enough not to heed the doctors with so little education about the clinical practice of breastfeeding, or the supportive mother’s groups which respected those doctors, and advised sunlight, fresh air, and lanolin as panaceas for nipple trauma. Instead I researched and found a breastfeeding pioneer doctor, Mavis Gunther, who said “there is no excuse for slovenly terms like cracked nipples, which are used only by those who have not troubled to see what the injury is.” And after dealing with positioning and attachment, dermatitis due to nipple creams prescribed inappropriately by doctors, and unrecognised thrush, I was pain-free in 36 hours. Whereas in Tuteur’s experience – “some women can do everything right, and still have this pain. It simply has to be ignored until it goes away, and it is hardly surprising that some women do not want to wait that long.” Certainly not surprising, when a mother’s milk has no special value over formula, a mother’s desire to breastfeed not validated, and above all, when a mother is dealing with a doctor who accepts that excruciating pain cannot be ended without weaning – because she does not know enough to end the pain. (Which, believe me, CANNOT be “ignored.” It is worse than labour, as Gunther also said. When teaching doctors, I ask them to visualise a paper cut on the glans penis. Most of the lads instinctively cross their legs.) Such an ignorant doctor is, I believe, a key part of the massive US healthcare problem of infant feeding ignorance. Yet Tuteur has the impudence to criticise the globally-acclaimed Professor Ruth Lawrence, whose work to educate health professionals has been exemplary, along with other members of the Academy of Breastfeeding Medicine that she and Professor Larry Gartner helped create.

And by the way, my mother was right. Once I got past the problems, the struggle was hugely worth it. Life-changing. No connection like it. Loved it. Mourned its inevitable end, when my youngest was almost four. You wouldn’t know it from Amy’s work, but breastfeeding can be a transformative experience for many women. As long ago as 1985, a chapter in Breastfeeding Matters addressed this question of breastfeeding and the mother. The joy and pleasure of breastfeeding, the grief that women feel when it’s time to end the breastfeeding experience, can be significant. Forced abrupt weaning can even trigger psychosis. [https://journalbipolardisorders.springeropen.com/articles/10.1186/s40345-016-0059-z http://europepmc.org/articles/PMC2491208

That’s not surprising. Breastfeeding is a unique whole-body experience, for both mother and baby. Outstanding feminist sociologist Ann Oakley put it like this: “The total of 2 1/2 years spent breastfeeding have given me a satisfaction quite incomparable with any other. There is something so rewarding about sustaining and making a child happy with one’s own milk. Each time each child smiled, nuzzled her or his soft head into my neck, or even thoughtfully poured the overflow down my blouse, I did feel my productivity and therefore value as a person confirmed. No other work I’ve done has ever made me feel quite that way.”

That’s personal validation, appreciated by a woman validated in very many other ways for her very many talents. But most mothers have to get past a problematic, unsupported, formula-undermined beginning, to learn what Professor Oakley meant. In a petty attempt to undermine me, a  longterm feminist, by suggesting that I reduce women to their breasts, Tuteur belittles the idea that breastfeeding success against the odds can make any woman feel validated. She clearly doesn’t know how important this can be to women, though she claims to have breastfed four children for ‘as long as they wanted’. I have to wonder, how long was that? She seems to have so little of the visceral understanding and mutual recognition of the power of this embodied connection that, in my experience, breastfeeding mothers share. Perhaps as a working mother she “combo fed” from very early on, so that her babies chose the bottle pretty quickly: that would have been usual twenty to thirty years ago in her private hospital demographic. I can only speculate and wonder about the source of her denialism, which the debate demonstrates is not rooted in science.

For the record, Dr Mavis Gunther, practising obstetrician said to have helped 40,000 mothers birth babies, described this experience in 1976 as follows – “There is an accompaniment to a satisfying feed which many women experience: a deep feeling of tranquillity, a repose that restores, a confirmation of her love of the baby and her hopes that he will grow… I am unaware of it happening during bottle feeding.” (And formula fed babies can be taught to self-feed and bottles propped, limiting the possibility of this unique maternal experience.)

