Friday, April 16, 2010

Watch Your Language

By Diane Wiessinger, M.S., IBCLC
Photo © 2009 Danelle Frisbie
Article first published in the Journal of Human Lactation, 12:1, 1996. [Note: 14 years later we still face the same problems regarding our literature and our language! It's time for a change.]



The lactation consultant says, "You have the best chance to provide your baby with the best possible start in life, through the special bond of breastfeeding. The wonderful advantages to you and your baby will last a lifetime." And then the mother bottlefeeds. Why?

In part because that sales pitch could just as easily have come from a commercial baby milk pamphlet. When our phrasing and that of the baby milk industry are interchangeable, one of us is going about it wrong...and it probably isn't the multinationals.

Here is some of the language that I think subverts our good intentions every time we use it.

Best possible, ideal, optimal, perfect. Are you the best possible parent? Is your home life ideal? Do you provide optimal meals? Of course not. Those are admirable goals, not minimum standards. Let's rephrase. Is your parenting inadequate? Is your home life subnormal? Do you provide deficient meals? Now it hurts. You may not expect to be far above normal, but you certainly don't want to be below normal.

When we (and the artificial milk manufacturers) say that breastfeeding is the best possible way to feed babies because it provides their ideal food, perfectly balanced for optimal infant nutrition, the logical response is, "So what?" Our own experience tells us that optimal is not necessary. Normal is fine, and implied in this language is the absolute normalcy - and thus safety and adequacy - of artificial feeding. The truth is, breastfeeding is nothing more than normal. Artificial feeding, which is neither the same, nor superior, is therefore deficient, incomplete, and inferior. Those are difficult words, but they have an appropriate place in our vocabulary.

Advantages. When we talk about the advantages of breastfeeding - the "lower rates" of cancer, the "reduced risk" of allergies, the "enhanced" bonding, the "stronger" immune system - we reinforce bottlefeeding yet again as the accepted, acceptable norm.

Health comparisons use a biological, not cultural, norm, whether the deviation is harmful or helpful. Smokers have higher rates of illness; increasing prenatal folic acid may reduce fetal defects. Because breastfeeding is the biological norm, breastfed babies are not "healthier;" artificially-fed babies are ill more often and more seriously. Breastfed babies do not "smell better;" artificial feeding results in an abnormal and unpleasant odor that reflects problems in an infant's gut. We cannot expect to create a breastfeeding culture if we do not insist on a breastfeeding model of health in both our language and our literature.

We must not let inverted phrasing by the media and by our peers go unchallenged. When we fail to describe the hazards of artificial feeding, we deprive mothers of crucial decision-making information. The mother having difficulty with breastfeeding may not seek help just to achieve a "special bonus;" but she may clamor for help if she knows how much she and her baby stand to lose. She is less likely to use artificial milk just "to get him used to a bottle" if she knows that the contents of that bottle cause harm.

Nowhere is the comfortable illusion of bottlefed normalcy more carefully preserved than in discussions of cognitive development. When I ask groups of health professionals if they are familiar with the study on parental smoking and IQ (1), someone always tells me that the children of smoking mothers had "lower IQs." When I ask about the study of premature infants fed either human milk or artificial milk (2), someone always knows that the breastmilk-fed babies were "smarter." I have never seen either study presented any other way by the media - or even by the authors themselves. Even health professionals are shocked when I rephrase the results using breastfeeding as the norm: the artificially-fed children, like children of smokers, had lower IQs.

Inverting reality becomes even more misleading when we use percentages, because the numbers change depending on what we choose as our standard. If B is 3/4 of A, then a is 4/3 of B. Choose A as the standard, and B is 25% less. Choose B as the standard, and A is 33 1/3% more. Thus, if an item costing 100 units is put on sale for "25% less," the price becomes 75. When the sale is over, and the item is marked back up, it must be marked up 33 1/3% to get the price up to 100. Those same figures appear in a recent study (3), which found a "25% decrease" in breast cancer rates among women who were breastfed as infants. Restated using breastfed health as the norm, there was a 33-1/3% increase in breast cancer rates among women who were artificially fed. Imagine the different impact those two statements would have on the public.

Special. "Breastfeeding is a special relationship." "Set up a special nursing corner." In or family, special meals take extra time. Special occasions mean extra work. Special is nice, but it is complicated, it is not an ongoing part of life, and it is not something we want to do very often. For most women, nursing must fit easily into a busy life - and, of course, it does. "Special" is weaning advice, not breastfeeding advice.

