Moral superiority gone wrong?

The other day, on a breastfeeding themed facebook page / blog that I follow and admire (Analytical Armadillo), the ethics of the Optigrow Infant Feeding study and the process of recruitment of babies for it was questioned.

I was interested because we took part in this study and I had my own dilemma about whether or not it was a good thing to be part of it. To summarise, the study is based at a University and is testing a formula milk which has a different composition to current formula milks on the market, being higher in protein and lower in fat contents which, in this respect and this respect only, makes its composition closer to that of breastmilk. As feeding formula milk carries a higher risk of development of type 2 diabetes and heart disease in later life, as well as obesity, it is hoped that the development of this new formula may reduce this risk. For the study, babies are recruited in the first 24 hours of life and the criteria are that baby is either exclusively breastfed or exclusively formula fed. If recruited in the second group, baby will get randomly either normal or new type formula for a year. Exclusivity of feeding either breastmilk or formula milk is required for the first 10 days for the purpose of this study.

The thread on the Analytical Armadillo facebook page started out with concern about the ethics of recruitment. I chipped in my own experience - partly because I'd been through the process and partly because I was rather keen to see this topic explored what with my own thought process about the study. The concern in the thread was that someone from the Optigrow study was going around a postnatal ward offering free formula for a year and that this undermined breastfeeding at a very crucial and vulnerable time.

Now, it is no secret that I'd like to see higher breastfeeding rates because there is no question that they are low, and in fact very low in socially deprived areas of the country. I'm also very critical of the marketing strategies of formula companies, which claim that their formula is closest to breastmilk and similar rubbish. I'm also very aware that the discourse around breast is best is misleading, with its wording of "benefits of breastfeeding" rather than "risks of formula feeding" (the former implies that formula feeding is normal and you get a benefit if you breast feed, while the latter implies that breast feeding is normal and the poorer health outcomes in baby and mum when formula feeding are a risk to both).

Furthermore, I'm acutely aware that our culture around parenting favours formula feeding. New mums are expected to be yummy mummies, to continue their pre-baby lifestyle, to demonstrate they take it all in their stride. "Me time" is a big thing that apparently every mum should have every day, and which includes an expectation that mum has a right to spend time away from baby. The expectation is so strong that I felt more than awkward when receiving an invitation for a night out when my youngest was 6 months and I had to decline because there was no way I could have left her at home even for a few hours. Mums are expected to return to work after no more than 9 months of maternity leave (which translates to 7-8 months after birth of baby) and a return to work of course means that many will move over to formula at that point. The demands of being a mother to a newborn are downplayed and there is little recognition of parenting being a full time job in itself. I have elaborated on this because this culture is significant as it favours the bottle. The bottle is freedom from baby, it allows others than mum to take on the feeding and caring aspect more readily and I'm pretty sure that this is the main reason why many new mums who can breastfeed but choose not to from the start do so.

So if we want to improve breastfeeding rates overall, we are up against a culture that makes it difficult to breast feed, we are up against marketing and advertising that sell us formula as the next best thing, and a discourse around breastfeeding that implies that formula feeding is in fact the norm. As a consequence. there are places in Glasgow where breastfeeding rates are as low as 8% at the 6-8 week postnatal appointment. The highest rates I could find were 68% at 6-8 week appointment, in the most affluent areas, which is still low in my view, considering 95% of women can breastfeed (and do in many countries).

This leaves us with between 32% and 92% of new mums who formula feed 8 weeks post birth, and rising the older the infant gets. Anecdotally, of all the parents I know (and I know a lot, as we attend many playgroups and most of my friends have had babies, and almost everyone I know intended to breastfeed) I only know one person who breastfed longer than I did (I stopped at 23 months with my first, falling short of WHO guidelines). The point I'm trying to make is that in reality, a lot of babies are fed on formula milk whether we like it or not.

Considering the facts, improving formula to reduce the risk of obesity, diabetes and heart disease must be a good thing because it would benefit the long term health of up to 92% of babies in some parts of the country, while we work on changing the culture that makes new mums choose formula over breast.

The response I received to this point was:

"Lactating mums need to STOP giving formula manufactures access to their children/milk! Would you give your business information to your rival company? Yes they need to make better formula for the TINY % of babies/women for whom BFing is not a possibility BUT whilst they are aggressively marketing formula as a life style choice and comparing it to BM and violating the WHO code they can do it without help from us!! Grrrrr!"

I take offence at this statement. I did not sell my baby to anyone. I considered carefully the ethics of the study and decided that from a pragmatic perspective, bearing the health outcomes of babies in mind, it was a good thing to take part in it. I'm not naive or stupid, I made an educated and informed decision.

