When Tabitha Walrond's 7-week-old infant died of starvation last year, the fact that this young New York mother had attempted to breast-feed her baby -- albeit with obvious lack of success -- was widely blamed for the complex and haunting tragedy. The national headlines regarding the Walrond case were ongoing and sensational. "Nursed to Death" read one. "Breast-feeding can kill?" inquired another.
During the same period, the similar death of the 6-week-old breast-fed baby of another New York mother, Tatiana Cheeks, raised further breast-feeding concerns in the press and with the public. This time one headline read "Nursing Death?" In 1995, a widely-circulated Wall Street Journal article detailing dehydration in several middle-class breast-fed babies whose mothers had experienced breast-feeding difficulties led to a surge in phone calls to pediatricians and hospital hotlines across the country from new parents worried that breast-feeding itself could somehow harm their infants. Given this environment, many conscientious new parents may conclude that formula-feeding represents a safer alternative to the potential "dangers" of breast-feeding. In fact, nothing could be further from the truth.
In virtually all of the reported cases each year in which a breast-fed baby becomes seriously ill as a result of her mother's feeding choice, the problem is actually one of not breast-feeding -- meaning that, as in the Walrond and Cheeks cases, some uninformed and unsupported nursing mothers are not aware that they aren't effectively transferring milk from their breasts to their babies. In sharp contrast, however, routine formula feeding -- even when done properly by parents -- is itself a contributor to overall rates of infant morbidity and mortality in the United States. This is because -- despite what manufacturers' advertising would have parents believe -- today's commercial infant formulas, while a marked improvement over the homemade concoctions of years past, still represent a flawed and highly inferior imitation of our own, species-specific milk.
According to the American Academy of Pediatrics' most recent member survey, a majority of baby doctors see slightly more formula-fed babies than breast-fed babies admitted to the hospital for instances of malnutrition and failure to thrive. But this represents only the tip of the iceberg when it comes to the differences in rates of morbidity and mortality between formula-fed and breast-fed infants in this country. When the overall health of formula-fed infants in the U.S. is compared to that of breast-fed infants -- even after controlling for variables such as parents' socioeconomic backgrounds -- it becomes clear that formula-fed babies are sicker, sick more often, and are more likely to die in infancy or childhood. However, parents often lack access to this information, and in fact, are often the recipients of misinformation, thus denied the ability to make truly informed choices regarding how they will feed their babies. Although the phrase "breast-feeding is best" is tossed around so liberally as to have been rendered almost meaningless, many Americans are under the mistaken impression that today's commercial infant formulas are nearly identical to human milk. And because of this, parents who routinely approach other important infant health and safety issues in a thoughtful, deliberate way are largely unaware that in epidemiological terms, the decision to formula-feed when breast-feeding is an option places their child at demonstrably higher risk for a wide variety of ailments.
"Parents are not adequately informed regarding the real risks of artificial milks [infant formula]," says Nancy Wight, MD, FAAP, IBCLC, and a neonatologist at Children's Hospital in San Diego. She says that she considers it part of her job to strongly encourage the parents of her patients to breast-feed. "Doctors never worry about making parents feel guilty when we discuss childhood immunizations, car seats, seatbelts, bicycle helmets or fencing around pools. I have an obligation to my patients to give them correct information -- not formula marketing slogans -- and let them make the choice."
Dr. Lawrence Gartner, MD, FAAP is a respected medical authority on infant feeding who has played a role in drafting policy statements for the AAP regarding this issue. He agrees that parents today aren't fully aware that the breast-or-bottle decision is more than just another neutral lifestyle choice."Compared to other equally important child safety issues like car seat use or babies' sleep position, parents should understand that the decision whether to breast- or bottle-feed ranks right up on top when it comes to protecting babies. The AAP certainly puts it in that category."
In fact, the AAP explicitly states that encouraging breast-feeding among parents is "as important to preventive pediatric health care as promoting immunizations, car seat use, and proper infant sleep position."
Katherine Dettwyler, Ph.D., associate professor of anthropology at Texas A&M University and an internationally recognized expert on infant nutrition, agrees with Gartner's assessment of the relative risks of "artificial feeding" for American children. "I would rank the decision of how to feed your baby as the No. 1 infant safety issue in this country," says Dettwyler.
Despite the widespread misperception that aggressive promotion of breast-feeding has had a major impact on how we feed our babies, more than 70% of infants in the United States are fed infant formula as their primary source of nutrition for most of their critical first year of life. According to a recent report in the Washington Post, although a federal survey in 1995 found that 58% of American mothers start off breast-feeding their babies -- the same percentage as a decade earlier -- 20% fewer mothers today are still breast-feeding after three months. While it is certainly true that many individual formula-fed infants will do "just fine" (as will most unvaccinated individuals in the United States), the research clearly indicates that, as a population, America's formula-fed babies are not "fine" at all.