Breastfeeding is best; artificial milk is second best. Not according to the World Health Organization. Its hierarchy is:
1) breastfeeding
2) the mother's own milk expressed and given to her child some other way
3) the milk of another human mother
4) artificial milk feeds (4).
We need to keep this clear in our own minds and make it clear to others. "The next best thing to mother herself" comes from a breast, not from a can. The free sample perched so enticingly on the shelf at the doctor's office is only the fourth best solution to breastfeeding problems.

There is a need for standard formula in some situations. Only because we do not have human milk banks. The person who needs additional blood does not turn to a fourth-rate substitute; there are blood banks that provide human blood for human beings. He does not need to have a special illness to qualify. All he needs is a personal shortage of blood. Yet only those infants who cannot tolerate fourth best are privileged enough to receive third best. I wonder what will happen when a relatively inexpensive commercial blood is designed that carries a substantially higher health risk than donor blood. Who will be considered unimportant enough to receive it? When we find ourselves using artificial milk with a client, let's remind her and her health care providers that banked human milk ought to be available. Milk banks are more likely to become part of our culture if they first become part of our language.

We do not want to make bottlefeeding mothers feel guilty. Guilt is a concept that many women embrace automatically, even when they know that circumstances are truly beyond their control. (My mother has been known to apologize for the weather.)

Women's (nearly) automatic assumption of guilt is evident in their responses to this scenario: Suppose you have taken a class in aerodynamics. You have also seen pilots fly planes. Now, imagine that you are the passenger in a two-seat plane. The pilot has a heart attack, and it is up to you to fly the plane. You crash. Do you feel guilty?

The males I asked responded, "No. Knowing about aerodynamics doesn't mean you can fly an airplane." "No, because I would have done my best." "No. I might feel really bad about the plane and pilot, but I wouldn't feel guilty." "No. Planes are complicated to fly, even if you've seen someone do it."

What did the females say? "I wouldn't feel guilty about the plane, but I might about the pilot because there was a slight chance that I could have managed to land that plane." "Yes, because I'm very hard on myself about my mistakes. Feeling bad and feeling guilty are all mixed up for me." "Yes, I mean, of course. I know I shouldn't, but I probably would." "Did I kill someone else? If I didn't kill anyone else, then I don't feel guilty." Note the phrases "my mistakes," "I know I shouldn't," and "Did I kill anyone?" for an event over which these women would have had no control!

The mother who opts not to breastfeed, or who does not do so as long as she planned, is doing the best she can with the resources at hand. She may have had the standard "breast is best" spiel (the course in aerodynamics) and she may have seen a few mothers nursing at the mall (like watching the pilot on the plane's overhead screen). That is clearly not enough information or training. But she may still feel guilty. She's female.

Most of us have seen well-informed mothers struggle unsuccessfully to establish breastfeeding, and turn to bottlefeeding with a sense of acceptance because they know they did their best. And we have seen less well-informed mothers later rage against a system that did not give them the resources they later discovered they needed. Help a mother who says she feels guilty to analyze her feelings, and you may uncover a very different emotion. Someone long ago handed these mothers the word "guilt." It is the wrong word.

Try this on: You have been crippled in a serious accident. Your physicians and physical therapists explain that learning to walk again would involve months of extremely painful and difficult work with no guarantee of success. They help you adjust to life in a wheelchair, and support you through the difficulties that result. Twenty years later, when your legs have withered beyond all hope, you meet someone whose accident matched your own. "It was difficult," she says. "It was three months of sheer hell. But I've been walking every since." Would you feel guilty?

Women to whom I posed this scenario told me they would feel angry, betrayed, cheated. They would wish they could do it over with better information. They would feel regret for opportunities lost. Some of the women said they would feel guilty for not having sought out more opinions, for not having persevered in the absence of information and support. But gender-engendered guilt aside, we do not feel guilty about having been deprived of a pleasure. The mother who does not breastfeed impairs her own health, increases the difficulty and expense of infant and child rearing, and dismisses one of life's most delightful relationships. She has lost something basic to her own well-being. What image of the satisfactions of breastfeeding do we convey when we use the word "guilt"?

Let's rephrase, using the words women themselves gave me: "We don't want to make bottlefeeding mothers feel angry. We don't want to make them feel betrayed. We don't want to make them feel cheated." Peel back the layered implications of "we don't want to make them feel guilty," and you will find a system trying to cover its own tracks. It is not trying to protect her. It is trying to protect itself. Let's level with mothers, support them when breastfeeding doesn't work, and help them move beyond this inaccurate and ineffective word.

