Breast-Feeding or Formula? For Americans, It’s Complicated

https://www.nytimes.com/2018/07/14/health/trump-breastfeeding-history-nyt.html

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For as long as there have been babies, there have been debates over how to feed them.

Wet nursing, which began as early as 2000 B.C., was once a widely accepted option for mothers who could not or did not want to breast-feed, but it faced criticism during the Middle Ages and the Renaissance. The profession eventually declined with the introduction of the infant feeding bottle in the 19th century.

Today, and throughout the 20th century, the benefits of infant formula vs. breast-feeding have been examined from every angle. What was in vogue one decade became critiqued the next as cultural norms shifted, then shifted again.

Earlier this week, it was revealed that the Trump administration opposed an international resolution to encourage breast-feeding, stunning maternal health advocates and drawing swift criticism. But this isn’t the first time the United States has rejected such a measure.

Below, we chart America’s complicated history of infant feeding, starting with the spread of formula.

It may be hard to imagine now, but infant formula wasn’t always a staple lining store shelves. It took many decades of advertising, legislation and scientific advances for it to become the $70 billion industry that it is today.

Formula manufacturers began to advertise directly to physicians in the early 20th century, according to an overview of infant feeding published in The Journal of Perinatal Education. In 1929, the American Medical Association formed the Committee on Foods to approve formula safety, “forcing many infant food companies to seek AMA approval or the organization’s ‘Seal of Acceptance.’”

By 1932, manufacturers were prohibited from advertising to anyone other than medical professionals, creating a “positive relationship between physicians and the formula companies,” the overview states.

Several years later, in 1937, The New York Times interviewed a pediatrician in Brooklyn who said that out of 400 newborns he encountered in the past year, only two were exclusively breast-fed.

“About half these mothers attempted breast-feeding on my urgent advice at first, but most of them quit,” he said. “They had heard that babies did as well on cow’s milk nowadays and did not want to overeat, gain weight or lose their girlish figures.”

By the 1940s and ‘50s, formula was regarded by the public and much of the medical profession as safe and convenient, but even back then there were glimmers of dissent.

In 1947, the United States Children’s Bureau issued a manual advising women to breast-feed, in an attempt “to get baby off a bottle and back to his mother.”

Rooming-in, the practice of having a mother share a hospital room with her baby rather than housing the baby in a nursery, soon became a popular option. At one hospital in Connecticut, 75 percent of expectant mothers requested a rooming-in plan, according to a New York Times article from 1950.

And pediatricians urged mothers to breast-feed. The American Academy of Pediatrics published a study suggesting that psychological factors can play a role in milk production, and that mothers with positive attitudes about breast-feeding are more likely to be successful.

But some women received the opposite advice from their own doctors.

“In 1957, pregnant with my first child, I told my doctor that I planned to breast-feed,” Barbara Seaman, a writer and patients’ rights advocate, recalled in an essay.

“You wouldn’t make a good cow,” the doctor told her.

In the 1970s, breast-feeding became more widely accepted in the United States, not only in the privacy of one’s home but in public, too. In 1977, a survey by a formula manufacturer indicated that nearly two out of five American mothers breast-fed their babies, “double the percentage of 15 years ago.”

In other countries, it was a different story.

The World Health Organization sounded the alarm about a worrisome trend: a decline in breast-feeding in the developing world.

The Western “fashion” of not breast‐feeding had “caught on with the better off classes in urban areas of developing countries and, even worse, continues to spread among the least well‐to‐do,” a 1973 report said. “Not only is breast milk unique and impossible to imitate — despite manufacturers’ claims — but the cost of cows’ milk preparations remains beyond the means of the average family of the developing world.”

Critics said baby formula manufacturers were contributing to malnutrition and higher infant mortality rates, in part because the costly formula was being watered down to make it last longer, but also because the milk solids were being mixed with unclean water.

In 1977, labor, religious and health organizations boycotted Nestlé, one of the biggest producers of infant formula, in response to rising infant mortality rates in developing countries.

Then, in 1979, at a conference sponsored by the World Health Organization and the United Nations Children’s Fund, the baby food industry agreed to ban the promotion of infant formulas that discouraged breast-feeding.

A couple of years later, in 1981, the W.H.O. voted 118 to 1 to adopt a nonbinding code restricting the promotion of infant-formula products. The United States, under President Ronald Reagan, was the lone dissenting vote.

The decision drew a chorus of critics, much like the Trump administration’s recent stance on the marketing of powdered formula to women in developing countries.

Elliott Abrams, then the assistant secretary of state for international organization affairs, said in 1981 that it was a free-speech issue.

“Despite our governmental interest in encouragement of breast-feeding,” he said, the W.H.O. recommendations for a complete ban on advertising infant formula and the proposed restrictions on the flow of information between manufacturers and consumers “run counter to our constitutional guarantees of free speech and freedom of information.”

Two high-ranking officials at the United States Agency for International Development resigned in protest.

The Nestlé boycott ended in 1984, the year the company adopted the W.H.O. international marketing standards on baby foods. But the boycott resumed in 1988, the same year that the formula industry began advertising directly to the public, something that the American Academy of Pediatrics opposed.

Infant formula has become safer and more nutritious over the years, in part because of the nutrient requirements of the Infant Formula Act of 1980, which followed a 1979 recall of chloride-deficient formulas that sickened thousands of infants and resulted in scores of lawsuits.

Bottles are safer, too. In 2009, Avent America, Disney First Years, Dr. Brown’s, Evenflo, Gerber and Playtex agreed to stop using the chemical bisphenol A to treat its plastic baby bottles.

And in response to concerns about genetically modified foods, Similac introduced GMO-free infant formula in 2015.

Despite these advances, no formula can completely mimic the composition or immunological benefits of breast-feeding. The adage “breast is best” is still widely accepted.

But now a new movement called Fed is Best has arisen because of the pressure placed on women to exclusively breast-feed, sometimes to the detriment of their infants. The movement seeks to educate families about all of the safe feeding options available to them, and the complications that can arise when exclusively breast-fed newborns don’t receive enough breast milk.

What is often missing from the debate over breast vs. bottle is the fact that so many women do both. Breast-feeding is still considered the gold standard, but formula supplementation is commonplace, especially as women return to work after maternity leave. For many mothers, this is the best of both worlds.

Even so, in developing countries, formula still presents a problem, just as it did decades ago.

“Malnutrition and poverty are the precise settings where you absolutely do need to breast-feed,” Dr. Michele Barry, senior associate dean for global health and director of the Center for Innovation in Global Health at Stanford School of Medicine, told The New York Times. “Because that’s the setting where access to safe and clean water for reconstituting powdered formula is often impossible to find.”