Secondly, the statement argues that there are deserving babies vs undeserving babies (the "TINY % of" babies where mum can't breastfeed vs the babies of mums who choose not to breastfeed). Nevermind that many mums who end up not breastfeeding didn't choose this but struggled so bloody hard that it became an impossibility for them, the bottom line of this statement is that if you choose not to breastfeed your baby should rightly be exposed to risky formula even if less risky formula exists.

Now, you can argue about the ethics of the study as much as you want, but how about the ethics of this statement? Do we have two classes of babies? It's about the baby's health not the mum-who-chose-not-to-breastfeed's health! (and I reiterate that most mums who choose not to breastfeed didn't do this lightly and that usually there's a very good reason for this choice, ignoring this is plain patronising towards these mums).

At the same time I'm open to discussing the ethics to this study and I'm really keen to find out more. The two points in question are: the ethics of recruitment and the agenda of those who fund the study. Let's start with the second point: It has been mentioned that it's in fact funded by formula producers. It wouldn't surprise me because let's face it, state funding is being cut left right and centre, and a lot of academic studies depend on private investment. And private investment can only be obtained if there is something in it for the investor. So, formula producers are the likely investors. Of course there is a conflict of interest but I would still maintain that for the sake of the greater good (=health of babies) we shouldn't categorically dismiss any study that is funded by formula manufacturers. Instead, we should make sure that the study is scientifically sound, peer reviewed and that in the case of introduction to the market of the new "closer to breastmilk" formula, the marketing of this formula is factual, and that advertisement is controlled.

As to the recruitment, I can only speak for myself. I was approached because I was exclusively breastfeeding. The mum opposite me was mix feeding and did not get approached. When approached I was extremely tired after 3 consecutive sleepness nights (2 spent in labour followed by one with a mucusy post c-section baby). The researcher recognised that this did not constitute an ability to sign a consent form. She noted my interest and insisted on consent from dad, and returned hours later after I had had some sleep. At no point was the fact that there would be free formula mentioned to me. I cannot see therefore that anything in the recruitment process undermined my intention to breastfeed.

Quite the contrary - I was open to mixed feeding due to my previous experience of breastfeeding. The study required exclusive breastfeeding for 10 days. Somehow this gave me some goal to work towards, and once I'd reached it it was going so smoothly that in fact my baby didn't touch a drop of formula. As to the claim that apparently the first 10 days of the life of a baby and how it is fed seem to have a disproportionate influence on the risk of developing obesity, diabetes and heart disease - well, I don't know if this is true, but the study claims that because this is so, they "only" need exclusive breastfeeding for the first 10 days for the baby to qualify for the (breastfed) control group. This statement at no point translated to me as "after 10 days you can give baby a bottle".

To me, this process is good enough. It was made clear that I could leave the study at any time (and I was close to it because the recording of feeds really got on my socks). There are elements in the forms to be completed which I would change (e.g. for recording feeds in a 24 hour period, there are only 10 lines, and a breastfed baby is likely to feed more often than that). It may be that the process was less ethical in other postnatal wards and that clearly needs to be addressed.

The bottom line for me though remains the same. Refusing to allow the development of a healthier formula is patronising and morally wrong. Health inequalities between the richest and the poorest are a rift that divide and blight our society. Anything that can help to improve the health of our future generation is a good thing. Even if formula companies pay for it. We need, however, to hold them accountable and make sure the information gained is used in the best possible way.

A good example?

As part of the Optigrow feeding study that we stupidly signed up to in a daze of postnatal hormones, I now have to complete a 5 day food diary for the study requirement at the 6 month mark.

As an aside, let me qualify my use of "stupid" first.
I'm sure this is useful research and there may be great benefit for babies born in the future. The study is not stupid as such, it's me who's stupid to have signed up for it, because it's a right pain in the bum. I had to complete endless feeding diaries at various stages (each of the first 10 days, at 1, 2, 4 months for three days each) plus heavy water tests (4 of those at each of those months), amongst other things. As to the feeding diaries, well, at night time I'd rather not have to wake up to an extent that I can see and actually remember the time of a feed. Add to that a frequently feeding baby but only space for 10 feeds in a day (I'm never sure what counts as a feed- I mean, do I count hourly feeds in the evenings/at night as separate feeds, or only if there is a minimum 2 hour gap? And how do I tell comfort suckling from a proper feed?) which always reminds me that yes, she is a rather frequent feeder and shouldn't I be concerned, are they telling me that if she feeds more than 10 times in a 24 hours period we're waaayyy off the chart and she's not getting enough? Plus, the convenience of breast feeding is not having to watch the clock, so I strongly resented having to fill in this diary (and I admit I made up part of it). The heavy water test - oh my. Another obnoxious little addition to a total of 10 days. Doesn't sound much, but it involves checking nappies every 30 hours until there is a pee, and again until there is another one. Which severely interferes with busy schedules and makes for a baby who is constantly disturbed in her sleep.