TRIVIAL MATTERS… A LOT

But I should make it clear that Amy Tuteur ‘supports’, which is to say, doesn’t totally dismiss breastfeeding. Instead, she damns it with faint praise. For her, the living tissue breastmilk is just like the ultra-processed infant formula, one of two excellent choices, with a few unimportant advantages. As she sees it, “breastfeeding has real short-term benefits, but for term infants in countries with reliable water supplies, benefits are small.” Indeed, she says elsewhere that breastfeeding harms tens of thousands, even kills babies in America. (In fact it is the negligent management and lack of adequate healthcare support that puts new mothers at risk of having an inadequate milk supply.) So she agrees with Hanna Rosin’s ignorant opinion piece – one of many, used like scientific references – that those small putative benefits are to be put “on the plus side of the ledger, and other things – modesty, independence, career, sanity – on the minus side and then tally them up and make a decision.” How balanced is that? You can’t have modesty, independence, career or sanity if you breastfeed? Was that Tuteur’s/Rosin’s experience? It might explain a lot.

To say that no baby born at term in America has died recently because formula-fed/not breastfed is just absurd. Consider the 50% reduction in SIDS cases among infants fully breastfed for two months – which says formula feeding doubles the risk of cot death in term infants. www.sciencedaily.com/releases/2017/10/171030123401.htm There’s a long list of health concerns for term infants, many leading to deaths, summarised in chapter 2.11 of Milk Matters (it’s a free download at https://www.researchgate.net/publication/333717900_Milk_Matters_Book_One_by_Maureen_Minchin/ Tuteur insists we shouldn’t worry about formula-fed term babies, but she doesn’t catalogue the deaths and lifelong disability caused by necrotising enterocolitis and sepsis and meningitis in American infants, not all of them pre-term and sick. Deaths from gastroenteritis and bronchiolitis and other infectious diseases are far more common in formula-fed children. A formula-fed infant in a NICU is up to ten times more likely to develop such devastating problems, and roughly a fifth of those affected by NEC will die. Which for some could be preferable to the life they will have, brain-damaged and unable to eat normally. Class actions by parents of survivors harmed recently are likely to be successful, since all that has been known for fifty years or more, and proven definitively since the early 1990s.

And this real feminist can’t overlook or ignore, as Tuteur blithely does, maternal disease, cancer, depression, and premature maternal deaths, for that matter. The evidence for higher rates of morbidity from cardiac disease and reproductive cancers continues to increase: search any database. This doctor, who is so concerned about formula-feeding mothers being shamed, doesn’t see the need to advise women of the higher rates of reproductive cancers that not-breastfeeding women everywhere experience. Breastfeeding may even “attenuate the increased risk in women with a first pregnancy at older ages”, typical of advantaged women – like her online followers perhaps? Some of whom may have another child and be able to reduce their risk? I think that denying this information to any female is appalling. http://europepmc.org/abstract/MED/30964816.

Perhaps Tuteur feels that in America those risks are “trivial”? Or that women who matter (some of us don’t) can all afford the medications and surgery and hospitalisation these conditions often involve. Chapter 2.10 of Milk Matters covers some of the maternal risks, though there have since been many more recent studies: here’s a couple of big population-based studies for starters, and an overview in contemporary OB/GYN https://www.contemporaryobgyn.net/article/long-term-maternal-benefits-breastfeeding Trivial? Not real? https://www.ahajournals.org/doi/pdf/10.1161/JAHA.117.006081 https://www.ncbi.nlm.nih.gov/pubmed/12133652

As I said, basically Tuteur’s argument is that breastfeeding’s “benefits” for term infants are “trivial” in a country like America where everyone has access to clean water [really?? wells near old industrial and fracking sites? climate change effects? Flint, Michigan? Minnesota? https://www.mprnews.org/story/2019/04/03/minnesota-tightens-rules-on-forever-chemical-in-drinking-water?] For Tuteur, just as for the infant formula industry, it is only the water and poverty which causes problems, and only in countries other than America. And formula itself is a perfectly satisfactory substitute for breastfeeding, “one of two excellent ways to nourish an infant” (p. 243). Not even the formula companies will publicly go that far nowadays (but then, they do read the science.) They say strongly that breastfeeding is superior to formula, and their product is for use only ‘when breastfeeding fails or is insufficent’. Industry knows – perhaps Tuteur doesn’t? – that no powdered formula can be sterile, and that recalls of formula happen, due to the discovery of pathogens linked to sepsis, meningitis, even deaths (fortunately hard to prove as due to formula, because of the nature of the powder, and the tests used.) Possibly Tuteur takes for granted – as high income women sometimes do – the use of pre-packed liquid end-sterilised ready-to-feed formula, a product well beyond the means of most people (now that the US government no longer pays full price for infant formula it gives away. The shift to formula powder is recent in the United States.) But liquid RTF formula is a product with its own problems – see Milk Matters pp. 246-250 ).

