As a starting point for considering the benefits of breastfeeding, the logical point of reference is the case presented by U.S. Surgeon General Regina Benjamin in her "Surgeon General's Call to Action to Support Breastfeeding 2011." That case is mainly built on various studies that tend to support the idea that breastfeeding reduces various childhood diseases. That case as presented will be discussed below. But first it is worth mentioning that many scientific studies have found that breastfeeding (or more breastfeeding) is associated with increased levels of various diseases; the list includes 26 such studies just in the categories of asthma, allergies, and diabetes alone, three studies regarding autism rates related to breastfeeding, and one major study finding a dose-response relationship between certain toxins in breast milk and behavior scores in the breastfed children that indicate likelihood of later having ADHD. Those studies will not be presented here, since they are covered in www.breastfeeding-studies.info.
In her “Call to Action,” the Surgeon General alleges that “the Agency for Healthcare Research and Quality (AHRQ) … reaffirmed the health risks associated with formula feeding and early weaning from breastfeeding.” That short statement is very inaccurate in two important ways:
1) In the contracted report referred to by the Surgeon General, the opening page clearly states, “No statement in this report should be construed as an official position of AHRQ….” The reader should think carefully about what that says about the regard for accuracy on the part of the authors of this Call to Action, when they say that their major source document represents the position of an authoritative agency which agency clearly disallows any such attribution.
2) The Surgeon General’s Call to Action makes a second untrue statement related to benefits of breastfeeding when saying that the document in question “…reaffirmed the health risks associated with formula feeding and early weaning from breastfeeding.”(1) The Surgeon General acknowledges elsewhere, relatively inconspicuously (p. 33), that "research on the health outcomes of different modes of infant feeding is limited to observational studies, the results of which can only provide inferences on the association between feeding type and outcomes (unlike experimental or randomized controlled trials, which permit assessment of cause and effect)." The dictionary definition of "inference" that fits well here is "conclusion that, though it is not logically derivable from the assumed premises, possesses some degree of probability."(2) Studies of a kind that only indicate "some degree of probability" and that don't show cause and effect cannot "reaffirm" claims about benefits of breastfeeding, such as the Surgeon General says are reaffirmed. (more below) It is with good reason that the U.S. Agency for Healthcare Research and Quality points out that observational studies are subject to "error" and "false conclusion."(3)
Ample associations of high death rates with sunshine would be found by doing observational studies of people in Florida. Sunshine could then be alleged to be a “risk” factor on the basis of observational studies, in the same way that formula feeding is alleged to be a “health risk” for infants on the basis of various associations. In the case of Florida, the real, underlying cause of the death rate is the disproportionately large number of old people in that state. (Age is what scientists call a “confounding factor” in this case.) In the case of illnesses “associated” with bottle feeding, two of the confounding factors are the low-income status of the parents and the high prevalence of smoking in those households; both of these factors are known to be (a) disproportionately high among women who do not breastfeed(1) and (b) causally related to increased levels of the same illnesses that the Surgeon General attributes to formula feeding. (See Section D of this paper regarding the known adverse health effects of typical low-income conditions and household smoking on children.)
Another important confounder is the health of the mother; according to a document explaining findings of a research team of the Norwegian University of Science and Technology, "If a mother is able to breastfeed, and does so, this ability is essentially proof that the baby has already had an optimal life inside the womb." Continuing, the document referred to the findings of the PROBIT study in Belarus, "the largest study that has been done on breastfeeding and health" (which was apparently also the only study on effects of breastfeeding that has minimized effects of confounders by means of randomization of participants). "This study cuts the legs out from underneath most of the assertions that breastfeeding has health benefits, the researchers say." (1a) It should be noted that this 2010 article, on the official website of the Norwegian University of Science and Technology and accessed in 2013, indicated no specific authors; it therefore appears that its statements can be considered to be official statements of the University of Science and Technology.
It is noteworthy that this is a recent statement from the University of Science of Norway, a country that might have the highest breastfeeding rates in the entire world, and whose up-close experience with the effects of breastfeeding probably has no parallel. Notice in this chart that apparently only one other European country even approaches Norway's long-term high breastfeeding rate.
Returning to a concluding comment on the topic begun a little earlier: Associations cannot affirm or "reaffirm" anything, especially when there are known, important confounding factors present, and when there are many studies that arrived at findings contrary to the allegedly "reaffirmed" conclusions.
In another case in which the Surgeon General strongly and incorrectly implies existence of high-quality evidence for benefits of breastfeeding, note the following statement in her Call to Action: “As stated by the U.S. Preventive Services Task Force (USPSTF) evidence review, human milk is the natural source of nutrition for all infants.” However, the only evidence considered in that review was about effectiveness of certain measures in promotion of breastfeeding, not evidence about actual health benefits of breastfeeding.(4) Again, where evidence of desirability of breastfeeding is claimed by the Surgeon General, a closer look reveals that there is actually no such evidence.