Pros and cons, advantages and disadvantages. Breastfeeding is a straight-forward health issue, not one of two equivalent choices. "One disadvantage of not smoking is that you are more likely to find secondhand smoke annoying. One advantage of smoking is that it can contribute to weight loss." The real issue is differential morbidity and mortality. The rest - whether we are talking about tobacco or commercial baby formulas - is just smoke.

One maternity center uses a "balanced" approach on an "infant feeding preference card" (5) that lists odorless stools and a return of the uterus to its normal size on the five lines of breastfeeding advantages. (Does this mean the bottlefeeding mother's uterus never returns to normal?) Leaking breasts and an inability to see how much the baby is getting are included on the four lines of disadvantages. A formula-feeding advantage is that some mothers find it "less inhibiting and embarrassing." The maternity facility reported good acceptance by the pediatric medical staff and no marked change in the rates of breastfeeding or bottlefeeding. That is not surprising. The information is not substantially different from the "balanced" lists that the artificial baby food salesmen have peddled for years. It is probably an even better sales pitch because it now carries very clear hospital endorsement. "Fully informed," the mother now feels confident making a life-long health decision based on relative diaper smells and the amount of skin that shows during feedings.

Why do the commercial baby formula companies offer pro and con lists that acknowledge some of their product's shortcomings? Because any "balanced" approach that is presented in a heavily biased culture automatically supports the bias. If A and B are nearly equivalent, and if more than 90% of mothers ultimately choose B, as mothers in the United States do (according to an unpublished 1992 Mothers' Survey by Ross Laboratories that indicated fewer than 10% of U.S. mothers nursing at a year), it makes sense to follow the majority. If there were an important difference, surely the health profession would make a point of staying out of the decision-making process. It is the parents' choice to make. True. But deliberately stepping out of the process implies that the "balanced" list was accurate. In a recent issue of Parenting magazine, a pediatrician comments, "When I first visit a new mother in the hospital, I ask, 'Are you breastfeeding or bottlefeeding?' If she says she is going to bottlefeed, I nod and move on to my next questions. Supporting new parents means supporting them in whatever choices they make; you don't march in postpartum and tell someone she's making a terrible mistake, depriving herself and her child." (6)

Yet if a woman announced to her doctor, midway through a routine physical examination, that she took up smoking a few days earlier, the physician would make sure she understood the hazards, reasoning that now was the easiest time for her to change her mind. It is hypocritical and irresponsible to take a clear position on smoking and "let parents decide" about breastfeeding without first making sure of their information base. Life choices are always the individual's to make. That does not mean his or her information sources should be mute, nor that the parents who opt for bottlefeeding should be denied information that might prompt a different decision with a subsequent child.

Breastfeeding. Most other mammals never even see their own milk, and I doubt that any other mammalian mother deliberately "feeds" her young by basing her nursing intervals on what she infers the baby's hunger level to be. Nursing quiets her young and no doubt feels good. We are the only mammal that consciously uses nursing to transfer calories...and we're the only mammal that has chronic trouble making that transfer.

Women may say they "breastfed" for three months, but they usually say they "nursed" for three years. Easy, long-term breastfeeding involves forgetting about the "breast" and the "feeding" (and the duration, and the interval, and the transmission of the right nutrients in the right amounts, and the difference between nutritive and non-nutritive suckling needs, all of which form the focus of artificial milk pamphlets) and focusing instead on the relationship. Let's all tell mothers that we hope they won't "breastfeed" - that the real joys and satisfactions of the experience begin when they stop "breastfeeding" and start mothering at the breast.

All of us within the profession want breastfeeding to be our biological reference point. We want it to be the cultural norm; we want human milk to be made available to all human babies, regardless of other circumstances. A vital first step toward achieving those goals is within immediate reach of every one of us. All we have to do is...watch our language.



If you found this article of interest, you may desire to ensure you regularly receive your own copy of the Journal of Human Lactation (JHL). Taking out membership in the International Lactation Consultant Association (ILCA) includes the benefit of four issues of the JHL a year. See their home page for how to join.

More from Diane Wiessinger at Common Sense Breastfeeding.


For further information on breastfeeding, see resources (books/articles/websites) on this page.


References:

1. Olds D. L., Henderson, C. R. Tatelbaum, R.: Intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics 1994; 93:221-27.