Tuteur also states that WHO and UNICEF recommendations were written for, and are applicable only to, less affluent nations. Both global organisations utterly reject that distinction, seeing all human babies as having the same basic physiological needs, and supporting the Baby-Friendly Hospital Initiative in all countries. In the UK, where there is a National Health Service and healthcare is available to all, UNICEF actually auspices it. And breastfeeding is seen as an important part of any move towards reducing social inequalities that limit the human potential of the population. Breastfeeding advocacy is part of the global movement for women’s human rights. Enabling breastfeeding is a piece of the social equity jigsaw, needed both to reduce mortality and improve survival. Some relevant links…

https://bfmed.wordpress.com/2018/05/09/breastfeeding-advocacy-and-womens-rights/

https://bfmed.wordpress.com/2016/04/03/nickkristof-when-whites-just-dont-get-it-breastfeeding-is-not-a-personal-behavior/

https://bfmed.wordpress.com/2019/04/16/eliminating-disparities-in-breastfeeding-and-infant-mortality-conference-2018/

https://bfmed.wordpress.com/2015/10/18/promotion-without-support-a-reply-to-editorials-that-attack-breastfeeding-advocacy/

SCIENCE

So much misrepresentation and sensationalism is tedious to keep cataloguing and rebutting. To here, I have focused on the breastfeeding chapter, Breast is not always best. It should be said in passing, that of the 35 references for that chapter, more than half are opinion pieces or reportage from one or another jaundiced point of view.

It is in respect to the science that Tuteur’s ignorance shows most clearly. She dismisses as not evidence for breastfeeding benefits, “The statements of authority figures or organizations, scientific citations of studies that found effects in small groups, the naturalistic fallacy (“if it’s natural it must be good”), personal beliefs and personal anecdotes, mathematical models based on extrapolation of small studies.” Yet her book gives just such anecdotes, and cites just such studies, ones inadequately described or misinterpreted.

The first such study was the very small and roundly criticized supplementation study, described earlier. https://infantfeedingmatters.com/elf-feeds-a-fairy-story-analysed/ The second is a sibling cohort study which I analyse on pp. 144-5 and 162-4 of the downloaded Milk Matters; it too has been extensively critiqued at https://bfmed.wordpress.com/2014/03/01/reports-on-breastfeeding-sibling-study-are-vastly-overstated/ And Tuteur misuses the results of the PROBIT study, looking at an intervention designed to encourage breastfeeding in a very different culture where breastfeeding was common in both arms of the trial, and formula feeding a recent innovation. PROBIT was NOT a study designed to compare the health of children who were exclusively or partially breastfed, or not breastfed at all.

There are many problems with most of the infant feeding research, virtually all of which favour the null hypothesis, reducing outcome differences between breastfed and not breastfed children. I have described the various streams of evidence elsewhere. https://infantfeedingmatters.com/evidence-streams-in-infant-feeding-ex-debate/

Tuteur rarely, if ever, mentions the objective measurable  biological science underpinning the growing global awareness of the concept of programming health for life, the developmental origins of health and disease (DOHaD). We hear nothing of findings such as the increase in DNA damage and chromosomal breaks found in formula fed infants by curious cancer researchers (Milk Matters p.32). There is no mention of the work that leads scientists to state that “the suckling period is critical for epigenetic development of intestinal stem cells, with potential important implications for lifelong gut health, and … the gut microbiome guides and/or facilitates these postnatal epigenetic processes.” http://www.genomebiology.com/2015/16/1/211 doi:10.1186/s13059-015-0763-5   Why would she mention it, when she considers irrelevant all laboratory based science, all animal studies, all observational/correlational studies with small sample sizes (by which she means less than huge population-based studies), and much more?

So nowhere would she quote Professor Allan Walker saying “Breast milk stimulates the proliferation of a well-balanced and diverse microbiota which initially influences a switch from an intrauterine Th2 predominant to aTh1/Th2 balanced response and with activation of T-regulatory cells by breast milk-stimulated specific organisms … The breastmilk influence on initial intestinal microbiota also prevents expression of immune-mediated diseases (asthma, IBD, type 1 diabetes) later in life through a balanced initial immune response, underscoring the necessity of breast feeding as the first source of nutrition.” Mind you, she probably didn’t read that paper, also referenced in Milk Matters.

