To reinforce that “breast is best” for babies and that formula feeding is inferior, in 2022, the American Academy of Pediatrics (AAP) affirmed its decades-long stance in favor of exclusive breastfeeding (EBF), meaning nothing but breastmilk, arguing for this in the first six months and calling breastfeeding and human milk “normative” and “a public health imperative.” The policy stated that “medical contraindications”—reasons not to breastfeed—“are rare”; the only “true” ones, according to the organization, are infants with galactosemia (a metabolic disorder) or parents with HIV.
Looking back at my own experience, I’m convinced that the pressure to breastfeed contributed to my developing postpartum anxiety and obsessive-compulsive disorder. I later learned that this pressure could harm mental health in even more acute ways, including potentially increasing the risk of suicide. I was struggling but determined to breastfeed exclusively because I believed that it would reduce my child’s risk for several diseases and boost lifelong achievement. I was wrong, largely because I was misled. As a reproductive rights activist and journalist who has covered issues concerning kids and food since 2014, I agree with the growing opposition to the decree that exclusive breastfeeding is imperative. Barriers to breastfeeding are real and disproportionately affect marginalized people, many of whom return to work not long after childbirth. The fight for the right to breastfeed rages righteously, and I consider myself a fervent supporter. At the same time, adoptive and other parents who can’t provide human milk or choose not to feel shamed. No matter how cherished our right to breastfeed is, so is our right to feed our infants with or without our bodies.
Because we are told that science shows that “medical contraindications” to exclusive breastfeeding are rare, millions of parents wonder what’s wrong with us when it doesn’t work out. Though breastfeeding proponents suggest that true physiological issues that contribute to low milk supply are “rare,” this science is hardly conclusive. Some studies show that everything from breast surgery to polycystic ovarian syndrome to diabetes to chronic stress and far more can disrupt lactation, and, together, these conditions affect far more than one in 10 birthing folks. Christie Del Castillo-Hegyi, an emergency medicine physician, mom of three, and co-founder of the nonprofit Fed is Best Foundation (FIBF), says that the push for universal EBF makes it “difficult to understand the nuances, the exaggerations and the risks of such a recommendation.” The FIBF’s mission is to advocate for families who have encountered complications in attempting to adhere to EBF. The reliance on breastfeeding can also lead to a violation of children’s right to be satiated.
Proponents often say that breastfeeding is “free,” but it’s not. There’s the cost of our time, effort, pumping equipment and the pausing of pursuits. Those costs and benefits vary for different people. I didn’t realize that EBF would take so much out of me. As I recovered from a traumatic birth, my baby cried unless she was on my breast, which many EBF advocates say is normal, so I nursed constantly. When we were discharged from the hospital, she had lost 9 percent of her birth weight, which was within the 7–10 percent that’s considered normal in an EBF newborn in many birthing facilities. I was told to continue nursing “on demand” at home. On day four of her life, I was devastated to learn that she had lost over 12 percent of her weight. Our doctor recommended supplementing with formula, assuring us that it would be okay and that I could wean off formula in a few days. I felt anything but okay.
Fortunately, my newborn didn’t have to be readmitted to the hospital, or worse. It’s crucial to know the signs that a newborn isn’t getting enough milk, including crying all the time when not on the breast. Extreme dehydration can have severe immediate and long-term consequences. Rarely, it can be fatal. EBF advocates suggest that colostrum, or drops of the clear substance excreted before copious milk production, is plenty to feed a newborn in the first few days of life. But it’s not always enough. EBF is not Mother Nature’s design. Caregivers have fed infants substances in addition to or instead of their own birth parents’ milk and in many cultures for a slew of reasons, including milk supply taking a few days to “come in” and personal preference. These alternatives included milk from human wet nurses and animal milk.
Bottles of formula saved my baby and me. That weekend, following frequent breastfeeding sessions, my partner topped off our voracious newborn with formula while I spent another 20 minutes with an electric pump to further stimulate milk production. The three-day around-the-clock ordeal produced the desired effect. Soon, I was making enough milk, and we ditched formula. It didn’t occur to me that I had the choice to skip the strife and use formula from the get-go instead of avoiding it, using it with a sense of shame and then toiling to stop using it.
“The amount of emotional freight that's attached” to EBF “is grossly disproportionate to the benefit,” says Daniel Summers, a pediatrician and father of four who supports patients’ choice to use formula. The formula industry’s predatory historical and current practices don’t mean that formula is inherently bad or that human milk is “best.”
None of this is to say that it’s a lie that breastfed infants fare better than their formula-fed peers on a population level. Rather, it’s not the human milk conferring better outcomes. The bulk of infant feeding data are observational and come with confounders. In wealthier nations, people who breastfeed tend to be more financially secure, live near fewer hazards and have stable co-parenting relationships. Sibling studies account for these confounding factors because siblings are exposed to similar environments. In 2014, U.S. researchers looked at thousands of siblings born since the 1980s. Breastfed babies from different families had a lower incidence of asthma, hyperactivity, and more; they also showed higher reading and math comprehension than formula-fed babies. When they compared babies who were breastfed with siblings who received formula, almost all of those differences became insignificant.
The bottom line is, safe human milk, infant formula prepared correctly with safe water, or a combination of both are fine choices for full-term infants. Privilege and better outcomes go hand in hand. For meaningful interventions that lead to positive outcomes, Summers would like to see support around “the actual logistical needs” of disadvantaged families. An important note: human milk has been shown to protect premature newborns from a life-threatening bowel infection that can cause holes in intestinal walls. For full-term infants, even though breastmilk contains some remarkable substances, there isn’t evidence that it’s the mechanism behind superior short-term and long-term outcomes.
It’s easier to put the onus on parents to exclusively breastfeed than to solve systemic problems that impact kids’ well-being. All humans have the right to consider the pros and cons of using their bodies to feed their newborns and make their own informed choices, including the choice to use formula, whether the reason is a medical contraindication or straight-up not wanting to.
This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.