by Ranjini (Rini) Ghosh
When it comes to safe infant feeding, the “Breast-is-Best” mantra is the standard in hospitals, from prenatal education sessions and through the postpartum hospital stay and beyond. It’s based on guidelines from the American Academy of Pediatrics and the World Health Organization that infants be exclusively breastfed (EBF) for the first six months—that means absolutely no food or drink other than breastmilk. As a mother of two and a health policy researcher, I fear that the current environment may be failing to empower parents to feed their infants safely.
I’m concerned that healthcare providers aren’t educating parents on safe feeding outside of exclusive breastfeeding. In the absence of comprehensive guidance before leaving the hospital with their newborns, parents are left vulnerable to mistakes that may contribute to the very harms that infant feeding education should prevent.
Current feeding education seems to rely on the assumption that most everyone has the desire and ability to breastfeed exclusively, so healthcare providers end up glossing over or ignoring other options. The rationale seems to be that teaching parents how to feed their infants outside of exclusive breastfeeding will validate formula and lead to lower breastfeeding rates. In recent decades, infant feeding policy has ignored the real-world experiences of new parents and failed to address highly likely scenarios, like sleeplessness, insufficient milk production, latching issues, the desire for bodily autonomy, and an impending return-to-work date. Regardless of the reason behind breastfeeding cessation or supplementation, if exclusive breastfeeding for six months is the public health standard, then there is a gap between expectation and reality for most new parents.
Breastmilk or formula, either or both can be “best”
Parents deserve to make fully informed choices to feed their babies safely. And their choices deserve to be supported with the same fervor, whether it’s exclusive breastfeeding, pumped breastmilk, formula, or a combination.
Formula can be a perfectly safe infant feeding choice, as long as you follow a few basic rules (which I’ll get to in a bit). You can head over to the SciMoms post, “Is Breastfeeding Really Best and Is Formula Harmful?” for details on what the science really says (and doesn’t say) about breastmilk and formula.
That doesn’t mean that breastmilk isn’t amazing, because it is— it has antibodies, a unique microbiome, and even stem cells. But there isn’t evidence that breastfeeding leads to better outcomes compared with responsibly manufactured, safely prepared formula. It seems counterintuitive, but the commonly touted benefits of breastfeeding overstate the science.
The notable exception is the protective benefits of breastmilk against necrotizing enterocolitis, a dangerous bowel disease in premature babies. There is strong evidence that a human milk diet is key in safely feeding premature infants—human milk alone isn’t sufficient to support the growth of a very low birth weight baby, so a human-milk derived fortifier is often added.
If the official recommendation is to exclusively breastfeed for the first six months, then why aren’t most parents following the recommendations?
Parents are told that exclusive breastfeeding is easy and natural. Parents are led to believe that babies need just a few drops of colostrum—the early substance that comes from the breasts before full lactation— to fill their tiny bellies. They’re told that any formula supplementation after birth will ruin the so-called “breastfeeding relationship.”
But there’s a big discrepancy between expectation and reality for a lot of new parents.
Based on my observations as a parent who is active in online evidence-based parenting communities, decisions about infant feeding are often a matter of circumstance rather than informed choice. A parent may decide to breastfeed exclusively right from the moment their baby is born, but things don’t always go according to plan. Whether the end of exclusive breastfeeding is an active or a passive decision, one thing is true— when a parent decides to reach for formula or the pump at 2 in the morning, they often don’t have reliable information on how to do it safely.
The reality of exclusive breastfeeding
There are plenty of reasons parents end up not breastfeeding exclusively or at all. Those with trauma or medical conditions (both mental and physical) are more likely to decide not to initiate breastfeeding. Some parents just don’t want to breastfeed, and, believe it or not, that’s a valid reason to choose formula.
There’s also delayed onset of lactogenesis (when the milk that “comes in” after small amounts of colostrum takes more than 72 hours postpartum). It occurs in up to one in every three first-time birthing parents. Starvation in exclusively breastfed babies accounts for the development of jaundice in around 10-18% of babies and excessive weight loss in approximately 25% of newborns. Even after a parent has initiated breastfeeding and fed their babies sufficient milk during the first few weeks postpartum, they may still end up choosing to supplement with formula. Breast-is-best proponents maintain that not having enough milk is usually a misguided perception rather than a common experience, even though breastfeeding parents’ experiences with low milk supply are very real.
The reality of pumping
The outsized focus on exclusive breastfeeding leaves out important information on the dos and don’ts.
In the U.S., where most parents return to work while their baby is well under the six-month mark, exclusive breastfeeding is predicated on successful pumping and storage of expressed milk. In a 2002 survey of breastfeeding parents, those who had pumped and fed pumped milk successfully were 75% less likely to discontinue breastfeeding within 12 weeks postpartum than those who hadn’t.
However, a 2008 study of infant feeding practices found that only 61% of parents who used a breast pump to express milk received pump education from a medical professional. Others relied on friends, family, media, and the internet. For instance, when I gave birth to my first, and expressed a desire to breastfeed, I was advised to not introduce a bottle or a breast pump before six weeks postpartum. This was despite my medical team being fully aware that I had to return to work three weeks after delivery.