Nor would she cite the growing scientific opinion that milk is “the single most important postpartum element in neonatal metabolic and immunologic programming” (ref. Milk Matters, p.31) Her understanding of immunology is seriously deficient. Associate Professor Katie Hinde’s work is singled out for ridicule, but in fact uses ultrasound studies that clearly demonstrate limited backflow of milk/saliva into breast ducts as the baby feeds. A true denialist, Tuteur simply doesn’t believe what every milk scientist knows, that antibodies can be passed to the baby in breastmilk. Protective antibodies “cannot be passed in breastmilk” she says, on p. 130. Yet scientists long ago described the enteromammary and bronchomammary pathways whereby sensitised cells migrate from the gut and respiratory tree to the breast, and there stimulate antibody production, with the antibodies passing into milk. [Known about since 1978 and 1981, as references in every edition of Breastfeeding Matters make clear. Discussed in the free online Cambridge University Press book, Ever Since Adam and Eve: the evolution of human sexuality. https://www.researchgate.net/publication/317244602_Ever_since_Adam_and_Eve_the_Evolution_of_Human_Sexuality ] Mammals do respond to pathogens by making antibodies that do reach the offspring via milk. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1061123/ Despite what th science says, Tuteur simply doesn’t believe that the maternal breast tailor-makes antibodies to pathogens the breastfed child has been exposed to. And fails to mention that every day mothers are transmitting milk-borne pluripotent stem cells to infants. Is that simple ignorance or stubborn denialism? Both are morally culpable in any advantaged doctor who presumes to advise women about infant feeding.

Oh, but she is an expert. “Breastfeeding can’t replace vaccination,” she declaims. No one said it does, so far as I know.  But in fact, breastfeeding is the  first and most fundamental vaccination, the most important influence on the gut microbiome, daily ever-changing immune protection. https://news.un.org/en/story/2016/07/535732-breastfeeding-within-hour-birth-provides-babys-first-vaccine-says-unicef https://www.nature.com/articles/s41586-018-0617-x

Errors happen in studies, of course. I have written to scientists whose conclusions don’t accurately reflect their evidence. Rarely will the error favour breastfeeding, however. In most cases, the problem is that there are simply no truly exclusively breastfed infants in the study, but the control group is said to have been exclusively breastfed; in effect, two mixed-fed groups are being compared. Or the authors omit from the abstract and conclusion, a finding from the study which shows breastfeeding has benefits that formula doesn’t.

A classic example of this latter failing was a paper comparing two formulas with a so-called “exclusively breastfed reference group”. It wasn’t that! Read http://europepmc.org/abstract/MED/24500150 Infants were just solely breastfed at time of entry, of up to two months old. And to add to the confusion, the formula-fed infants had been breastfed for anything from 5-41 days, on average around 3 weeks, before trial entry. And both groups got tastes of food from 4 months. So, three groups of differently mixed-fed infants. The experimental formula was said in the conclusion –which is all most people read – to have “eradicated the gap” in cognitive development with breastfeeding – and yet, in the paper, the so-called breastfed reference group babies “performed better on the verbal analysis scales“. Let’s do that trial with truly EBF from birth and truly EFF from birth infants? I’d put long odds on the differences becoming much more significant. And let’s follow those children long-term. And let’s look at who funds such misleading studies.https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-S3-S18

Within the health industry and research professions there seems to be widespread anxiety about upsetting people who don’t like the conclusions research produces – but only when the conclusions favour breastfeeding. Nobody enjoys negative or uncivil feedback, and the internet creates opportunities for cowards hiding behind pseudonyms (typical of the most ardent cultists.) And of course the huge underpinning of research to infant formula companies creates pressures towards minimising differences. Why? because formula is necessary to WEIRD society. A senior FDA scientist told me that “We have to reassure parents that infant formula is safe, because American society depends on bottle feeding.” But of course that’s true, American society does. Societies have to change, to end their dependence on bottle feeding. And better-informed ob/gyn doctors are among those trying to make change: https://www.contemporaryobgyn.net/editors-choice-cog/breastfeeding-myths-and-mainstays-obstetrician

Omnivore infants can survive, and have survived, on other foods than breastmilk. But not without consequences. We have only recently learned that those pluripotent stem cells in breastmilk reaching infant organs including the brain. (Tuteur doesn’t mention that either). Though we have known since the 1980s that in organ transplantation, the best chance of success comes from having a donor related to your mother, but only if you were breastfed. The world is coming to realise that breastmilk, white blood, is indeed “the elixir of life’ as Tuteur said it would be, if it did as its advocates claim. The unchallenged global consensus endorsed even by the infant formula industry is that it does. Read https://infantfeedingmatters.com/tuteur-debate-minchin-1/