2. Lucas, A., Morley, R., Cole, T.J., Lister, G., Leeson-Payne, C.: Breast milk and subsequent intelligence quotient in children born preterm. Lancet 1992; 339 (8788): 261-64.

3. Fruedenheim, J.L., Graham, S., Laughlin, R., Vena, J.E., Bandera, E., et al: Exposure to breastmilk in infancy and the risk of breast cancer. Epidemiology 1994, 5:324-30.

4. UNICEF, WHO, UNESCO: Facts for Life: A Communication Challenge. New York: UNICEF 1989; p. 20.

5. Bowles, B.B., Leache, J., Starr, S., Foster, M.: Infant feeding preferences card. J Hum Lact 1993; 9: 256-58.

6. Klass, P.: Decent exposure. Parenting (May) 1994; 98-104.

~~~~~


16 comments:

  1. I loved this. LOVED IT. I was just thinking the other day about how you don't see "The benefits of not smoking while pregnant" panflits. It is alot about our language, langauge does shape the way we think. Thankyou, I will share this far and wide.

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  2. Such a fantastic article!

    I've shared this with many of my BF mama friends and many of them have admitted to having feelings of inadequacy and failure when their breastfeeding infants had normal occurrences of gas or reflux (as if something was "wrong" with their milk), or when their baby was deemed to weigh too little at the doctor's office (as if their milk was not supplying enough nutrition), or even feeling inadequate for not having the ability to find a quiet place an relax while nursing.

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  3. Barefoot Momma ;-)April 17, 2010 8:04 PM

    Personally, I refer to formula as substandard infant food. Babies deserve better! If everyone who could breastfeed would, then we'd have plenty of extra human milk available for the mom's who can't breastfeed.

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  4. Great article! It really does put an interesting spin on how terminology can twist reality to make people feel better about their choices. Aside for those For whom bf just doesn't work, it really is a sad commentary on society that so many mothers give up this beautiful bonding experience because it doesn't "fit" their modern lifestyle. I'd like to see women have minimum one year maternity leave so we all have the opportunity to do what is best for our babies.

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  5. It's a little long so I couldn't read it all, but I LOVE this article. I have never thought of breastfeeding using the "normal" language and I didn't realize how I was thinking of it until now.
    My first was in the NICU and it took me 3 months of pumpinguntil he miraculously latched one day. I know it can be hard but I wanted my children to have what God intended, not the 4th best.
    Thanks for posting this.

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  6. Thank you for posting this. My son was in the NICU for 3 months and they started him on formula right away without asking me! I fought for what is the norm, only to be told that it would be too hard to pump, store, and keep fresh. He ate through a tube, and was never able to eat orally, but after day 2 he was never given formula again. I pumped for 4 months until the day he passed away from other health related issues. But I have no guilt, knowing that I did what was normal. It would have been easy to give in, but because I was informed about the shortcomings of formula, I stuck with it. I believe that my little man was better off for it. I can only imagine the other health issues he would have had if I didn't give him my milk. :)

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  7. Thank you for posting this so fairly. My daughter was born with a cleft palate and I pumped for three months before I had to start giving her formula. But no one had told me I could have feed her breast milk longer if I had used a certain supplemental system and being a teenaged mother, I had no idea. But I hate it that so many people who are pro-breast feeding, or whatever you like to call them, look down their noses at me and tell me I should have "tried hard" or "done more research" or used a milk bank (which by the way, costs a fortune and I think is extremely unfair since all the milk they collect comes in by donation, but thats another story). Maybe that is true, but where were you when I was struggling with pumping all day and all night and trying so hard to get those first three months worth of breast milk to my daughter? Oh, anyway, I really appreciate that this was not a "bottle bashing" article but it was fair. Thanks so much for that.

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  8. I've breastfed 3 kids now (ok, currently feeding the third). I was utterly uneducated when I had the first one, and breastfed her because it just seemed like what you should do. No guilt, no worry, no assumption of doing 'the best thing', no fear of failure.

    So of course I've just done the same thing with the next two. I'm lazy, breastfeeding is good for lazy people. Baby cries? Have a boobie! Too easy.

    This is how it should be.

    The annoying thing is the local nurses seem to think it is unusual that I have a happy baby putting on the median amount of weight, with just breastmilk!

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  9. "Baby cries, have a boobie." lol!

    I couldn't agree more about mothering at the breast. Though the point of this post wasn't religious, I think it's important for those of us who do follow a Judeo-Christian religion to note that the Bible speaks many times of God nurturing His people at His breast. So if you believe in God, you pretty much have to view parenting as something that is done at the breast, not in a bucket or bouncy swing. I don't think many modern religions do a good job of pointing that out.

