Talking about breastfeeding: ways of changing the conversation

"My friend/colleague/doctor has looked into it and says there is no convincing evidence of benefit for breastfeeding in high-income countries. What can I say to him/her? Have you got any links or pointers for having the discussion?"

I've been asked variations of this question many times, sometimes face to face and sometimes online, and I've had conversations directly with the people who have made the original statement. Often I've felt a sense of being a rabbit in the headlights: how to sum up, rationally and in a nutshell, why I think breastfeeding matters so much, in the UK or elsewhere? I can't always remember the details of research, and often find it hard to summarise the complexities of the reality and politics of the situation, but at the same time I really want to communicate with people about breastfeeding and have them go away from our conversation thinking about it. When I hear myths I want to challenge them; when I hear that people have very different views from mine I want to explore why that is. It isn't easy to do!

However, as with many things, I find that practice has made these conversations a little easier. I now find that instead of launching in to a spiel about breastfeeding, understanding where someone's viewpoint has come from is the first step. Why did the friend/colleague/doctor decide to look into breastfeeding in the first place? Was it because of a personal decision or experience, or is it an area of professional interest? How did they come to their conclusions? I genuinely want to hear about how and where people are finding their information.

Then, I often find myself acknowledging where the other person is coming from. This time the person saying they had no convincing evidence for breastfeeding in high-income countries was a scientist in an unrelated discipline who had made a personal survey of breastfeeding research, and had examined the methodology of studies with a critical eye. That's something I can get on board with -  I've done it myself, and of course we should be critical of research! Having established some common ground between us, I can acknowledge that there are indeed problems with the way some breastfeeding research is done, and that there are those who think that the importance of breastfeeding is overstated. I have now put myself in a position where I can explain why I don't agree without it seeming like an argument, rather than a discussion.

Another useful thing can be to establish what it would take to convince someone to think beyond their current position. In this case, the person who asked me the question thought that only a cast-iron randomised controlled trial (RCT) would be good enough to convince the scientist. That's good to know, because I won't be able to give them what they want. RCTs can't ethically be done in infant feeding. But because I know what the person wanted to find, I can explain why it doesn't exist, which must be the next best thing. Having the conversation in terms that suit the context is very important; I have very different conversations with people depending on who they are and what the situation is. I would not talk to a sleep-deprived new mother about meta-analyses and the ethics of research! 

So how did I answer the question? I tried to include what I thought would make sense to the scientist who had voiced their opinion: recent meta-analyses in peer-reviewed journals. I tried to address their personal concerns about the validity of the research, and to show that the effects of breastfeeding in high-income countries have been studied. I  also tried to suggest a few topics for further reading, and to introduce the idea that the burden of proof should not really be on breastfeeding, which is normal behaviour for humans, but on the long-term safety of formula milk. I wasn't trying to 'win' by presenting a cast-iron case; I was trying to show that alternative viewpoints are possible and credible.

I ended by inviting further contact if it's wanted or needed, now or in the future. Being open to further dialogue is really important for breastfeeding advocacy; what I really want is for people to be able to come back to me with more questions or discussion points, because then we keep communicating - and maybe I can put them in touch with other people or organisations, or suggest sources of information. It's amazing what that sort of networking can achieve; if you can be the person others seek out when they want to know something about breastfeeding, that's fantastic.

All this is important in a wider context too. The recent WBTi report , and Unicef Baby Friendly's 'Change the Conversation' campaign, have shown what we need to do to improve breastfeeding rates in the UK, and highlighted the difficulties we have when talking about breastfeeding and advocating for policy change. Every conversation we have with another individual about it is a tiny step on the road towards improving the situation, for the benefit of mothers and babies. If we can make those conversations count, while avoiding arguments and entrenched positions, we're all doing our bit to make the world a better place.

I'd love to know how others handle this sort of conversation/question, and other thoughts on ways to change the conversation about breastfeeding. I've included my email in response to the question at the top of this post below for anyone who is interested (and because it can be useful to have links in one place!); what do you think?

Hello,

Here are some links/discussion points that you could raise. 

First, a 2016 meta-analysis is one of the papers in a Lancet special series on breastfeeding, which specifically tackles the question of breastfeeding's relevance in middle and high income countries:
http://www.thelancet.com/series/breastfeeding

(It's worth noting that in the absence of RCTs, which, as discussed, are unethical in bf because you can't randomise babies to receive what you know is a poor substitute for breastmilk (when I say poor, I mean that formula lacks oligosaccharides, HAMLET, lactoferrin etc that have known immunological effects in the infant), meta-analyses are one of the better tools we have.)