There are many other science-related aspects that could be discussed here, and many are covered in my online debate replies. All add up to what the UK Royal College of Paediatrics and Child Health (lactivists, Amy T?) approved in the NHS-funded e-Learning for Health module on Infant Formula, which begins with: “The only accepted alternative to breast milk for infants up to 6 months of age is infant formula, which supports bodily growth along parameters different from those of the breast-fed child, and provides no immunity against disease. Many of the health outcomes of breastfeeding compared to formula feeding are dose-related: that is, better outcomes are associated with longer duration and exclusive breastfeeding, or less exposure to infant formula. For infants, formula will always be an inferior choice to breast milk.” Sometimes, formula is an unavoidable option, and it’s the parents’ business to decide. But they shouldn’t make that decision assuming that it makes no difference to their child’s health, short or long-term, or the mother’s own health for that matter.

Tuteur asserts that the predictions made about the benefits of breastfeeding should be able to be graphed the way the correlation between smoking and lung cancer can be graphed.  In fact, if she is referring to excellent statistical work projecting massive savings in lives and societal costs, by Melissa Bartick, the World Bank, UNICEF and WHO, or the Oxford Perinatal Epidemiology Unit, we could not expect the predictions to have been proved true. Why? Because the clearly-stated conditions for the projections – the extent  of breastfeeding in practice and its duration – have not been met. You don’t have to be a genius to know that you can’t plot the effects of what hasn’t yet happened. But equally, all government planning is done on the basis of such projections, and economists all the way up to the World Bank find the projections valid: we should ignore them all, and just believe Amy? Cultists might, I suppose. Intelligent readers are less likely to.

AND NOW THE MONEY!

Another chapter, The Business of Breastfeeding is equally problematic. First our Amy gets the history completely wrong. In the 1980s, the mother support group La Leche League International recognised the need to identify health professionals who knew something about breastfeeding. Their volunteer mother leaders were forbidden to give medical advice, only permitted to give classes, and support and provide basic resources). They could not ‘diagnose’, and were obliged to refer women with ‘medical’ problems on to health professionals. So leaders needed to identify professionals who would not just give a bottle (the way Dr Amy seems to) as the solution to a breastfeeding problem. It was LLL Leaders who began to try to educate health professionals, and LLLI’s Board, dominated by health professionals, which saw the need for such resources. LLLI raised money to help create a fully independent, legally accredited, certifying body, the International Board of Lactation Consultant Examiners.

The problem of ignorant health professionals was acute in all western nations. Formula feeding was the norm. 1970s breastfeeding rates around 20-25% meant that few healthworkers had been breastfed, and few had breastfed their children. Lactation and breastfeeding did not feature in medical curricula. In both Australia and America in the 1980s, economic circumstances were forcing women to return to work, like it or not. (Some would prefer to stay at home, and do not think it a waste of their talents to care for their own child, but this always involves substantial financial loss, and is impossible for many outside Tuteur’s level of advantage.) The volunteer pool of women willing and able to help others with breastfeeding had never been huge, nothing like the numbers needed to reach all women in societies where 80% had been formula fed. That inadequate pool began to dry up. It had never been big enough or wealthy enough to reach beyond the demographic that spawned it, advantaged women. Some volunteer leaders wanted to continue helping mothers, but were unable to do so without accreditation and income.

The knowledge and skills the volunteers had developed in community experience meant that a minority would go on to train as pioneer lactation consultants. However, the vast bulk of the new profession created in 1985 consisted of medically-certified nurses, doctors, midwives and allied health professionals, including pharmacists, obstetricians and paediatricians, even neonatal specialists. These were people already charging for their time – as I daresay obstetrician Tuteur then did, before retiring in 2003, and did not see herself as exploitative. There was no sudden influx of new people, ‘lactivists’, simply a formal process for recognition of appropriately qualified people who had studied human milk and lactation. Eligibility criteria to sit the exam are fairly high, and failure is not unknown! IBLCE never has and does not generate funds for LLLI: it has repaid the loan. That’s the truth.