    Anyway, I am sharing this post as well. Brava!!

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  10. To the last Anon -

    Noting your comment, you may also enjoy these articles:

    Breastfeeding Baby Jesus http://www.drmomma.org/2009/12/breastfeeding-baby-jesus.html

    Breastfeeding in Public: A Christian Father Speaks Up http://www.drmomma.org/2010/05/breastfeeding-in-public-christian.html

    Breastfeeding in Church: A Picture of Christ's Sacrificial Love
    http://www.drmomma.org/2010/06/breastfeeding-in-church-picture-of.html

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  11. Let's start telling Mothers about pharmaceutical options for increasing milk supply. I have PCOS & never had enough milk to breast feed exclusively. Only 2 years after the fact did anyone (lactation consultant, Dr, friend etc) tell me there is medication that can increase milk supply. I took every single stinkin suggestion, you name the tea, the supplement, the pumping after feedings, I did it - for 9 months. Not once did any of these well meaning sources ever say anything about medication. I believe in & agree with holistic health but right now after reading this I don't feel angry about some Dr telling me to give my baby a bottle (which they never did) I feel angry towards the devout holists that left out information that could have made it so I could have breast fed my baby for longer. It's frustrating to feel like the only person that believes in integrated healthcare: western, eastern, & holistic combined & used to make informed decisions to maximize the quality of ones health & life.

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  12. Pharmaceutical options are certainly well known (and often recommended even before other non-pharma hormonal strategies are tried) by LCs around the nation. They are highlighted in the book "Making More Miilk" -

    http://astore.amazon.com/peacefparent-20/detail/007159857X

    and seem to be commonplace among most lactation consultants and groups. As with all drugs, there are side effects (sometimes bad, for some mothers) and a woman should be fully informed on all aspects of her options so she can make the best decision for herself and her baby.

    Frequently, the reason for low milk supply is that hormones have been so powerfully impacted (via artificial hormones taken, drugs at/surrounding birth, birth trauma, not being skin-to-skin with baby in the early weeks/months, lack of baby wearing, lack of cosleeping, and mom working apart from her baby for many hours each day are just several of the ways that milk-producing hormones are influenced). It is very difficult, even with pharmaceutical options, to reverse the effect of this hormonal activity. If the foundation is not laid for a healthy breastfeeding relationship, it is tough to build on top or 'fix' what is broken at the very core.

    It again comes back to being well informed - how lactation works, how milk supply is impacted, and the many options available when the system breaks down. Our current culture fails mothers when we do not offer them ALL information pertinent to breastfeeding - pharma options included - before their babies are born (when milk supply begins its manufacture).

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  13. Hi
    I've been in both worlds.
    Breastfed my daughter for 2 years.
    Had brain surgery when she was almost 3.
    Pituitary gland (and therefore prolactin gland removed.
    Recovered from cushings disease. Got pregnant with help of hormones.
    Gave 2nd daughter 5 days of colustrum (from relaxin made by placenta)
    Give my daughter formula for most feeds from birth.
    However am proud to give her bottles everyweek of her aunty's milk (my sister in law)

    It's hard bottlefeeding, my bub does cry more than her big sister did, has more wind and nappies too, but is healthy and happy and mine.

    I can't imagine why people would choose bottlefeed

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  14. Hi,I breastfed my children.With my first it could have gone either way and I was lucky. I was a LLL for ten years. I was inspired to start listening to the stories of women when breastfeeding hasn't worked out. I would encourage you to do this too it gives us the most accurate info on what is needed.What I now know is that for many women bottle feeding is not a choice, it is the end to a sense of prolonged crisis. IMO learning to deal with this crisis and provide a safe place for women to talk about difficulties would be a great step forward. Acknowledging women's grief when breastfeeding doesn't work out is also important.If women were better supported when breastfeeding didn't work out this would be a great service for breastfeeding.For more info see a face book page I have created- supportive community when breastfeeding doesn't work out.

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  15. Amazing post!!! Thoroughly enjoyed it. Thank you so very much for this insight!!

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  16. Carrie! I had the same thing in the hospital! If I could do it all over again, I would have raised heck! Did not even bother to ask... Another barrier to breastfeeding is that men are accusing women of breastfeeding as a tactic for keeping their children from them in divorce/split situations! They are using breastfeeding against them in court! And just because this sounds ridiculous, it may not to a childless judge.

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