Friday, 20 January 2017

Talking about breastfeeding: ways of changing the conversation

"My friend/colleague/doctor has looked into it and says there is no convincing evidence of benefit for breastfeeding in high-income countries. What can I say to him/her? Have you got any links or pointers for having the discussion?"
I've been asked variations of this question many times, sometimes face to face and sometimes online, and I've had conversations directly with the people who have made the original statement. Often I've felt a sense of being a rabbit in the headlights: how to sum up, rationally and in a nutshell, why I think breastfeeding matters so much, in the UK or elsewhere? I can't always remember the details of research, and often find it hard to summarise the complexities of the reality and politics of the situation, but at the same time I really want to communicate with people about breastfeeding and have them go away from our conversation thinking about it. When I hear myths I want to challenge them; when I hear that people have very different views from mine I want to explore why that is. It isn't easy to do!

However, as with many things, I find that practice has made these conversations a little easier. I now find that instead of launching in to a spiel about breastfeeding, understanding where someone's viewpoint has come from is the first step. Why did the friend/colleague/doctor decide to look into breastfeeding in the first place? Was it because of a personal decision or experience, or is it an area of professional interest? How did they come to their conclusions? I genuinely want to hear about how and where people are finding their information.

Then, I often find myself acknowledging where the other person is coming from. This time the person saying they had no convincing evidence for breastfeeding in high-income countries was a scientist in an unrelated discipline who had made a personal survey of breastfeeding research, and had examined the methodology of studies with a critical eye. That's something I can get on board with -  I've done it myself, and of course we should be critical of research! Having established some common ground between us, I can acknowledge that there are indeed problems with the way some breastfeeding research is done, and that there are those who think that the importance of breastfeeding is overstated. I have now put myself in a position where I can explain why I don't agree without it seeming like an argument, rather than a discussion.

Another useful thing can be to establish what it would take to convince someone to think beyond their current position. In this case, the person who asked me the question thought that only a cast-iron randomised controlled trial (RCT) would be good enough to convince the scientist. That's good to know, because I won't be able to give them what they want. RCTs can't ethically be done in infant feeding. But because I know what the person wanted to find, I can explain why it doesn't exist, which must be the next best thing. Having the conversation in terms that suit the context is very important; I have very different conversations with people depending on who they are and what the situation is. I would not talk to a sleep-deprived new mother about meta-analyses and the ethics of research! 

So how did I answer the question? I tried to include what I thought would make sense to the scientist who had voiced their opinion: recent meta-analyses in peer-reviewed journals. I tried to address their personal concerns about the validity of the research, and to show that the effects of breastfeeding in high-income countries have been studied. I  also tried to suggest a few topics for further reading, and to introduce the idea that the burden of proof should not really be on breastfeeding, which is normal behaviour for humans, but on the long-term safety of formula milk. I wasn't trying to 'win' by presenting a cast-iron case; I was trying to show that alternative viewpoints are possible and credible.

I ended by inviting further contact if it's wanted or needed, now or in the future. Being open to further dialogue is really important for breastfeeding advocacy; what I really want is for people to be able to come back to me with more questions or discussion points, because then we keep communicating - and maybe I can put them in touch with other people or organisations, or suggest sources of information. It's amazing what that sort of networking can achieve; if you can be the person others seek out when they want to know something about breastfeeding, that's fantastic.

All this is important in a wider context too. The recent WBTi report , and Unicef Baby Friendly's 'Change the Conversation' campaign, have shown what we need to do to improve breastfeeding rates in the UK, and highlighted the difficulties we have when talking about breastfeeding and advocating for policy change. Every conversation we have with another individual about it is a tiny step on the road towards improving the situation, for the benefit of mothers and babies. If we can make those conversations count, while avoiding arguments and entrenched positions, we're all doing our bit to make the world a better place.

I'd love to know how others handle this sort of conversation/question, and other thoughts on ways to change the conversation about breastfeeding. I've included my email in response to the question at the top of this post below for anyone who is interested (and because it can be useful to have links in one place!); what do you think?

Hello,
Here are some links/discussion points that you could raise. 
First, a 2016 meta-analysis is one of the papers in a Lancet special series on breastfeeding, which specifically tackles the question of breastfeeding's relevance in middle and high income countries:
http://www.thelancet.com/series/breastfeeding
(It's worth noting that in the absence of RCTs, which, as discussed, are unethical in bf because you can't randomise babies to receive what you know is a poor substitute for breastmilk (when I say poor, I mean that formula lacks oligosaccharides, HAMLET, lactoferrin etc that have known immunological effects in the infant), meta-analyses are one of the better tools we have.)
Second, this set of papers in a 2015 special issue of Acta Paediatrica; the editorial sums up the issues with bf research (also common to nutrition research in general) and explains how researchers have attempted to allow for the flaws in studies to reach their conclusions: http://onlinelibrary.wiley.com/doi/10.1111/apa.2015.104.issue-S467/issuetoc 
There has been an RCT of a breastfeeding support intervention in Belarus that showed that increasing breastfeeding rates (by supporting the mothers to bf for longer and more exclusively) reduced rates of some infections: https://www.ncbi.nlm.nih.gov/pubmed/11242425 
Here you can download the evidence-base for the Unicef Baby Friendly Standards, which have been developed specifically for the UK: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/advocacy/the-evidence-and-rationale-for-the-unicef-uk-baby-friendly-initiative-standards/ 
This report looked specifically at the costs to the NHS in the UK of not breastfeeding: the conclusions are conservative and based on good-quality evidence for just a few diseases: http://discovery.dundee.ac.uk/portal/files/1290558/Preventing_disease_saving_resources.pdf 
Finally, here is the link to the very interesting work that looked at the evidence base for health claims made in ads to health professionals for formula milk; arguably the burden of proof should be on the intervention to show that it does not cause lasting harm; in my view we do not have this proof (far from it). The flaws in the research we rely on for the safety of formula are at least as bad the flaws in the bf research! http://www.firststepsnutrition.org/pdfs/Scientific_and_Factual_booklet_for_web.pdf 
Other areas that are well worth consideration are thymic size/immune system development, the differences in microbiome between bf and ff infants, and the epigenetics of bf; here the research is in its infancy, but the picture so far suggests far more substantial differences between bf and ff infants than we have previously thought, with consequences for long-term health. 
I'd also encourage a look at the evidence for the health of mothers, not just infants; for example the research on ovarian cancer, osteoporosis and heart disease. 
If you want to put us in touch or pass on my email address, that's fine - I'm always happy to discuss. 
Good luck! 

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