Second, this set of papers in a 2015 special issue of Acta Paediatrica; the editorial sums up the issues with bf research (also common to nutrition research in general) and explains how researchers have attempted to allow for the flaws in studies to reach their conclusions: http://onlinelibrary.wiley.com/doi/10.1111/apa.2015.104.issue-S467/issuetoc 

There has been an RCT of a breastfeeding support intervention in Belarus that showed that increasing breastfeeding rates (by supporting the mothers to bf for longer and more exclusively) reduced rates of some infections: https://www.ncbi.nlm.nih.gov/pubmed/11242425 

Here you can download the evidence-base for the Unicef Baby Friendly Standards, which have been developed specifically for the UK: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/advocacy/the-evidence-and-rationale-for-the-unicef-uk-baby-friendly-initiative-standards/ 

This report looked specifically at the costs to the NHS in the UK of not breastfeeding: the conclusions are conservative and based on good-quality evidence for just a few diseases: http://discovery.dundee.ac.uk/portal/files/1290558/Preventing_disease_saving_resources.pdf 

Finally, here is the link to the very interesting work that looked at the evidence base for health claims made in ads to health professionals for formula milk; arguably the burden of proof should be on the intervention to show that it does not cause lasting harm; in my view we do not have this proof (far from it). The flaws in the research we rely on for the safety of formula are at least as bad the flaws in the bf research! http://www.firststepsnutrition.org/pdfs/Scientific_and_Factual_booklet_for_web.pdf 

Other areas that are well worth consideration are thymic size/immune system development, the differences in microbiome between bf and ff infants, and the epigenetics of bf; here the research is in its infancy, but the picture so far suggests far more substantial differences between bf and ff infants than we have previously thought, with consequences for long-term health. 

I'd also encourage a look at the evidence for the health of mothers, not just infants; for example the research on ovarian cancer, osteoporosis and heart disease. 

If you want to put us in touch or pass on my email address, that's fine - I'm always happy to discuss. 

Good luck! 

The WBTi report on breastfeeding in the UK - and why we need it

Since I got back from the Unicef Baby Friendly conference last week, it’s all been a bit eventful in the breastfeeding world – there was a poorly written and researched article published in New Scientist (the Unicef response is here), longer-term breastfeeding was discussed (again) on This Morning, with a GP who didn’t know her stuff on the subject, there was a furore in the Daily Mail and on social media over a mother refused a parking voucher from Tesco because she only bought infant formula (see Baby Milk Action’s excellent discussion of this here), and we discovered that the CPHVA conference, for health visitors, has sessions (and no doubt exhibition stands) sponsored by formula manufacturers. The publication of the WBTi (World Breastfeeding Trends Intiative) report on breastfeeding in the UK couldn’t be more timely – it’s abundantly clear that we need a strategy if we are to counter the anti-breastfeeding culture that we have in the UK.

The WBTi report, published today (15 November) and launched at the House of Commons tonight, is the culmination of two years of work by a huge number of people and organisations. Using a system developed by IBFAN, data has been collected for 10 ‘indicators’ – these correspond to policies and programmes recommended in the WHO Global Strategy for Infant and Young Child Feeding, which the UK supported when it was adopted by the World Health Assembly in 2002. In other words, although the WBTi system has been designed to be used internationally, it is very relevant for the UK and shows how we are doing against criteria that our government has signed up to. The idea is that the process is repeated every 3-5 years to track trends. On the international WBTi website you can see how other countries have scored.

The report begins with a series of 'Report Cards' that sum up the findings in a simple scorecard, with each country of the UK given a total out of 150, and an amalgamated score for the UK as a whole. The UK scored 81/150. England has the lowest score of all the four nations at 80.5/150; Scotland and Northern Ireland score much better, in part due to the fact that all their maternity units are Baby Friendly. For comparison, Afghanistan scored 80/150 in 2015. If like me you think that this isn't good enough, then the great thing about this report is that it offers a way forward. The work that's been done has identified the gaps in UK breastfeeding policy and made recommendations - that have been agreed upon by the contributors to the report (a host of breastfeeding organisations and public health bodies, among others) - that we could act on, right now.

The report's recommendations echo a growing consensus that currently, women in the UK who want to breastfeed are being failed - not only by a lack of skilled support for breastfeeding (the table in Indicator 5, which shows which health professionals have training in breastfeeding, is well worth a look), but also by an entire culture and society that undermines it. Other recent publications, including the Lancet series on breastfeeding, a special issue of Acta Paediatrica and Unicef's Call to Action make many of the same points. Dr Amy Brown, of Swansea University, has written extensively about the subject in her book Breastfeeding Uncovered.

Turning the situation around is not impossible. We know, from a mountain of published evidence, what works. The main problem - and one of the chief recommendations of this report - is that there is no national strategy on infant and young child feeding, no national coordinator and no means of sharing good practice UK-wide. To address this would be relatively simple and relatively cheap - what's needed is the political will to tackle it. From better national leadership on the issue, other improvements could follow: we could fully implement the Code, we could address gaps in the training of health professionals, we could collect better data, we could ensure that infant feeding is considered in the formation of other policy (like the obesity 'plan')... and then, as all these areas interact like cogs in a machine, we would see a shift in society's attitudes, increased breastfeeding rates, improved health outcomes and cost savings... and happier, better supported mothers. (This isn't just conjecture - see the breastfeeding gear model, which uses Brazil and Mexico as examples, on p68 of the report.)