What’s Tuteur’s  lie? The situation was not , as Tuteur says, that “Prior to the 1980s a volunteer from La Leche league would assist any women with breastfeeding” but then, Tuteur alleges, LLLI “realised the money to be made by professionalising breastfeeding advice and created the lactation consultant credential” so that “women suddenly had to pay for help that previously they got for free.” Slanderous, wrong, sloppy research, unconscionable lies, Ms Tuteur. I know, I was involved, the only non-American in the earliest stages of that development. Because LLLI recognised that in my book Breastfeeding Matters: what we need to know about infant feeding, I had identified in Australia the same problems as in the United States. LLLI could see that volunteer ranks would thin, as family finances tightened in the Greed is Good 1980s. But LLLI and many other “lactivist “ organisations like the Australian Breastfeeding Association, and dozens of other IBFAN (International Babyfood Action Network) member groups, continued then, and continue now, to provide free volunteer support and education in countries around the world. LLLI/ABA/IBFAN mothers do not charge for their help, though all volunteer organisations do need to raise money from education. And all struggle for volunteers to train in nations where breastfeeding had become a persecuted minority activity by 1970, so that most grandmothers had bottle fed and could not help with breastfeeding problems, and women could not breastfeed in public. These unpaid and unsung volunteers are some of the “vile lactivists” Tuteur excoriates as “Sanctimommies” and worse, “cruel” people who strive to hurt and shame other mothers as a way of feeling superior themselves. Tuteur uses a curiously revealing phrase, alleging that this motivates ‘lactivists’ : “the joy of shaming.” To me, that seems to describe her writing, but she is the one who should be shamed – and ashamed..

Of course in capitalist America, many other courses and certificates have since emerged, and the relative stringency of their certification is unknown. Such an industry would not be needed, or commercially viable, if it was mandatory – as it should be – for every standard medical trainee to learn about breastfeeding. Lactation lasts longer than pregnancy, and can be just as complex, and affects more people than many of the other conditions and diseases that those healthworkers must pass exams about. Imagine if doctors got just one hour’s education on the whole of pregnancy, and then were the go-to for pregnant women. That’s what had been happening with lactation: almost no education, and then advising women feeding babies. Fortunately, some doctors have listened to mothers, and now taken the initiative in trying to remedy this ignorance, so things are improving. It helps that doctors have been convinced by the science, and ensure that their own babies are breastfed, or get breastmilk, at least for the early stages of infancy. Many choose to work part-time to enable breastfeeding. It also helps that for the first time there is some substantial funding going onto the cause of medical education, and projects such as e-Learning for Health in the UK, and LactaMap have been funded https://www.lactamap.com/home/about-us

MORALS AND MONEY

More ignorant comment from Tuteur: she alleges that “The moralisation (?) of breastfeeding has paralleled the monetisation of breastfeeding. It wasn’t until lactivism became a business that breastfeeding became a moral imperative.” For crying out loud, people have been ‘moralising’ about breastfeeding for many centuries, sometimes to encourage it, sometimes to condemn it. Not until the 1990s were there even a few thousand certified lactation consultants, many of whom were doing pretty much the jobs they always had been. Correlation is not causation, parallel lines don’t meet.

As for breastfeeding as “a moral imperative” – for some in cultures that value breastfeeding and children, such as muslims, catholics or orthodox jews, it may well be so, and there’s nothing wrong in that – unless you’re an advantaged irreligious bigot. For many, probably most women globally, it’s not a moral imperative,  just a biological imperative, as I said earlier. Apparently Tuteur doesn’t realise that mothers might feel, intensely, that their bodies ought to work well, and so feel grief or disappointment when struggling to do what they feel is biologically normal. I would expect even a long-retired obstetrician still to understand the grief involved in infertility or pregnancy loss. When women want to breastfeed, take it for granted that the breast should function, understand that their milk has unique value, they can grieve when things don’t work as they should. And that grief comes not from moralising, or societal pressure, but from deep within, probably an outcome of the evolutionary process in which lactation is the key mammalian survival mechanism, together with the complex hormonal changes of pregnancy and birth and lactation. It’s physiologically normal to breastfeed, and so it’s biologically normal to be upset if that doesn’t work well. In my experience, nothing takes away that regret and grief from women who wanted to breastfeed fully and were not able to. (Even if the baby does well on formula, with no digestive issues emerging a week or so later, as is common.) Breastfeeding grief is felt just as infertile women feel grief when their bodies do not work the way they expect them to. Not because anyone else ‘makes them feel guilty’ or shamed. (Though some have been shamed by doctors after confiding that grief! “Why would you worry about that? Baby is doing fine.” “It’s just your hormones, you’ll get over it.” ) Like all mammals, humans have powerful inbred instincts. “Normal” is not altogether a social construct! And instinct can be stronger than logic.