The Surgeon General points out that breast milk is "natural." But that "naturalness" arose in a bye-gone era, under conditions that do not exist in most parts of the developed world today, conditions that in the past permitted breast milk to be relatively free of toxins. Developmental toxins and carcinogens that were either very scarce or non-existent 50 or 100 years ago are now recognized as being highly concentrated in breast milk.
Given the fact that the studies on which the Surgeon General bases her position merely found associations, in observational (non-randomized) studies, valid use of the results would require emphasis on the fact that something entirely separate from the bottle feeding could be the cause(s) of the associations presented. A modicum of research would find, and concern for correctness would require emphasizing, that low income conditions, smoking, and maternal health deficiencies could well be the real causes of those same adverse health conditions, instead of bottle feeding.
Also important to focus on is the following quotation from p. 162 of the AHRQ-contracted report: “... the outcomes analyzed in this review represent only a portion of all possible health outcomes related to breastfeeding reported by investigators worldwide.” The PubMed Health web pages (http://www.ncbi.nlm.nih.gov/pubmedhealth/s/diseases_and_conditions/a/) list 358 different diseases and conditions under the letter "A" alone. Clearly, there had to be considerable selection that took place in determining which relatively few health outcomes were to be discussed in the Surgeon General’s Call to Action. Considering the thousands of existing diseases and health conditions, random variation would predict that some of them would be higher with one kind of infant feeding than with another.
Examples of selectivity exercised by the promoters of breastfeeding:
-- when deciding to discuss type 2 diabetes and not type 1 (type 1 diabetes is over twice as prevalent in high-breastfeeding as in low breastfeeding European countries).
-- when deciding not to discuss pertussis (whooping cough), a cause of thousands of infant deaths per year, which is fifty times more prevalent in high-breastfeeding European countries than in low-breastfeeding countries. (more in Section 1.2.p.2 of http://www.pollutionaction.org/breastfeeding-and-autism-and-cancer.htm)
-- something else omitted when selected illnesses are discussed by the promoters of breastfeeding: many important diseases have become much more prevalent among children and young people since breastfeeding rates have gone through a transition from low to high, including actual epidemics arisen in three of the disorders that are alleged to be lower among breastfed infants. (see www.breastfeedingprosandcons.info)
Given the acknowledged absence of established causality, plus the known confounding factors in these cases, as well as the small percentage of all possible health conditions that were selected for reporting on by the Surgeon General, there is no affirmation of health risks of formula feeding.
An especially impressive-looking “excess risk” of 257% is attributed in this same chart to “Hospitalization for lower respiratory tract diseases in the first year.” This statistic came from only one study, in which the authors exercised considerable selectivity in deciding which other studies they would draw on for their data, and this study dealt only with hospitalization rates for the illness. The Surgeon General’s document failed to mention that several studies failed to find any benefits of breastfeeding in reducing rates of lower respiratory tract disease per se. Bear in mind that bottle-feeding mothers are very disproportionately likely to be of low income, with reduced access to and use of health care, when reading the following: According to the U.S. CDC, "Delaying or not receiving timely and appropriate care for chronic conditions and other health problems may lead to the development of more serious health conditions that require hospitalization. Hospital stays for specific conditions have been identified as potentially avoidable in the presence of appropriate and timely ambulatory care....The rate of avoidable hospitalizations is inversely associated with the median income of the patient’s area of residence. In 1989–91 the avoidable hospitalization rate among residents of low-income areas with median household income less than $20,000 was 2.4 times that for residents of high-income areas with median income $40,000 and over."(285b)p.133 Avoidable hospitalizations among the (known disproportionately-low-income) bottle-feeding households, combined with poorer nutrition, crowded housing and day care, household smoking, and poorer air quality in low-income areas could easily have accounted for the entire 257% difference, without even considering the selectivity that the authors exercised in deciding which other studies to drawn on for their data.
Section B: A reminder about the many studies finding adverse effects of breastfeeding:
Amid all the discussion of the weaknesses of the grounds for the claims about benefits of breastfeeding, the following should be remembered: Those who promote breastfeeding make all those claims, as weak as they are, without providing the slightest hint that there could be any evidence on the other side of the issue. Any presentation on this subject that aspires to be above the level of half-truth should at least mention the fact that over 50 scientific studies have found that breastfeeding is associated with increased levels of various diseases, including 26 such studies just in the categories of asthma, allergies, and diabetes, three studies regarding autism, and one major study regarding breast milk toxins related to ADHD-like behavior. Those studies are listed in www.breastfeeding-studies.info.
A question that should be addressed to those who are recommending breastfeeding, but which they probably won't want to answer:
Given (a) the inconclusiveness of the studies that support breastfeeding,** (b) the known concentrations of environmental toxins in recent human milk,** and (c) the many close correlations between variations in breastfeeding levels and similar variations in levels of several epidemics of childhood diseases (seen in national health data**): How can we know that breastfeeding is more beneficial than harmful?
** Supporting information and references to authoritative sources regarding matters raised in this question are included in a one-page printable version of this question, to be found at www.pollutionaction.org/Q.pdf .