This report, with its overview of the current situation, could be hugely important - it can inform what we do, and where we direct our campaigning efforts. Do read the whole thing if you can, and reflect on what you could do to make a difference.

Not #scientificandfactual at all – how UK breastmilk substitute ads to health workers break the rules

Most readers of my blog will know that in the UK infant formula (first stage, or from birth formula) cannot be marketed to parents, or be discounted or promoted in shops. Manufacturers use follow-on formula to get around these advertising restrictions, but there are still rules that they must follow and they can be pulled up by the Advertising Standards Agency for breaking them. When shops break the rules on infant formula promotion – by discounting it, or positioning it in premium spots in store – they can be reported to Trading Standards. It’s far from a perfect system; no prosecutions have been brought, and companies are not fined nor have to apologise for infringing the rules, but the principle of challenging misleading marketing does at least exist. Baby Milk Action, with the help of its members and the public, monitors advertising to parents and compiles a report ‘Look What They’re Doing in the UK’ to expose the companies' tactics.

When it comes to advertising aimed at health professionals, however, the situation is very different. Many people don’t know that breastmilk substitutes can be marketed to healthcare professionals: in journals and magazines, on professional websites and at conferences and study days. Although the Department of Health has regulations stating that this advertising must be ‘scientific and factual’, there is no monitoring and no mechanism for reporting marketing that breaks the rules, other than to complain directly to the Department of Health.

First Steps Nutrition Trust’s recently published resource ‘Scientific and Factual – a review of breastmilk substitute advertising to health professionals’ looks more closely at the science used to back up the claims made in advertising in professional journals and magazines. We know from research that advertising is effective – why else would the companies spend vast sums on advertising space? – and that adverts that carry simple, easy-to-understand messages relating to the reader’s own scientific knowledge are very ‘believable’. The companies know this too, and they also know that few health workers will have the time or resources to investigate the references given in tiny print at the bottom of carefully crafted adverts. Graphs, charts and statistics create the appearance of ‘a scientific basis’, even when what they show is not scientifically correct or objective.

The resource looks in detail at adverts that appear in publications including the Journal of Family Health, the Journal of Health Visiting and Dietetics Today, but the same and similar adverts appear in many other publications aimed at health professionals in a wide range of fields. When the references given to support the claims made in the adverts are scrutinised, the findings are often shocking.

An advert for Cow & Gate Comfort milk, marketed as relieving colic, which shows an emotive image of an exhausted mother, appeared in the Journal of Health Visiting in March 2016. The main claim, in red type, is that ‘95% of paediatricians reported an improvement in common infant feeding problems with a formula like Cow & Gate Comfort¹’ [italics added]. Closer reading of the reference given reveals that the study, funded by Numico (Danone) did not use Cow & Gate Comfort milk; the test formula had different energy, protein, carbohydrate and mineral content. NHS Choices says that there is no evidence for any treatment that is beneficial for colic, which resolves itself. The conclusion that the advert is deliberately misleading is inescapable.

SMA, now owned by Nestle, has been rolling out a new product, SMA PRO, and many stores have illegally cleared stock of the previous formula by marking it down in price to make way for the new product (lots of examples have been posted on the Baby Milk Action Facebook page). An extensive advertising campaign to health professionals has accompanied the roll-out. Dietetics Today carried two adverts for SMA PRO in March 2016, a shorter one-page ad and then a longer, more ‘scientific-looking’ ad – this in itself is a tactic designed to reassure the reader that the information given in the simpler advert is supported by the ‘science’ given in the more complex version. The main claim in the simpler advert is that SMA PRO is ‘Clinically proven¹’. This is supported by one reference to a poster presentation given by Nestle employees at a conference – not a peer-reviewed publication as required by the Department of Health regulations. The poster reports a meta-analysis of four studies looking at infants fed with Nan milk (another Nestle product). It is not clear whether this Nan formula is the same as SMA PRO. It is impossible to know how the manufacturers can use this evidence to claim that SMA PRO is clinically proven, or what it is ‘clinically proven’ to do. That such shaky evidence can be used to support a headline claim on a new product shows just how confident the companies are that they will not be challenged.

There is much, much more detail in the resource, which has painstakingly reviewed all the scientific papers the companies have cited to support their claims. If, having read it, you’re outraged by how misleading these adverts are, there are plenty of suggestions for action on the First Steps Nutrition Trust website. Health professionals can demand change, by complaining to the journals and professional bodies that carry advertising and allow it at events, and writing to the Department of Health regulators. The Royal College of Paediatrics and Child Health voted at its AGM in April to ‘decline any commercial transactions or any other kind of funding or support from all companies that market products within the scope of the WHO Code on the marketing of breast milk substitutes’ – other professional organisations can be lobbied to pass similar resolutions. For more information, and links to further reading, see the campaign pages on the First Steps Nutrition Trust website. Baby Milk Action is urging the UK parliament to enforce marketing restrictions on the promotion of formula to parents too – see more on their website here or make a donation to support their work.