On Sunday, July 8, the New York Times published an article on what it characterizes as a stunning opposition to a UN-affiliated World Health Assembly resolution on breastfeeding. The Times reports that US delegates used “strong-arm tactics,” acting in opposition of evidence-based research supporting breastfeeding as the healthiest option for children, and embraced instead interests of infant formula manufacturers. Read “Opposition to Breast-Feeding Resolution by U.S. Stuns World Health Officials.”

We spoke to Dr. Scott Krugman, Vice Chair of Pediatrics at the Herman & Walter Samuelson Children’s Hospital at Sinai in Baltimore and Vice-Chair of the American Academy of Pediatrics Council on Community Pediatrics, for his reaction to this news.

Dr. Krugman is the past chairman of the Maryland Chapter of the American Academy of Pediatrics and the 2015 Maryland Pediatrician of the Year, an award bestowed upon him, in part, for leading Franklin Square Hospital’s efforts to offer breastfeeding classes and other healthy baby initiatives in a community in Baltimore County, Maryland. He has been involved in caring for children and creating systems to care for children in the community for decades. In partnership with the Baltimore County Department of Health, he has been trying to reduce infant mortality in Eastern Baltimore County for a decade through efforts to reduce sleep-related sudden infant deaths and improving the social determinants that lead to low birth weight through the Healthy Babies Collaborative.

JPHMP Direct: Thank you for speaking with us, Dr. Krugman. What is your reaction to this article in the New York Times?

Dr. Scott Krugman: Like most pediatricians who read this article, I was quite stunned. While of course not every mother can successfully breastfeed, the public health benefits of breastfeeding promotion globally are not in doubt. Access to clean drinking water and affordable formula in developing countries is limited at best – and supporting breastfeeding can be the only option for children to get adequate nutrition. As such, supporting a resolution that advocates for successful breastfeeding globally makes sense. Breastmilk does not cost a poor family anything. Breastfeeding promotion is especially important in low-income areas of developed countries where rates are very low. The marketing budgets for formula companies are large, and only public health entities promote breastfeeding. As such, having strong language that limits marketing of formula makes sense as it somewhat evens the playing field.

JPHMP Direct: According to the article, an anonymous spokesperson for the Department of Health and Human Services responded by email that “the resolution as originally drafted placed unnecessary hurdles for mothers seeking to provide nutrition to their children. We recognize not all women are able to breast-feed for a variety of reasons. These women should have the choice and access to alternatives for the health of their babies, and not be stigmatized for the ways in which they are able to do so.” As a pediatrician, can you speak to the types of hurdles some mothers face in this regard, including stigmatization, and whether, in your opinion, this is a sound basis for opposing the resolution?

Dr. Scott Krugman: In developed countries we frequently encounter “mom shaming,” especially on the internet and in social media. Frequently moms try to “one-up” each other with trying to do the right thing for their child and making other mothers feel a sense of inadequacy if they aren’t following the “best practices.” The bottom line is parenting is hard and parents are frequently faced with difficult decisions about how to feed their children, make ends meet, and care for their children. There should be no shame at all when parents do the best they can. That being said, I don’t think a UN resolution promoting breastfeeding is the appropriate place to discuss maternal shaming. In some parts of the US, there is a bias toward bottle feeding (inner city African American neighborhoods, for example). While in some developing countries, being able to formula feed is a status symbol of wealth. The ultimate goal is to have children receive adequate nutrition and thrive. The American Academy of Pediatrics recommends exclusive breastfeeding for the first 6 months of life, and that should be the goal. But ALL mothers should be supported in feeding their children in whatever form. In my mind, these are both laudable goals and should not be linked together.

JPHMP Direct: Why is breastfeeding important to the health and development of children? What are the main advantages?

Dr. Scott Krugman: Breastmilk really is the ideal food source for infants. Not only does it have the needed calories and nutrients that every baby needs, but it also has IgA antibodies that protect children from infections. And, as mentioned above, breastfeeding avoids the risk of infection via unsafe water sources. Additionally, the fatty acids in breastmilk promote myelination of neuronal connections, which help infant brain development, though the data on IQ benefit is likely confounded by other factors. Recent studies have linked breastfeeding with a healthier microbiome as compared to children who are formula fed. UNICEF has a nice summary of the status of breastfeeding worldwide, which you can read here.

JPHMP Direct: What are the possible health implications, particularly in developing countries, of watering down the language of this resolution?

Dr. Scott Krugman: By promoting the marketing of formula without providing efforts for clean water and sanitation, infants in developing countries will be more likely to be formula fed. As noted above, this will increase the risk for children getting sick from diarrheal illnesses.

JPHMP Direct: Are FDA regulations on infant formulas sufficient given that FDA guidelines stipulate that manufacturers are responsible for monitoring new infant formulas with oils containing DHA and ARA, which may have long-term effects on growth and development? Do infant food manufacturers engage in misleading marketing of breast milk substitutes and other baby foods?

Dr. Scott Krugman: Formula companies have recently been marketing a wide range of claims for their formulas – like “sensitive stomachs,” “brain development,” and “immune boosting” without oversight from the FDA. Formula is currently regulated like supplements and vitamins, so it does not need to meet evidentiary requirements for health claims like pharmaceutical drugs. There is no evidence base for any of these claims and they frequently push parents to choose formulas that their children don’t need (ie, lactose free – there are practically no lactase deficient babies). All of the marketing and unnecessary formula adds cost to the health system and offers little benefit.

JPHMP Direct: What stance should the public health community take on this issue?

Dr. Scott Krugman: The public health community should continue to do what it always does – advocate for the best evidence-based practices locally and globally. Everyone who cares about the health of children needs to stand up and speak up for effective public health programs that improve health. Clearly, this can be done locally in hospitals and communities by supporting new mothers and helping them breastfeed. It can also be done via local and national policies that promote breastfeeding and incentivize breastfeeding over formula (like added foods for breastfeeding mothers who receive SNAP benefits). And it can be done via advocacy through social media, editorials, and letters to papers in order to help policy makers be aware of the issue.

JPHMP Direct: Thank you, Dr. Krugman. We appreciate your thoughts on this important subject.

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