We have good reason to say that those who recommend breastfeeding probably will not have an answer to the above question. A slightly different version of essentially this same question was mailed to four different high officials at the U.S. Department of Health and Human Services, who are heads of divisions that are involved in promoting breastfeeding. As of 12 and more weeks after mailing those letters, no reply has been received. Several months earlier, each of those officials had sent one response to an earlier letter that brought up the matters above, and none of their responses said anything in criticism of any of those points. Those points are all well substantiated. So the question that comes at the end, above, is a logical question to ask. But the promoters of breastfeeding appear to be unwilling or unable to respond to it. If they can't or won't answer that question as part of an informed debate on this matter (therefore to email@example.com, as well as to you), should anybody pay attention to their advice?
Researchers may or may not try to adjust or control for the bias arising from low incomes and tobacco smoking that are disproportionately present among the bottle-feeding families. If any adjustment used is only one quarter of what the real conditions would justify, nobody could point to any standard by which the adjustment could be considered insufficient. The bandwagon effect of expecting only benefits of breastfeeding apparently has unfettered ability to bias any adjustments. In one of the few cases found by this author in which details are provided about the nature of adjustments or controls used to deal with confounding factors, a research team labeled one of their charts “Cognitive Ability & Duration of Exclusive Breastfeeding / Controls Included“ when the “controls” apparently included no controls for parental intelligence. (Bear in mind that high-school graduates are known to breastfeed at about half as high a rate as college graduates, meaning that any comparison would automatically have a serious confounding factor that was apparently not even considered.)
Another study points out that “Health care professionals can be a negative source of support (for breastfeeding) if their lack of knowledge results in inaccurate or inconsistent advice.” (7) Yes, that must be it, “lack of knowledge” has to be the reason why highly-educated, experienced health care professionals would provide allegedly “inaccurate” advice to their patients, by counseling against breastfeeding. Serious study of the subject matter of their professions, or extensive long-term observations of their patients, couldn’t be affecting the advice they give. If somebody advises against breastfeeding, by definition they couldn’t have good reasons for that. To partially excuse the closed-mindedness that many researchers display regarding the subject that they ought to instead be considering with open minds, we should remember the very strongly-stated, indisputably one-sided position of the highest medical authority in the U.S. government, Surgeon General Regina Benjamin. (8) With extremely strong promotion of one side of this issue coming from the very top (also including from the other Federal health-related agencies), with obvious implications regarding attitudes expected of recipients of government research grants, how many researchers would be brave enough to express genuine question about benefits of breastfeeding? Put another way, how many researchers would approach their studies today without already having accepted that the only matter that is open to question is, “how great are the benefits of breastfeeding?”
Known Effects of Low Income Conditions and Tobacco Smoking on Health of Children, often Confused with Effects of Bottle Feeding on Health of Children:
It is important to know some of the health effects of low-income existence and smoking, which are crucial in understanding the basic differences between breastfeeding and bottle-feeding households. Bear in mind that those two groups differ greatly according to income levels, with bottle-feeding mothers being very disproportionately of low income, according to the Surgeon General’s own data for the U.S. and according to studies in the U.K. and Australia. (see Section 1.2.s.1.a of www.pollutionaction.org/breastfeeding-and-autism-and-cancer.htm, ) According to a major study funded by the U.S. Public Health Service, “Disparities in childhood asthma can be directly tied to several factors which disproportionately affect lower income children and children of color, including substandard and over-crowded housing, poor ambient air quality (often related to living near freeways, ports, or industrial sources of pollution); exposure to pesticides, particularly among migrant families but also children attending schools close to fields where pesticides are sprayed; and attendance in older schools with poor indoor air quality. Lower income children are also more likely to face barriers to quality health care to treat and control their asthma. Obesity and its consequences, such as diabetes, are widespread in this country, especially among poor, ethnic and racial groups. Children covered by Medicaid are nearly six times more likely to be treated for a diagnosis of obesity than children covered by private insurance.”(9)
Many other studies have extensively documented adverse health effects of poverty on children, including not only frequency but also severity (including the severity that leads to hospitalization for respiratory diseases.(10) For children in low-income households, frequency of delayed immunization is three times the average, and asthma and bacterial meningitis are twice as common. “In the first year of life after the neonatal period, death rates are double to triple those of other children; after the first year, death rates due to disease are triple to quadruple among low-income children…. A study in Toronto demonstrated that children living in socioeconomically deprived areas were far more symptomatic than the adults in these areas from exposure to ambient air pollution in their neighborhood…. Several studies have linked pesticide exposure in childhood to increased rates of leukemia and brain cancer.”(284) It should be noted that pesticide exposure would be increased not only in agricultural areas but also in crowded, low-income conditions where insects such as roaches would be more likely to be a serious problem. Strong correlation between low-income neighborhoods and childhood obesity has been found recently in a study cited by the NIH. (284b)
Effects of confounders related to socio-economic status in studies dealing with cognitive effects of toxins that are heavily present in human milk (PCBs, specifically) have been well reported in the journal, Environmental Health Perspectives.(285b1)
In trying to explain the reasons why lower-income children “suffer disproportionately from almost every disease and show higher rates of mortality,” poor housing, lower-quality nutrition, and reduced access to quality medical care are key factors that are focused on. The lower an individual is in socioeconomic status, the more likely he or she is to experience adverse environmental conditions, such as exposure to pathogens and carcinogens. (285) The reader should bear in mind that the adverse outcomes alleged by the Surgeon General to result from not breastfeeding are known to result from conditions that are typical in low-income households, and bottle feeding is very disproportionately common in the low-income households.