As ‘the joy of shaming’ phrase exposes, Tuteur’s writing has some very curious, perhaps unintended relevations. What do we make of her statement that the benefits of breastfeeding are “small and short-term. That’s why there is no reason for any mother who chooses bottle feeding to feel guilty.”(p.134-5) Which implies that were she to accept the global consensus that  the benefits are clearly proven both large and long-term, she herself might feel guilty, or feel that others should do so…

Personally, I believe that women need never feel guilty about their infant feeding practice, if it is the best decision for the family in their circumstances. No one can assess that better than they. I also know that many women are not making free and informed choices, but constrained and ignorant ones. The decision can be heavily influenced by factors outside their control, and the outcomes influenced by the past feeding practised by generations long-gone. And social structures need to enable choices to be carried through. Again, why should the mother feel guilty? I’ve written an appendix about guilt and responsibility In Milk Matters.

MORE SWEEPING ASSERTIONS

Other passages in the book jump out at me: sweeping assertions without even the courtesy of a citation, so that readers could evaluate the accuracy of her sound bites. For instance: the allegation that scientists’ results don’t justify their assertions of benefit for breastfeeding. Who is referred to, what article, what journal, when? Tuteur should be brave, name and shame them, rather than slander all scientists, as this sweeping generalisation does. Of course named scientists might object and prove Tuteur got it wrong – and probably she did, given the standard of this book’s research.

Then how about Tuteur’s statement that “lactivists often claim that infant formula was invented even though there was no need for it.” Reference please? If it’s true, those people are ignorant, and we can educate them. Most advocacy writing in fact describes the real physiological causes that create a need for substitutes for mothers’ milk. And I have traced the historical context in which it emerged and was protected, promoted and supported by the US Government.

Or her statement that lactivists claim that “an unholy alliance of formula makers and physicians subsequently tricked women into believing in non-existent benefits.” Again, reference please. But does Tuteur believe that widespread marketing of a modern ‘scientific’ product from the 1860s onwards did not influence the increase in artificial feeding practices, and the perception of ‘equivalence’ that undermines breastfeeding? (Like some American manufacturers around 1930, she doesn’t like that accurate collective term for bottle feeding.) Does she think that companies spend all those many billions of marketing dollars, more than on research, to no avail? I’m not going into this history piece further, as in September I will be able to post online my chapter on the history of infant feeding, from the recently published text, Breast Milk and Breasfeeding: from Biochemistry to Impact.

But Tuteur goes on and on like that, with statement after statement untethered to any reference. It seems she thinks we should all just take her word for it.  Even if she didn’t lie,  why would anyone accept her word over the global consensus? Who is Amy Tuteur that she outranks WHO, UNICEF, the AAP, ACOG, national governments, and so on and on? She offers no evidence for her views, simply declares it a logical fallacy to accept the evidence of authorities with access to all the evidence and expertise in interpreting it. It would be far more illogical for anyone to accept Tuteur as an  authority. Consider what she does next.

N-WORDS, TRUTH AND LIES

Which brings me to Tuteur’s allusion to the deeply offensive racist N-word. I’m not a woman of colour, but I suspect some who are might find it offensive, and very like cultural appropriation, for a wealthy white woman to say “the two ugliest N-words in contemporary parenting are these: normal and natural.” (p.311). She goes on to say that there is “a fundamental ambiguity between normal as common and normal as morally preferable.” So for Tuteur “normal” is either usual (‘of course what we wealthy Americans do is the human norm’), or else value-laden.

There is a third option in use by healthworkers. As noted earlier, breastfeeding is simply physiologically normal, neither usual (in America that’s bottle feeding) nor morally preferable (that’s whatever’s best for the family). Normal is simply what mammalian bodies have evolved to do. Or in the case of adult women, to choose not to do if their circumstances warrant that, since humans live in complex societies and can assess options. But breastfeeding being factually, physiologically, biologically normal means that not to do it will involve the emergence of unpredictable physiological differences. The not-breastfed child will not be the exact child they would have been if breastfed. More and more biological studies are showing that to be the case. Nutrition influences gene expression and shapes growth and development. Now that the tools exist to look, research reveals minor to substantial differences in organ size and development, in MRI-proven brain white matter and ultrasound-measured reproductive tissue development, in body mass and composition, in risk of disease and disorder. And the mother who does not breastfeed will be different from the woman she would have been if she had breastfed: more at risk of disease and death because existing in an un-physiological hormonal state after birth. This is not moralising. This is not scare-mongering, even if people find it scary. It’s just biological fact. Does it matter? the epidemics of vertically communicated disease that plague the WEIRD world and command suggest to me and others that it does. Read the now-online part of Milk Matters and see what you think, gentle reader. https://www.researchgate.net/publication/333717900_Milk_Matters_Book_One_by_Maureen_Minchin