No, I didn't like feeding diaries or heavy water tests one bit and had I known how much work it is, I'd not have signed up. Or at least I'd have demanded money for the effort.

Now, at 6 months, I have to complete a 5 day food diary. Luckily, we've not really started weaning (she's a week short of 6 months anyway) and it's not too hard. But if we had, it would have been another massive effort. And I have to admit that I'm partly delaying the start of weaning until after Wednesday because of this requirement - I so can't be bothered recording every crumb she eats.

Now to my main point (yes, there is one) - what disturbs me is the "sample" food diary that comes with the study, the one that's meant to give parents an idea of how to complete the food diary form. Now remember, this food diary is taken a week before the 6 months mark, and again a week before the 12 months mark, i.e. both before the baby turns one.

The examples include a chocolate hobnob, a slice of chocolate cake, scrambled egg, strawberry jam. My jaw drops open. The remainder of foods is made up of jars, or goodies such as white bread and sweetened yoghurt.

So we have food which isn't great but kind of ok, and food which is actually not recommended before the age of one. In a sample food diary. To me this sends out the message that this is normal food a baby might be weaned on, and for the first time parent, it may even serve as a source of ideas for nutritious meals, after all it comes from an infant feeding study!

What were they thinking when they drew this up? The only reason to present such an atrocious example of weaning foods is to say to those parents who do wean their babies on chocolate hobnobs (though know that this is not ideal) that it's ok, you may put it into the diary and don't have to keep it secret from us. But even then, I still feel what they've done is shockingly wrong. It is a sample menu and it will be taken as an example of what a baby might be weaned on. It will encourage people to offer stuff that's not good for such a young baby earlier than they would have otherwise. Nevermind the missed opportunity of providing a good example of a weaning diet.

I'll be getting the chocolate cake (with icing and filling) out then. I'm sure she's gonna like it.

An infant feeding research dilemma

Just after Snowflake's birth, we were asked if we'd be willing to take part in a piece of research on infant feeding. The research was explained to me and once both parents had consented, we embarked on a route of rather a lot of data gathering. Part of this is noting down every feed in the first 9 days, regular measurements and a poo and feeding record at certain intervals (my initial enthusiasm is a bit dampened because the whole thing is a pain in the bum, especially with a cluster feeding baby and a mummy who doesn't wear a watch).

Initially, my understanding of the research was that it attempted to increase knowledge of how breastmilk and formula affect the development of obesity and heart disease in the population. There seems to be some understanding that if an infant is breastfed exclusively for even just the first 10 days, this leads to a significant reduction of cases of obesity and heart disease compared to formula fed babies. What is not established is why exactly this is so. The research tries to compare three groups of babies - those breastfed exclusively for the first 10 days, those fed exclusively on a normal formula and those fed on a newly developed formula which mirrors breastmilk in that it contains less calories from fat (less than normal formula). So the idea is that the calories from fat content in formula milk in the early days may set up the body in a way that it will require more fat and carbohydrates in the future.

Breastfed babies who take part in this study (i.e. Snowflake) provide the base line against which negative effects in relation to obesity/heart disease of either formula are measured.

The background to the effort is that because so many mothers decide not to breastfeed, if a formula could be designed which was closer to breastmilk in that it had the same beneficial effect on preventing obesity and heart disease, this would significantly improve the nation's health.

So here is my dilemma: I'm taking part in a study which, in effect, may lead to the promotion of formula feeding. While I accept that some mothers can't breastfeed and some choose for very good reasons not to breast feed (and I'm supportive of this choice), I'm also dismayed at the low breastfeeding rates particularly in the so called "deprived" areas of Glasgow (and the country), the link between poverty and low rates of breast feeding cannot be denied and it contributes to creating health inequalities from the point a baby is born, arguably earlier. I've talked about the significance of promoting breastfeeding from a poverty and health equalities perspective before.

I accept that it is easier to change formula than it is to change culture. I'm not sure if it's the right way or if it will most likely lead to even more mothers not breastfeeding. My worry is also that the knowledge obtained through this study, which is supported by the NHS, funded by pharmaceutical companies, may eventually be used by formula manufacturers who don't have the same ethics that the current funders and researchers have. It's all good and well to assure me that breast milk will always be best for baby, but a formula that can be marketed as preventing obesity and heart disease just like breast milk must be extremely attractive for less ethically committed manufacturers.

For now I've done my research and all the background of the study is kosher, but once the knowledge is out, can there be control over how it's used? And another question, who am I to decide that the only way to improve the nation's health is to go the long way and change culture, would it not actually be better to change what we can as soon as we can? If this new, fat reduced formula is better for the infant's health than the formula currently available, and if particularly mothers living in deprived communities aren't going to breastfeed anyway, is the ethical thing to do not to support the development of an improved formula that will help reduce health inequalities?

I have no final answer to my questions, but would be interested to hear what you think about all of this.