Even if researchers were to try to properly adjust or control for the confounders that apply in these studies, there is no way of knowing all of the confounders that apply, or their full significance (illustrative example will follow); and there is no evidence that good efforts have been made to properly adjust for all of the confounders – the major review of breastfeeding studies that is pointed to by breastfeeding proponents (the AHRQ-contracted report) doesn't even attempt to determine whether adjustments for confounders have been properly made. New findings continue to come out, such as about the many adverse health effects of close residential distance to vehicular traffic, which varies inversely according to income levels (and therefore inversely according to breastfeeding rates); strong preliminary evidence about those effects was just published in 2012.(286)
According to the U.S. CDC, in 1995, infants born to non-Hispanic white mothers with less than 12 years of education were 2.4 times as likely to die in the first year of life as those whose mothers had at least 16 years of education. ((285b) Highlights page) Other statements from that same CDC page, connecting adverse health outcomes in children with the socio-economic conditions that tend to characterize bottle-feeding households: (1) Overweight was also inversely related to family income among non-Hispanic white adolescents; "Poor white adolescents were about 2.6 times as likely to be overweight as those in middle- or high-income families." (2) During 1994–95, poor and near-poor children under 6 years of age were only about one-half as likely to have seen a physician in the prior year as middle- or high-income children. (3) Children 1–14 years of age living in low-income areas were more than twice as likely to be hospitalized for asthma as those in high-income areas during 1989–91, suggesting to the CDC they may have been unable to receive outpatient care that could prevent such a hospitalization. (Think about how this could be the real explanation for the connection between bottle feeding and hospitalizations for lower respiratory tract diseases, even while various studies found no association between bottle feeding and non-hospitalization cases of such diseases; there is a standard term -- used by the CDC -- for hospitalizations that could have been prevented with proper earlier care: "avoidable hospitalizations.") (4) In 1995 poor adults were about four to seven times as likely (depending on ethnicities and genders compared) as high-income adults to report that their health status was fair or poor; although this reporting applied specifically to adults, the same factors of reduced quality of personal care, hygiene, diet, housing and medical care that affect health of adults would almost certainly affect their children as well. (3) (Bearing in mind that prenatal care serves important purposes in promoting the health of the infant) the CDC points out, "Pregnant women who have more education are more likely to start prenatal care early and to have more visits." (6) Two studies from New Zealand, targeting people who lived in homes with inadequate heating, found that, after adding insulation to better regulate the homes' temperatures, the number of children and adults listed in "poor or fair health" fell by about 50 percent, relative to a comparison group with no housing changes. (http://www.nlm.nih.gov/medlineplus/news/fullstory_134998.html) Breastfeeding enthusiasts will focus on the "association" between bottle feeding and bad health outcomes, but the CDC apparently recognizes that the bad health outcomes actually result instead from conditions related to the low education levels and low income that disproportionately go along with bottle feeding.
Bearing in mind that low-income mothers and smokers are disproportionately likely to bottle-feed, note the following (from a Columbia University study) about what are likely to be some real causes of the worse health outcomes of bottle-fed infants: "Inner-city minority populations are high-risk groups for adverse birth outcomes and also more likely to be exposed to environmental contaminants, including environmental tobacco smoke (ETS), benzo[a]pyrene B[a]P, other ambient polycyclic aromatic hydrocarbons (global PAHs), and residential pesticides."(285c)
Smoking: Smoking is known to be more prevalent in families in which infants are bottle fed. According to the CDC, smoking cigarettes during pregnancy was found in a study to be strongly associated with lower socioeconomic status (and therefore with bottle feeding) among all racial and ethnic groups. And also, among various associated health outcomes for infants of mothers who smoke are Sudden Infant Death Syndrome and asthma. In the CDC's words, "In every race and ethnic group, the more education women had, the less likely they were to report smoking during their pregnancy."(285b) Among non-Hispanic white mothers with less than a high school education (who are very likely to bottle feed), smoking during pregnancy was found to be 15 times as prevalent as among white mothers with 16 or more years of education (who are least likely to bottle feed). (The difference was only 10 times when comparing lower- vs. highly-educated mothers in general.) To read about the known correlation of educational levels with breastfeeding rates, see Section 1.2.s.1.a at www.pollutionaction.org/breastfeeding-and-autism-and-cancer.htm .
Data from the U.K. (in this chart) shows the different rates of smoking across socio-economic groups; those socio-economic differences are known to equate with higher or lower rates of breastfeeding in the U.S., U.K. and Germany.
