Lactation Consultants and formula... How did guilt, pressure and feeling bullied become the issue?

As both a Pediatric Nurse Practitioner and International Board Certified Lactation Consultant, I have a unique perspective as both a patients pediatric provider as well as lactation consultant - these should not be two different hats that I wear but just additional qualifications to support my patients. When doing a newborn visit, I can feel the gravity of each families feeding decisions - whether breastfeeding, formula feeding, or combo feeding - there is a sense of hesitation when the parent first shares how they have decided to feed their baby. Parents feel judged if they breastfeed, fearing that their provider is ready to pressure them into supplementation early on to promote weight gain in those first weeks after birth. Parents feel judged if they formula feed, as if they didn't "try" hard enough or they are being selfish in their decision to not give their infant breastmilk. Combo feeders are caught in the middle, they often feel they are failing if they are not exclusively breastfeeding, feel judged if they give the baby a bottle of formula and/or are asked by friends and family why they don't just stop the hassle of breastfeeding and just give the baby formula. Where did all this judgment come from anyway?

There is a long and interesting history regarding the introduction of milk substitutes for human infants. As this is just a blog post, I will not delve into a full-blown history lesson but will talk about some key points. The first formula was introduced in the 1860s just 20 years after the first rubber nippled bottle was invented. Surely, women had issues breastfeeding prior to 1865 and that is where wet nurses were very widely utilized. It was well known at the time by physicians that human infants were unable to digest undiluted cow's milk due to the higher protein contents and lower carbohydrates as well as larger curds than human milk. As wet nurses fell out of favor, the medical community preferred breastmilk over the dilution methods of cow's milk and the available infant formulas of the time due to their high price - that is until the invention of unsweetened evaporated milk. Soon companies were mixing cow's milk with different ingredients to achieve milk that they felt was similar enough to breastmilk (as in the baby could digest it) and physicians were able to sell these new formulas with their own label and personalized branding on them. This was a pivotable switch as it showed that formula was considered medically acceptable and was eventually provided in the hospital setting which mothers felt was an easier and preferred way to feed infants with an obvious endorsement from their medical providers.

Formula companies started providing free milk to hospitals so that patients would favor their brand, a genius marketing strategy - if the hospital is giving it out of course it must be the best brand for your baby. Did you know how these two brands got their name? Similac="Similar to Lactation" and Enfamil = "Infant milk" which are still the primary formulas found in American hospitals today. Formula companies continue to provide free samples and newborn baby bags to many pediatrician offices to continue to promote their brand as medically recommended and endorsed.

The World Health Organization (WHO) published the International Code of Marketing of Breast-Milk Substitutes in 1981 to combat the predatory marketing of breastmilk substitutes as the overuse has been detrimental to the health of children across the globe. Yet, the United States has never adopted the code, even 40 years later. Why is that? MONEY and lots of it! The government and big business are so intertwined with the profits from formula, it is a hard sell to regulate the marketing of something that generated 3.65 Billion dollars in 2019 with a projection to exceed 5 Billion dollars by 2027. The dairy industry contributed over 5 million dollars to the 2020 election as part of their lobbying efforts - not all of this is specific to formula but does establish a relationship that is problematic when it relates to public health policy and political affiliation in regards to formula marketing and regulation.

Formula companies know how to skate around the WHO code and to shift the script from trying to promote formula as superior to breastmilk, instead they appeal to moms as a friendly and concerned ally in the overwhelming world of parenting. Most of the marketing strategies actually have moved away from trying to show any comparison to breastmilk and have instead appealed to the human side that breastmilk is best for baby but it is hard and they are just there if you need them to make life easier. Many formula companies have a club you can sign up for, you know, just to support a mother during pregnancy with weekly email pregnancy updates and send free samples of formula in a cute bag. These subtle strategies ingrain them as the good guys just trying to make things easier if and when breastfeeding doesn't work out. The issue is often that so little substantial breastfeeding education is given during pregnancy and a mom has to go out of her way to seek out a breastfeeding class or information. The reality is that most moms have to go back to work in 6-12 weeks and where does lactation fit into the realities of life and pressures of returning to work. Women/parents get the most information about pregnancy and childbirth from their providers, but outside of the formula marketing, how little education and support is for after baby is born. Families leave the hospital overwhelmed with little support and when things don't go as planned, the one constant if that formula at least will save the day.