"Sure, you can speak of the benefits of breast-feeding," explains Dr. Gartner. "But it's really just as accurate -- maybe more accurate -- to speak of the risks of formula-feeding. Unfortunately, the large volume of medical literature we now have that demonstrates this is written from the perspective of proving the 'advantages' of breast-feeding -- as if formula-feeding were the gold standard. But when you read the literature the other way around -- as it should be read, really -- the results are rather startling."
These "startling" results were crystallized in the AAP's exhaustively researched 1998 Policy Statement on Breast-feeding and the Use of Human Milk. For the first time, parents can easily access a readable, comprehensive overview of all the most current medical literature related to infant feeding. Summarizing the results of their study, the AAP Policy Statement notes that infants who are not breast-fed "in the United States, Canada, Europe, and other developed countries, among predominantly middle-class populations" see an increased incidence and severity of such diseases as diarrhea (a malady from which approximately 500 American children aged 4 and under lose their lives each year), lower respiratory infection, otitis media (ear infections), bacteremia, bacterial meningitis, botulism, urinary tract infection, and necrotizing enterocolitis. The AAP goes on to say that a number of studies now indicate that breast milk may lower babies' risk for sudden infant death syndrome, insulin-dependent diabetes mellitus, Crohn's disease, ulcerative colitis, lymphoma (cancer), allergic diseases, and other chronic digestive diseases.
"More than 1,000 childhood deaths per year in the United States could be prevented through breast-feeding," says Dr. Allan Cunningham, associate professor of pediatrics at the State University of New York Health Science Center, Syracuse and the author of scholarly articles on the mortality risks of bottle-fed babies in the United States. "This includes infants who die from a wide variety of illnesses such as diarrheal diseases like rotavirus, as well as pneumonia and bacterial meningitis. Although the 'Back to Sleep' campaign has made a large dent in the number of babies who die each year from crib death, my estimate is that you roughly double the statistical risk of a baby dying of SIDS if you formula-feed. This is something parents just aren't made aware of."
Dr. Cunningham has published research in leading pediatric journals indicating that for every 1,000 bottle-fed infants in the United States, 77 hospital admissions would result. The comparable figure for breast-fed infants was determined to be five hospital admissions. And Naomi Baumslag, M.D., MPH and Dia Michels note in their book, "Milk, Money and Madness" (Bergin and Garvey, 1995): "Even where bacterial contamination can be minimized, the risks of bottle-feeding are not inconsequential. Bottle-fed infants raised by educated women in clean environments, to this day, have significantly greater rates of illness and even death ... In a study that analyzed hospitalization patterns for a homogeneous, middle-class, white American population, bottle-fed infants were 14 times more likely to be hospitalized than breast-fed infants."
A May 1995 study reported in the Journal of Pediatrics, "Differences in Morbidity Between Breast-fed and Formula-fed Infants," examined "whether breast-feeding is protective against infection in relatively affluent populations." The study followed two groups of babies, each of whom was either breast-fed or formula-fed exclusively for the entire first year of life. The babies were matched for characteristics such as birth weight and parental socioeconomic status, and the study was controlled for the use of daycare. The results of this research revealed that, in the first year of life, the incidence of diarrheal illness among formula-fed infants was twice that of breast-fed infants and the number of prolonged ear infections (more than ten days in duration) was 80% higher in formula-fed infants. Breast-fed infants experienced 19% fewer ear infections overall.
In a study reported in the April 1999 issue of Pediatrics, researchers looked at the frequency of only three illnesses during the first year of life: lower respiratory tract illnesses, otitis media, and gastrointestinal illness. Infants in the study were healthy at birth and were classified as never breast-fed, partially breast-fed, or exclusively breast-fed, based on their mother's feeding choice during the first three months of life. According to the study's authors, "Frequency of office visits and hospitalizations for the three illnesses was adjusted for maternal education and maternal smoking, using analysis of variance." The results of the research revealed that there were 2,033 excess office visits, 212 excess days of hospitalization and 609 excess prescriptions for these three illnesses alone per 1,000 bottle-fed infants compared with 1,000 exclusively breast-fed infants.
To Dr. Dettwyler, more familiar illnesses, such as ear infections, represent an important aspect of the risks of formula-feeding which shouldn't be overlooked. "In this country we have just become accustomed to repeated ear infections in our babies. Although we can treat these problems with antibiotics, we should be asking ourselves how this affects our babies' quality of life," says Dettwyler.