The lack of education also means that parents using pumps haven’t been advised about safe infant feeding with pumped milk. There are multiple studies that find high levels of contamination of breastmilk collected by pumps. The points of contamination include the nipple, unwashed or improperly washed hands, and improper washing of pumps and bottles. At least one of these studies finds that the high levels of contamination in expressed (both by electric and/or manual pump) and stored milk is not suitable for very premature infants.
The reality of formula feeding
The lack of parental education on formula feeding also leaves gaps in knowledge that may be harming infants. A 2008 analysis of data collected by the Infant Feeding Practices Study (IFPS-II, a collaboration between the Food and Drug Administration and the Centers for Disease Control and Prevention) reveals a picture that I find disturbing: a majority of formula feeding parents receive no training on safe formula preparation and storage.
Official recommendations are to wash hands, bottles, and nipples before preparing formula, to use water heated to 70°C or higher to mix powdered formula and to discard formula left at room temperature after two hours. In the absence of step-by-step education on safely preparing, feeding, and storing formula, parents who use formula are making mistakes that increase the risk of illness.
The same IFPS-II study found that 55 percent of parents did not always wash their hands with soap prior to preparing formula, 32 percent didn’t wash bottle nipples prior to reuse, and 6 percent did not always discard formula left standing at room temperature after two hours. A separate study found that only 22 percent reported using warm enough water to reconstitute powdered formula, which helps prevent contamination.
Formula “stretching” or over-dilution of powdered formula while reconstituting is believed to be common but hardly studied, but there are reports of deaths and/or serious medical harm from this practice. A small 2012 study of food-insecure families visiting a Cincinnati clinic found that 15 percent of food-insecure families stretched formula. Over dilution of formula not only leads to inappropriate nutrition but also can cause a deadly condition called water poisoning. This is particularly concerning in light of the fact that WIC (the federal supplemental program for women, infants, and children) can be restrictive in how much formula they provide families, especially if they have shown an intention to breastfeed. This, of course, is a problem with food insecurity as much as it is lack of comprehensive information from healthcare providers.
The reality of complementary feeding/solid feeding
Gaps in infant feeding education for parents also impact how and when babies start solid foods—and the data suggest that there’s a significant disconnect between guidelines and practice, and that can lead to undesirable health outcomes in infants.
The push to exclusively breastfeed for the first six months is not only unrealistic for many parents, it is also no longer up to date. The latest evidence on introducing solids to infants advises the introduction of solids and all common allergens between the four to six-month window, as it seems to provide a protective benefit against developing allergies. The evidence for this protective benefit has led both the American Academy of Allergy and Immunology and the American Academy of Pediatricians to recommend introducing small amounts of allergenic solids in this window provided the baby is showing signs of readiness.
Solid food introduction entails just a few rules: infants under a year should never be given honey (due to botulism risk) or animal or plant milks (as it replaces the necessary nutrition from breastmilk and/or formula). Before four months, infants should receive nothing but breastmilk or safely-prepared formula— not even plain water, which can lead to water poisoning, hypernatremia, and inadequate nutrition. In addition, new foods should be introduced one-at-a-time in case of an allergic reaction; that way the allergenic food can be reliably identified. Complementary foods should not be offered before four months of age, because they displace the balance of nutrients found in breastmilk and formula that support a growing infant’s needs.
Despite widespread advice to avoid the too-early introduction of complementary foods, estimates suggest that 20 to 40 percent of US infants are introduced to solids before the four-month mark. One study found that about one-fourth of the mothers reported giving their newborns water at least three times per week. Another study analyzed data from a survey of infant feeding practices and found that 20 percent of mothers gave their baby juice before six months. More than half added salt to their infant’s food, which isn’t advised. All of these can have negative impacts on an infant’s short-term and long-term wellbeing.
Empowering Parents With Comprehensive Information
The “breast-is-best” environment frames formula feeding as risky but does not address common contraindicated feeding practices that have been documented in the scientific literature. Even though unclean hands, unsanitary bottles/pump parts, inadequate preparation and storage of milk, and early introduction of solids may not always cause illness, repeated exposures increase the probability of eventual harm.
Instead of framing formula as inherently harmful— which is patently untrue—healthcare providers should consider informing parents on how to mitigate the risks of all feeding choices. It makes sense for each family to know how to make safe infant feeding choices based on their dynamic circumstances.
If the goal of infant feeding policies is to ensure babies’ long and short term health, then infants deserve to be fed safely no matter the feeding choices parents make. That will require comprehensive, accessible guidance, even when plans to breastfeed exclusively change.
Breast pump safety and hygiene – https://www.cdc.gov/healthywater/hygiene/healthychildcare/infantfeeding/breastpump.html
Formula preparation, storage and handling – https://www.who.int/foodsafety/publications/micro/pif_guidelines.pdf
Ranjini (Rini) Ghosh is doing a PhD in Law and Public Policy at Northeastern University. Her dissertation focuses on infant feeding policies. She is a founding member of the Positive Inclusive Evidence-based Zone (PIEZ) family of Facebook groups which seeks to empower parents with scientific information on all aspects of parenting.