In regards to the hospital, in the first days of a baby's life, their stomach is small and mom's colostrum while potent with nutrition and antibodies may equate to only a teaspoon (about 5 mL) per feeding. Mom is tired and overwhelmed, questioning if the baby is getting enough breastmilk. The mother is handed a 60 mL bottle of formula "just in case" or to "help her get some sleep" because the baby will sleep longer between feedings and will be less fussy than if she exclusively breastfeeds her infant who needs to get smaller more frequent feedings, important to establishing a mother's milk supply. That one bottle in the hospital, while well-meaning by the staff or family member, sets off a cascade of feelings and fears and sets mom up for challenges from the start. Enter the Lactation Consultant into the scenario who can often be perceived as a boobie pusher and that moms need to breastfeed at all costs - which simply is not true. Lactation Consultants very often are the ones to throw the flag and recognize that supplementation is warranted and are very aware of the guilty feelings moms may have regarding giving their baby formula and are the ones that counsel families in the need for supplementation.

Do lactation consultants really demonize formula? Is it part of our training to guilt mothers into breastfeeding? Absolutely not! The lactation consultant is often the one that may dig into their toolbox to pull out formula if a baby is not thriving - but our toolbox is deeply armed with many different things to help support mom in her feeding decision. Lactation consultants work so hard to build mothers up and support them in the new foreign task of breastfeeding and caring for their newborns, yet we often have a reputation as the boobie bullies. Ask yourself, in your life, how many women have you watched latch a baby? Did your grandmother/mother/mother-in-law/Sister/Best Friend breastfeed? How do their feeding decisions affect yours? If those close to you did not breastfeed or if they did but struggled, how does that not affect your ability to confidently breastfeed your baby? 200 years ago, breastfeeding was the only choice, therefore those same women rallied around and supported the new mom to help teach her the art of breastfeeding and if she struggled, your sister/friend/cousin breastfed your baby in other words, all the mothers in your life were your Lactation Consultants! The mortality rate was terribly high before the introduction of digestible formula, when a wet nurse was not the answer or available - formula filled a need for survival for some and still does. Lactation Consultants truly want what's best for your baby and a good Lactation Consultant should respect a mother's informed feeding decision and be the cheerleader and support all new mommies/families need. As part of a Lactation Consultant's training and Code of Ethics, we are trained in the history and issues with breastmilk substitutes and predatory marketing and are held to a higher standard in regard to when formula is an appropriate medically indicated choice. Formula is a very important tool with a valuable place in our society and healthcare system, but it is not superior to breastmilk and no formula company would dare argue against that point. New parents are in such a vulnerable state, having a supportive healthcare team that they can trust and to help guide them when formula supplementation is needed/appropriate without leading to them feeling guilty or that they have failed their infant is so important. No part of this post is written with judgment as to a mother's choice on how to feed her baby, it is meant to shed some light on the negativity that Lactation Consultants do not support the use of breastmilk substitutes when we are just trained to identify its use judiciously.

In closing, I propose that we chuck the term "breast is best" and replace it with "support is best". The one thing that no one can disagree with is that all new parents just need non-judgemental unbiased SUPPORT! Give the parents the information and support that they need to navigate their own individualized journey to feeding their babies because breastfeeding is not a one-size-fits-all and either is formula feeding. Sending all new parents a warm hug of support, you got this!

While this post addresses more of my view from the United States, the negative effects of overuse and inappropriate marketing of formula have been devastating across the globe especially in impoverished areas. If this is a subject you find interesting, here are some great reads that are eye-opening to just how far formula marketing has gone and has negatively impacted public health across the globe and furthers health disparities.

https://www.unscn.org/files/Publications/SCN_News/extractscnnews.pdf (The Lesser Child - All good information but the first picture speaks a thousand words)

https://www.google.com/books/edition/The_Big_Letdown/9DoyCwAAQBAJ?hl=en&gbpv=1&printsec=frontcover (The Big Letdown by Kimberly Seals Allers - this book looks at how the lack of breastfeeding support further deepens the health disparities in the US)

https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00597-w (Selling Second Best: How Infant Formula Marketing Works)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7967752/ (Old Tricks, New Opportunities: How Companies Violate the International Code of Marketing of Breast-Milk Substitutes and Undermine Maternal and Child Health during the COVID-19 Pandemic)

http://www.usbreastfeeding.org/p/cm/ld/fid=991?fbclid=IwAR2d7Ph1g3pPvZaw-9ndjcjWIK5d1nRPohP-SjiUVqbFSchn-2Sw3J00CJE#session1 (2021 Webinar Series from the US Breastfeeding Committee regarding Commercial Milk Formula Marketing: Communities, Contexts, and Impacts)