Dr. Wight agrees. "We are accepting as normal, abnormal amounts of unnecessary illnesses such as otitis media, lower respiratory illness, gastroenteritis, diabetes and allergies, among others."
Despite the fact that the medical literature clearly supports the contention that formula-feeding represents a statistically riskier enterprise for American babies than does breast-feeding, this isn't a message parents often hear in the media. It's hard to imagine headlines proclaiming: "Mother's choice to formula-feed leads to preemie dying of necrotizing enterocolitis!" (Necrotizing enterocolitis is an inflammation of the large and small intestines, which carries a mortality rate of 20-40 percent for the 5-12 percent of all very premature infants who become ill with it. Formula-fed preemies are up to 10 times more likely to experience this serious complication, and of those infants who develop the illness, infants who aren't receiving breast milk are significantly more likely to require surgery and to die.) Individual health-care providers across the country are able to relate specific instances in which babies experienced less favorable health and developmental outcomes attributable to artificial feeding. But no one from the Wall Street Journal is calling to put these cases on the front page as evidence of the potential hazards of infant formula.
Dr. Linda Shaw, M.D., FAAP, is a practicing pediatrician in Altoona, Penn. who says that she sees "plenty of babies with formula problems ... Just a few months ago, I had a formula-fed infant I had to admit to the hospital for failure to thrive. I have also cared for infants with cow's milk protein allergies leading to gross rectal bleeding. I've seen lots of infants hospitalized with gastroenteritis or RSV [Respiratory Syncytial Virus, the single most common cause of lung infections in infants] that was worse because they weren't getting the maternal antibodies found in breast milk," says Shaw.
Catherine Bargar, RN, IBCLC is a lactation consultant in private practice in Ithaca, N.Y. She says that in her previous positions as Obstetrics Discharge Coordinator at an Ithaca hospital and as a staff member with a local office of the Women Infants and Children (WIC) supplemental nutrition program for low-income families, she saw "many babies who experienced significant negative health effects from formula." In some instances, these illnesses were actually due to improper formula-feeding, such as patients preparing formula with water from unclean wells, leading to babies with severe diarrhea requiring hospitalization. In many other cases, however, the problems Bargar observed were directly attributable to the risks inherent in any formula feeding.
"I saw countless babies suffering through numerous unsuccessful formula changes in an attempt to find one that the baby could tolerate. Details varied somewhat as to which formula had what negative effect, but the story was always the same: The mom had stopped breast-feeding or never even started and tried formula Brand X. The baby then vomited, got serious rashes, failed to gain weight appropriately, developed asthma, etc. They then switched formula numerous times with varying negative health effects and ended up with a sickly baby or toddler," recalls Bargar. "These children ended up on expensive and only marginally-tolerated formula. Often these babies were diagnosed with gastric esophageal reflux following expensive testing. This scenario was one I encountered at least daily."
Although commercial infant formulas are better than synthetic human milk substitutes of the past, the simple fact is that they can never duplicate the living, anti-infective and unique hormonal properties of real breast milk. "It has become increasingly apparent that infant formula can never duplicate human milk," wrote John D. Benson, Ph.D., and Mark L. Masor, Ph.D., in the March 1994 issue of the medical journal Endocrine Regulations. "Human milk contains living cells, hormones, active enzymes, immunoglobulins and compounds with unique structures that cannot be replicated in infant formula." Benson and Masor, both researchers for infant formula manufacturing giant Abbott Labs, went on to note that they believe that creating an infant formula that replicates human milk would be impossible.
This may come as a surprise to parents who see and hear frequent advertisements from infant formula companies touting their products as "a miracle" and "most like breast milk." In fact, formula manufacturers have no idea exactly how close their product is to breast milk because new ingredients and properties of breast milk are discovered every year. And even among those elements of human milk of which science is already aware, today's infant formula still doesn't measure up. Breast milk contains hundreds of known ingredients and elements which have not been -- or cannot be -- added to infant formula at this time.
"Modern formulas are only superficially similar to breast milk. Every correction of a deficiency in formulas is advertised as an advance. Fundamentally they are inexact copies based on outdated and incomplete knowledge of what breast milk is. Formulas contain no antibodies, no living cells, no enzymes, no hormones. They contain much more aluminum, manganese, cadmium and iron than breast milk. They contain significantly more protein than breast milk. The proteins and fats are fundamentally different from those in breast milk," says Dr. Jack Newman, a Canadian pediatrician who has been a UNICEF infant nutrition consultant in Africa, and has published articles on the subject of breast-feeding in Scientific American and several medical journals
Dr. Martha Neuringer, a research associate professor of clinical nutrition at Oregon Health Sciences University in Portland was quoted in 1994 by New York Times science writer Natalie Angier as saying that, "Human milk is an incredibly complicated substance. It contains proteins we haven't even identified yet, much less know the function of."