Uncomfortable facts need to be considered when making important decisions, not concealed because they might be upsetting. It’s a LOT more upsetting to discover after the event that you have inadvertently harmed a child, or increased your own breast cancer risk, when that could have been prevented, if only had you known. Research by Professor Ruth Lawrence found that understanding the risks before making a decision about infant feeding meant that mothers who knew, and bottle-fed, were later less distressed by media reports of the risks, than mothers who had not known about those risks before they chose to formula feed. Those who had known were not ambushed by the truth when it was too late to change; those who were bottle feeding had made a conscious choice.

LIES, DAMNED LIES AND…..

Given all that I’ve read of her writing, I’m somewhat surprised to read that Tuteur considers that it’s wrong to lie. When condemning someone else for misrepresenting her feeding practice as breastfeeding (when the woman also used bottles to feed her baby with her breastmilk), Tuteur says “Lying is not a good way to relate to others. It is a fundamental violation of their trust and has long-term consequences. They will be much less likely to trust you going forward.” (p. 325) Indeed. As I have learned dealing with her over the debate we have completed. What she said she would do, and what she did, differs greatly. What is recorded on Facebook pages and websites does not always accord with her version of events. To put it politely. (See my Tuteur-Minchin Timeline document on  tuteurminchindebate.wordpress.com)

But surely persistent misrepresentation of what others say or do (see above) is a form of lying? So too is creating strawmen or women in order to be able to cut them down.  But what’s her biggest lie?

Tuteur says on page 326 that everyone who wants to convince you that breastfeeding is not “trivial in the overall scheme of childbearing” is “willing to lie” to maintain “their own best interests.” That’s a very large, provably false claim. Since she says it categorically and deliberately, I consider it to be a lie. I know too many people of whom it is utterly untrue.

Tuteur also said about the woman she pilloried for lying, “She was actually engaging in the very behaviour she was ostentatiously condemning in print.”

And that seems to me a perfect summation of Tuteur’s writing, and a classic case of “physician, heal thyself”.

MY CONCLUSIONS

This was a deeply unpleasant book to read, feeding on and fostering bile, full of what I see as vitriol and hate speech. The book raises questions in my mind about how Tuteur profits – personally and financially? – from this sort of behaviour. Since writing exposes the writer, the book also raises questions about what problems the author has had to deal with, and the detail of her own parental experience. If anyone made to me such outrageous allegations about people she doesn’t know from Adam, I would be gently suggesting psychological counselling for anger management.

But privilege brings responsibilities. Harvard-educated doctors should do, and be, better than this. All that advantage, and this is the result – an insulting, divisive diatribe? A woman encouraging other women to increase their risk of disease and early death? Denouncing as self-interested and vile lactivists everyone from the World Health Organisation down to the unpaid volunteer mother supporter?

How did the publisher’s reviewers and legal team not see the defamatory, inflammatory, and societally unhelpful nature of the writing? Calculating that those slandered, like LLLI, were not wealthy or powerful enough to sue for damages would be despicable. Not what I would expect of any ethical publisher. Publishers have social responsibilities, never more important than in this era of fake news and lies. And they need to consider that real people, babies, women, and the next generation, can be harmed by printed lies. Personally, I think retired obstetrician Amy Tuteur, and her publisher, HarperCollins New York, should both be deeply ashamed of this book, no matter how much money they have jointly made from it.

Perhaps, by way of apology, HarperCollins might voluntarily donate the equivalent of Tuteur’s “six-figure advance” to LLLI, and a similar amount to the SUN, Scaling Up Nutrition movement, both helping women achieve their goals in feeding their babies. https://scalingupnutrition.org/news/sun-movement-newsletter-september-2018/

Because if this book and its website influences elite women in any country to choose Tuteur’s second “excellent choice”, then HarperCollins too is undermining public health for profit.

Maureen Minchin www.infantfeedingmatters.com

June 30, 2019