The following is taken from the “WHO Report on Tobacco Smoke and Child Health,” 1999: “…maternal smoking during pregnancy causes well-established, demonstrable harm by reducing birth weight and increasing infant mortality… Parental smoking is an important cause of lower respiratory tract illnesses … during the first years of life…. Both asthma and respiratory symptoms … are increased among children whose parents smoke, on the basis of over 60 studies…. Over 40 studies with different designs have investigated effects of parental smoking across a range of outcomes from acute otitis media to surgery for glue ear. Pooled relative risks for these outcomes range from 1.2 to 1.4…. Overall, parental smoking, particularly by the mother, appears to be responsible for between a third and a half of all SIDS cases…. Children of smokers… have lower scores in cognitive functioning tests… and have more behavioural problems, including conduct disorders, hyperactivity, and decreased attention spans…. Tobacco smoke, whether voluntarily or involuntarily inhaled, includes numerous carcinogens.” According to a Spanish study, pregnant women who smoke or inhale secondhand smoke put their children at risk for learning difficulties, attention-deficit/hyperactivity disorder and obesity. (http://www.nlm.nih.gov/medlineplus/news/fullstory_129421.html )
According to an American/Czech/Slovakian study, "early life vulnerability to cigarette smoke manifests as increased rates of lower respiratory infections, asthma or wheeze, middle ear disease and sudden infant death syndrome.... An experiment in primates indicated that cigarette smoke exposure in either the prenatal period or the first few months of life, alters maturation of the immune system. (285d)
According to a more recent study cited by the NIH, "spending just 10 minutes in the backseat of a car with a smoker in the front increases a child's daily exposure to harmful air pollutants by up to 30 percent. And cracking a car window doesn't help.... Exposure to PAH (found in tobacco smoke) has been linked to immune system problems, wheezing, IQ changes and allergy development, the researchers noted."(285a)
According to KidsHealth.org, "African-American infants are twice as likely.... to die of SIDS as caucasian infants. Other potential risk factors include: smoking, drinking, or drug use during pregnancy, poor prenatal care, prematurity or low birth weight, mothers younger than 20, tobacco smoke exposure following birth ...." (287a) Notice how extremely well this profile of risk factors for SIDS fits the profile of typical bottle feeding mothers: low-income, smoking, young, often African-American, less likely to get prenatal care. Is it any wonder that a higher percentage of bottle-fed than breastfed babies end up dying of SIDS? And how likely is it that the SIDS cases normally result from bottle feeding rather than from other factors, including the apparent major genetic vulnerability of African-Americans, low-income conditions, immature mothers, and (especially) smoking, all of which disproportionately go along with bottle feeding? See the many references to the recognized connection of smoking with SIDS in the previous paragraph as well as in this one. (Aside from blacks and Native Americans, SIDS affects about one out of 2000 U.S. children (287b))
Unmarried women breastfeed at about half as high a rate as married women. (Section 1.2.s.2 at www.pollutionaction.org/breastfeeding-and-autism-and-cancer.htm. “Adolescent mothers (most of whom are unmarried)… have less healthy babies overall than do older mothers.” (288) This reinforces the connection between low income, bottle feeding, and adverse health outcomes, with low income life being the probable underlying cause of the adverse health conditions, and bottle feeding going together with the low income but not being a cause of the illnesses.
“Poverty tends to be associated with an increased incidence of malnutrition, and malnourished individuals are more susceptible to infectious diseases. Overcrowding is known to promote the spread of infectious diseases.” (288a) Aside from malnutrition, it is clear that low-quality foods (high in calories, fat, sugar and refined flour) are less expensive than foods of the kind (especially fruits and vegetables) that build good immune systems and healthy bodies without obesity. The Surgeon General's Call to Action to Support Breastfeeding (p. 32) recognizes that low income leads to poorer health and health care, quite aside from any effects of breastfeeding. Low-income families are more likely to live in noisy neighborhoods, near trains, airports or major highways, with the result that they have greater difficulty gaining the restorative benefits of proper sleep, in addition to poor air quality in such areas.