In the June 1999 issue of Discover Magazine, it was reported that Swedish and British immunologists working with a grant from the American Cancer Society have discovered that one identified protein in breast milk, alpha-lactalbumin, literally destroys every cancer cell with which it comes into contact. According to lead scientist Catharina Svanborg, her team pursued this exciting research in an attempt to determine why "the relative risk of childhood lymphoma is nine times higher in bottle-fed infants, and the risk for carcinoma is also elevated."
"This [alpha-lactalbumin] is a substance that kills lots of tumor cells, every cancer we test it against. Lung cancer, throat cancer, kidney cancer, colon cancer, bladder cancer, lymphoma, leukemia, and pneumococcus bacteria too," explained Svanborg in Discover.
One new tack taken by infant-formula manufacturers has been to attempt to match the body chemistry of the breast-fed infant rather than the chemical makeup of breast milk itself. Abbott Labs researchers have stated, "A better goal is to match the performance of the breast-fed infant. Performance is measured by the infant's growth, absorption of nutrients, gastrointestinal tolerance and reactions in blood."
Yet even using this standard of measurement, bottle-feeding falls short. Levels of long-chain fatty acids -- a critical component of brain development in humans -- are markedly lower in the blood chemistry of artificially-fed infants. Additionally, certain hormones, minerals and amino acids are found at very different levels in breast- and bottle-fed babies. "Formulas succeed only at making babies grow well, usually, but there is more to breast-feeding than getting the baby to grow quickly," explains Dr. Newman.
In addition to the health risks inherent in feeding an inferior substitute for mother's milk -- formula-feeding can also be hazardous due to parental misuse or manufacturing error. Child health advocates, particularly those associated with the WIC program, report that some parents dilute their babies' bottles of formula in an attempt to make the expensive product last longer. This can cause malnutrition, or a condition known as "water intoxication," leading to brain swelling and seizures. Additionally, parents who do not have access to a safe water supply place their babies at risk of bacterial contamination when they prepare bottles of formula.
Formula manufacturing errors are also far more common than most American parents are aware. In fact, the federal Infant Formula Act, which aimed to improve the safety and effectiveness of infant formula, was passed after a manufacturing error allowed a large quantity of chloride-deficient formula to enter the U.S. marketplace, causing documented health problems in a number of babies.
According to information on a company Web site from "Qualicon, Inc.," a new DuPont subsidiary that describes itself as providing commercial diagnostics in food, pharmaceutical and personal-care products, an unnamed infant formula manufacturer recently discovered that "its finished product was consistently contaminated with low levels of Enterobacter sakazakii." Although Qualicon's report of this incident states that this substance is not a known pathogen, in fact strains of Enterobacter sakazakii are known to cause deadly illnesses such as meningitis in infants fed infected formula. In this case, Qualicon describes having isolated Enterobacter sakazakii "frequently in products from two (infant formula) factories and infrequently in products from a third." Qualicon found several hundred samples and more than 30 different strains of the bacteria in both raw materials and the environment at each site. This widespread problem was found to be caused by cross-contamination due to cleaning methods and personnel movement. As this information came from a Web site advertising Qualicon's services to the food industry and not from any infant formula manufacturer, parents are unlikely to have been aware of this potentially life-threatening infectious hazard.
In early June 1999, Mead Johnson, makers of infant formula brands including Enfamil and Prosobee, reported that 120,000 cans of infant formula shipped to stores late last year were being recalled due to a labeling mistake that could lead to "severe medical problems" in some babies. Company officials said the cans labeled as infant formula could actually contain the "adult nutritional supplement" Vanilla Sustacal. No public explanation was offered for the time lapse between discovery of the problem and the recall being issued. In another recent incident, a memo released by the Georgia WIC program on May 6, 1999 announced that in April of this year, Abbott Labs initiated a voluntary recall of its Ready-to-Feed (RTF) Isomil, an iron-fortified soy-based infant formula. The memo fails to mention exactly why the formula is being recalled. In April of this year, 75,000 32-ounce cans of Nestle's Carnation Good Start brand infant formula were recalled due to the product's having "curdled." No mention of this recall was made on Carnation's promotional Web site for parents.
In fact, between 1982 and 1994 alone, there were 22 significant infant formula recalls in the United States. At least seven of these were classified by the Food and Drug Administration as Class I, meaning health problems could be life-threatening to babies who were fed the tainted formula. In many cases, parents never become aware that their child's primary food source has been recalled because this would require checking with the FDA Enforcement Report every week to find out about any new problems with various brands.
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