It made intuitive sense that it would improve outcomes for babies. In fact, it made so much sense that it was implemented before large scale testing was conducted. Now, years later, it turns out that the benefits were dramatically overstated and the risks were ignored.
I could be talking about electronic fetal monitoring (EFM) that both monitors and records the fetal heart rate during labor. It made intuitive sense that it would improve outcomes for babies because the all too common phenomenon of stillbirth was preceded by abnormal fetal heart rate patterns. Once the equipment became available it was rushed into clinical practice rather than wait for large scale studies to prove its benefits. Now, decades later, we find that the impact on neonatal health is far less that we predicted and the side effects — particularly a dramatically increased rate of C-section for fetal distress — are far greater than we ever imagined.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Professional lactivists should learn from the mistakes of obstetricians. Just because something has intuitive appeal for improving outcomes doesn’t mean that it will.[/pullquote]
But I’m not talking about EFM; I’m talking about breastfeeding.
It made intuitive sense that breastfeeding would improve outcomes for babies because it had evolved to become the natural food for babies. In the wake of the Nestle debacle of the 1970’s, when African mothers were convinced to switch from breastfeeding to formula and their babies died as a result of the contaminated water used to prepare it, aggressive promotion of breastfeeding was rushed into clinical practice rather than wait for large scale studies to prove its benefits. Now, decades later, we find that the impact on neonatal health of term babies is nearly non-existent (though it is beneficial for preemies) and the side effects — including a doubling of neonatal hospital readmissions, an increase in neonatal hypernatremic dehydration and jaundice induced brain damage, and an epidemic of newborns dying in the hospital after being smothered in mothers’ beds or injured falling out of them — are far greater than we ever imagined.
The benefits of breastfeeding keep shrinking.
Consider the new paper from Kramer et al. on the latest results from the PROBIT study, Breastfeeding during infancy and neurocognitive function in adolescence: 16-year follow-up of the PROBIT cluster-randomized trial:
A total of 13,557 participants (79.5% of the 17,046 randomized) of the Promotion of Breastfeeding Intervention Trial (PROBIT) were followed up at age 16 from September 2012 to July 2015. At the follow-up, neurocognitive function was assessed in 7 verbal and nonverbal cognitive domains using a computerized, self-administered test battery …
We observed no benefit of a breastfeeding promotion intervention on overall neurocognitive function…
This is big news because the PROBIT studies were among the first to claim neurocognitive benefits from breastfeeding. But it is not surprising news since the Colen study, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons, demonstrated that nearly every puported benefits of breastfeeding disappeared when researchers corrected for maternal socio-economic status.
What should we do when we find that our intuitive sense of benefit is not supported by the scientific evidence?
In the case of electronic fetal monitoring, we are stuck between a rock and a hard place. Research shows that EFM has a high false positive rate meaning that it suggests fetal distress in many cases where the baby is not distressed. On the other hand, when the baby is distressed, it will be accurately reflected in the heart rate tracing and should be acted upon; so it does have important clinical utility. Moreover, though we understand the limitations of EFM, we have nothing yet with which to replace it. We continue using it despite its limitations because it does have significant benefits that outweigh the risks. In the meantime, ongoing research is looking for more reliable ways of monitoring babies in labor.
In the case of breastfeeding, we are not stuck at all. We have infant formula, an excellent form of nutrition for babies that has been shown over multiple generations and tens of millions of babies to produce healthy offspring indistinguishable from those who were breastfed. In fact, despite mathematical models claiming that lives and money are saved when breastfeeding rates increase, professional lactivists are unable to point to any lives of term babies or money saved as the breastfeeding rate has triple over the past 40 years.
What do breastfeeding and electronic fetal monitoring have in common? Both have failed to produce the benefits predicted; both have serious risks, and both are in need of revision.
We’ve stopped overstating the benefits of EFM and we should stop overstating the benefits of breastfeeding.
We are working assiduously to reduce the risks of EFM and we should be working assiduously to reduce the risks of breastfeeding.
We’re looking for a substitute for EFM that has the same advantages without the unfortunate side effects. We already have a substitute for breastfeeding that has nearly all the same advantages without the unfortunate side effects. It’s called formula and instead of demonizing it, we should be promoting its use when needed or wanted.
Professional lactivists should learn from the mistakes of obstetricians. Just because something has intuitive appeal for improving outcomes doesn’t mean that it will. And when it doesn’t, we should reassess our claims instead of doubling down on them.