One possibility might be to try to “adjust” or "control" for those conditions, in studies attempting to compare health effects of bottle- vs. breast-feeding. But there is probably no way to determine whether any such adjustments or controls are carried out competently; and that is a very important matter, given the complex and poorly-quantified nature of the effects of these confounders. In the AHRQ-contracted report that the Surgeon General relies on as the principal basis for her claim of benefits of breastfeeding, many studies were reviewed; and there seems never to have been an attempt to determine whether “confounding” factors (which include low income and smoking) are appropriately adjusted or controlled for. In the checklist form that was used for determining the merits of some of the studies (such as Gdalevich, 2001, and Collaborative Group, 2002, both of which studies received A ratings by the contractors), one of the questions is, “Did authors consider appropriate confounders and justification for adjusting or not adjusting for those confounders?” “Yes” is the highest possible rating. So, in those particular studies, it apparently didn't matter if the researchers didn't control for or made no suitable adjustment for confounding factors; if there had merely been apparent consideration of appropriate confounders, the study could (and often did) receive an “A” rating. And it appears that even obviously inadequate consideration of confounders passes the test, as will be explained. Other studies reported on by these contractors were graded A, B or C for assessment of confounders; looking at how those grades were assigned makes it appear that these contractors’ ratings for consideration of confounders were almost meaningless, considering how uncritically they gave out A’s and B’s. For the studies on asthma done by Kull (2002 and 2004) and Wright (2001), the studies received A grades for confounder consideration even though they did not adjust for effects of low income conditions. (Remember from earlier in this section the effects of crowded housing, poor air quality, and less adequate nutrition that disproportionately affect low-income families, all of which affect asthma incidence.) The Hauck study (2003) received an “A” for treatment of confounders in its SIDS study, even though it did not adjust for either income or smoking (see above about the very strong connection of SIDS with smoking). Duffy (1997) received a “B” for consideration of confounders in its AOM (ear infection) study even though the authors didn’t even adjust for smoking, much less for low income. In studies related to cancer prevalence, the Lee Sy (2003) and Jernstrom (2004) studies both received A grades for their dealing with confounders, even without making any adjustments for low income. In addition to the contractors’ low standards of quality as indicated by their looking for nothing more than consideration of appropriate confounders in some cases, and their very lax grading standards in other cases, there apparently was not even any attempt to judge whether any actual adjustments were made competently.
To summarize: None of the studies relied on by the Surgeon General to support her case provide useful evidence if they don’t contain verifiably valid adjustments for the confounding factors that are known to cause the very same illnesses that the Surgeon General attributes to breastfeeding. The report that she relies on for evidence (a) makes no attempt to determine whether controlling or adjustments have been done well, and (b) routinely gives “A” ratings for assessment of confounders when there is not even an indication of consideration of important confounders. It is no wonder that the Agency for Healthcare Research and Quality distances itself from this contracted report, on which the case for breastfeeding so heavily relies, by stating conspicuously upfront, “No statement in this report should be construed as an official position of AHRQ.”
What is surprising is that the Surgeon General of the United States should launch a major national initiative based on little more than such poor-quality evidence, and in addition misrepresent that evidence as being the position of an agency of higher authority than is actually the case. And it is especially bad that such poor-quality evidence is used as a basis for an initiative that would greatly increase exposure of infants to levels of dioxins that are estimated by the EPA to be 86 times higher than the reasonably-safe upper threshold of dioxin exposure estimated by the EPA, when it is known that bottle-fed infants receive exposures many times lower than that. (see www.breastfeeding-toxins.info)
That is probably an indication of what is going on here: a strong bandwagon effect based essentially on emotion, which causes people to reach for almost anything that might seem to be evidence at first glance, and to accept it as valid even though a close look would reveal that it is not good evidence.
Misuse of Observational Studies in Determining Public Policy:
The U.S. Agency for Healthcare Research and Quality further discusses the recognized problems inherent in observational studies (which are the sources of almost all of the Surgeon General’s data), pointing out that “error” and “false conclusion” can result from finding “associations” in observational studies.(277). (Note that the document being summarized here is genuinely a statement of the AHRQ, as opposed to a contracted product that the AHRQ conspicuously distances itself from, such as the one that the Surgeon General incorrectly represents as an AHRQ statement while relying on it as the basis for her position.) The AHRQ says that one important question to ask when looking at findings of a study is, "How likely is it that bias is affecting the results." And when considering how much attention should be paid to results of the “weaker study design” of non-randomized, observational studies (such as the Surgeon General relies on for her evidence), “The factors to be considered include the consequences of basing a decision on a false conclusion....”(277b) An unknown proportion of false conclusions is simply to be expected in such studies, given the normal expectation of confounders’ being present. And confounders (low income and parental smoking) are known to normally be present in studies comparing breastfed infants with bottle fed. It must be pointed out here that the Surgeon General of the United States is instituting major public policy on the basis of studies that are very much subject to false conclusions, and error in that policy has potentially extremely grave negative consequences. It is not disputed that neuro-developmental toxins are present in breast milk in concentrations that give infants exceptionally high doses at times when their brains are rapidly developing. (See www.breastfeeding-toxins.info, and also the indented sections of the introductory summary of www.pollutionaction.org/breastfeeding-and-autism-and-cancer.htm for a preview of some of the probable effects of exposure of infants to toxins typically contained in breast milk, including greatly increased rates of autism and cancer.) The only question is how great the harm caused is in relation to the presumed benefits of breastfeeding; and the Surgeon General does not provide evidence of a comparison having been conducted on this matter.
The Surgeon General's response to the above rebuttal of her position promoting breastfeeding: As of 12 months after the original presentation of this rebuttal to her in May of 2012, followed by two subsequent letters pointing out the wide exposure this is receiving and asking for her response, neither she nor her associates have responded to the contents of the above rebuttal. What does that say about the validity of their position?
A more complete rebuttal of the Surgeon General’s Call to Action to Support Breastfeeding also requires review of Sections 1.1.b and 1.2.p.2 at www.pollutionaction.org/breastfeeding-and-autism-and-cancer.htm.
Message to health professionals and scientists reading this paper: This author cordially invites you to indicate your reactions to the contents presented here. As of now, new parents almost never hear anything but completely one-sided promotion of breastfeeding, with no mention of possible drawbacks except in cases of serious problems on the part of the mother. If you feel that parents should be informed about both sides of this question and thereby enabled to make an educated decision in this important matter, please write to the author of this paper. Also, if you find anything here that you feel isn't accurately drawn from trustworthy sources or based on sound reasoning, please by all means send your comments, to firstname.lastname@example.org.
Comments from readers:
From this paper's inception in early 2012 until present, the invitation has been extended to all readers to submit criticisms of contents of this paper, asking them to point out how anything written here is not well supported by authoritative sources (as cited) or is not logically based on the evidence presented. As of May 4, 2013, after more than a year, no criticisms of contents of this paper have yet been received in response to that invitation. (That is significant, considering the thousands of visits we receive from readers every month.) We have received some e-mails that have not criticized contents of this paper but which are of interest; several of those comments or inquiries and our responses to them are entered at www.pollutionaction.org/comments.htm . All comments are welcome, especially those that point out any deficiencies in our evidence in relation to conclusions drawn or any lack of quality in the reasoning as presented. Please send comments or questions to email@example.com .
* About Pollution Action: Please visit www.pollutionaction.org
(1) Surgeon General's Call to Action to Support Breastfeeding, 2011. May specifically refer to Table 2; and Section D of www.breastfeeding-benefits.info
(3) Agency for Healthcare Research and Quality, U.S. DHHS, Systems to Rate the Strength of Scientific Evidence, Evidence Report/Technology Assessment: Number 47 http://archive.ahrq.gov/clinic/epcsums/strengthsum.pdf
(4) Annals of Internal Medicine: Interventions in Primary Care to Promote Breastfeeding: An Evidence Review for the U.S. Preventive Services Task Force Mei Chung et al.
(6) AHRQ “Lessons from Outcomes and Effectiveness Research” http://www.ahrq.gov/clinic/out2res/outcom3.htm
(7) J Obstet Gynecol Neonatal Nurs. 2002 Jan-Feb;31(1):12-32. Breastfeeding initiation and duration: a 1990-2000 literature review. Dennis CL. Faculty of Nursing, University of Toronto, Ontario, Canada. firstname.lastname@example.org
(9) Dana Hughes, DrPH, Mary Kreger, DrPH, et al.: Reducing Health Disparities Among Children: Strategies And Programs For Health Plans. Produced with support from the Health Resources and Services Administration, U.S. Public Health Service, At http://nihcm.org/pdf/HealthDisparitiesFinal.pdf; also see Gallup Well-Being, March 21, 2008 Among Americans, Smoking Decreases as Income Increases by Rob Goszkowski Am J Dis Child. 1984 Jul;138(7):629-32. Respiratory and gastrointestinal illnesses in breast- and formula-fed infants. Myers MG,et al; Effect of passive smoking on growth and infection rates of breast-fed and non-breast-fed infants.Yilmaz G, et al Department of Pediatrics, Keçiören Training and Research Hospital, Ankara, Turkey. email@example.com)
(10) Parker S, Double jeopardy: the impact of poverty on early child development. PediatrClinNorthAm.1968; 35:1227-1240. Starfield B. Child health care and social factors: poverty, class, race. Bull N Y Acad Med. 1989; 65: 299-306. Geltman PL, Welfare reform and children's health. Arch Pediatr Adolesc Med. 1996; 150: 384-389. Palfrey JS. Community Child Health: An Action Plan for Today. Westport, Conn: Praeger Publishers; 1995. Also see "Health Status and Socio-economic Status" in CDC document at http://www.cdc.gov/nchs/data/series/sr_10/sr10_191.pdf , p. 6.
(284) Child Health Care and Social Factors: Poverty, Class Race Barbara Starfield, MD, MPH, Professor and Head, Division of Health Policy, Johns Hopkins University School of Hygiene and Public Health, presented at 1988 Annual Health Conference of the New York Academy of Medicine
(284b) Poor Neighborhoods Home to More Obese Kids: Study Researchers find link between weight and the economic and educational status of the community By Robert Preidt Friday, November 16, 2012, Medline Plus, U.S. National Library of Medicine, NIH http://www.nlm.nih.gov/medlineplus/news/fullstory_131416.html
(285) Socioeconomic Inequalities in Health: No Easy Solution Nancy E. Adler, PhD (Vice-Chair, Dept. of Psychiatry & Director of the Center for Health and Community, University of California, San Francisco), et al., Journal of American Medical Association, 1993
(285a) Secondhand Smoke Very Unhealthy for Kids in Cars: Study Backseat exposure to polluted air is worse than in restaurants, bars, casinos By Robert Preidt Thursday, November 22, 2012 HealthDay, Medline Plus of NIH at http://www.nlm.nih.gov/medlineplus/news/fullstory_131561.html
(285b) found at http://www.cdc.gov/nchs/data/hus/hus98cht.pdf; also, about SIDS connection, Golding J. Sudden infant death syndrome and parental smoking—a literature review. Paediatr Perinat Epidemiol 11(1): 67–77. 1997. Other information connecting educational levels and smoking can be found in the following: Verbreitung, Dauer und zeitlicher Trend des Stilles in Deutschland, Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2007 May-Jun;50(5-6), p. 628 and also Breastfeeding Initiation and Duration: A 1990-2000 Literature Review Cindy-Lee Dennis, RN, PhD JOGNN in Review, Vol. 31, Number 1
(285b1) Schantz et al., Effects of PCB Exposure on Neuropsychological Function in Children Environmental Health Perspectives, Vol. 111 at at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1241394/pdf/ehp0111-000357.pdf p. 363
(285c) A summary of recent findings on birth outcomes and developmental effects of prenatal ETS, PAH, and pesticide exposures. Perera FP et al., Columbia Center for Children's Environmental Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA. firstname.lastname@example.orgNeurotoxicology. 2005 Aug;26(4):573-87.
(285d) Prenatal Exposures to Persistent and Non-Persistent Organic Compounds and Effects on Immune System Development, Irva Hertz-Picciotto et al., Nordic Pharmacological Society. Basic & Clinical Pharmacology & Toxicology 102, 146–154 Blackwell Publishing Ltd Doi: 10.1111/j.1742-7843.2007.00190.x
This organization consists to a great extent of one person, me (Don Meulenberg), but I receive considerable data-gathering and analysis assistance from several associates, as mentioned below. I am not a scientist, but my education included challenging biology and chemistry courses, in which I did well; and I am quite able to accurately pull together and summarize relevant sections from the many scientific studies and health data sources that are available in the fields I am concerned with. This orientation has some advantages compared with studies by PhD's, which tend to go into great detail in narrowly-defined areas, and which typically conclude with recommendations for future multi-year studies on the subject. I received scores in the top 1% on standardized tests when in high school, hold a B.A. cum laude from Oberlin College, and stood in the top third of my class during a year at Harvard's Graduate School of Business Administration. There were important aspects of the business-school case-study method that have been helpful in making my work more practically useful (I believe) than much or most of what has been written on these subjects, as follows: After carefully studying large amounts of printed matter on a subject and doing whatever numerical calculations seem relevant, one is expected to come up with well-considered recommendations for action. Apparent insufficiency of information available on a subject should not lead one to be satisfied to recommend future long-term studies, if there is a serious problem now. Work around gaps in the available data as best you can, and come up with an action plan reasonably quickly that you can defend in plain English on the basis of the data and common sense. As applied in this case, that approach meant poring through hundreds of studies and reports, plotting local disability data and analyzing pollution figures (with the aid of spreadsheet software), then winnowing out some apparent patterns for closer looks, utilizing the excellent computer expertise, diligent data analysis and real-world knowledge of Matt Hulbert, proof-reading, general assistance and excellent advice of Greta Hammen, accurate data entry, computations, and map-shading assistance from various associates (especially Richard Hybl and Tim Gill), considerable and invaluable assistance from reference librarians at the Central Rappahannock Regional Library (especially Lee Criscuolo and Courtney McAllister) in locating difficult-to-access scientific articles, very helpful thoughts and guidance to information sources from Professor James Corbett of the University of Delaware's College of Earth, Ocean, and Environment, and drawing on insightful comments and suggestions from various acquaintances, employees and friends, including parents from three separate families each with at least one boy and one girl.
I own a small U.S. manufacturing company and manage it when I'm not working on pollution and developmental matters. We are located in Fredericksburg, Virginia, USA. Since my company's products compete in a minor but significant way with imports from Asia, my attention was originally drawn to the subject of environmental toxins when I became aware of the increasing pollution emitted by ships bringing imports to U.S. shores. I was also inspired to look into the subject of sources of mental impairment by seeing an increase in sales of my company’s damage-resistant products for use in residences for mentally-handicapped young people.
I strongly encourage any reader to look in my writing for any statement that does not appear to be well supported by valid evidence or reasoning, or any passages that don't seem to make sense, and to inform me (and anyone else) about any apparent flaws. All comments that criticize specific passages will be posted at the end of the appropriate paper and responded to. Many people won’t like my conclusions, but if you can’t say anything about what is inadequate with the evidence or the reasoning that led to the conclusions, please don’t bother making a negative response. (But non-negative responses are always welcome.) My e-mail address is email@example.com .
Full disclosure: I have no financial or other interest in infant formula or in anything that could benefit from my research. The name of my small Virginia manufacturing company is not mentioned here because doing so might cause some people to think that my writing and publicizing of findings is intended to generate publicity and sales for my company. But anyone who is curious could find out the nature of my business with little difficulty.
Office Address: Pollution Action, 27 McWhirt Loop, Ste. 111, Fredericksburg, VA 22406
www.pollutionaction.org 540-370-1555 E-mail: firstname.lastname@example.org