Dear all:

The whole discussion about human milk would be a moot point if the subsidies had not created human milk scarcity.  In times of scarcity you have to make decisions that triage how you deal with available resources.  It is LOGISTICS problem, not an "EVALUATING OF THE EVIDENCE" problem.  So sometimes parents have to make the decision to use formula merely because of SCARCITY.  While this may be necessary in the short-run we absolutely should strive to do better.  Just like some organizations dump less than nutritional agricultural surplus food into emergency refugee conditions.  No one would argue that the people in emergency refugee conditions don't need food.  No one would refuse the food.  BUT it is much better when you can shift to more nutritious food.  

I had the misfortune of watching too many babies and young children DIE -- (with eyeballs literally melting and collapsing) from vitamin A deficiency that was accelerated when these babies and young children were fed food (which sped up their metabolism) that didn't contain much needed vitamin A.  Did the food save lives?  Yes.  Was the number of lives saved more than the number of deaths due to vitamin A?  Probably.  Would it have been better to provide food rich in vitamin A?  Absolutely.  Have the logistical problems of ensuring food donations are rich in micronutrients such as vitamin A been solved?  Not completely, but great progress has been made.  And progress was not made by just dismissing the problem as "well we don't have micronutrient rich foods available so this is the best we can do."

Can one really argue that once-pasteurized cow's milk from a local dairy that follows known sanitation procedures is WORSE than triple pasteurized powdered that has been sitting in an aluminum can for months or even years? Do you really need to PROVE that?  And since human milk can be readily pasteurized and is from the same species, do we really need to PROVE that it is safer than something stored in a can for months and years?  Do we really want to waste increasingly scarce research dollars that mostly end up actually going to formula industry backed research anyway on such questions?  Human milk is what human babies need to be fed.  We have sufficient and copious research from the dairy industry showing how to reduce and eliminate pathogens in cow's milk.  Those same principals apply to any species milk including human milk.

As for studies in developed and developing countries -- there is a difference between looking at the degree of contamination of substances other than breast milk in terms of the SHORT-TERM impact on diarrhea but the risk does not go away with good sanitation.  Nor does the risk of diarrhea magically go away at six months.  "AROUND" six months is merely the balancing edge where the risk of poor appetite and delayed cognitive development from inadequate iron and zinc start to increase and the risk of diarrhea from ingesting pathogen-contaminated food declines due development in the immune system.  For each baby, somewhere in that increasing risk and decreasing risk is a point at which it makes sense to start solids. 

I have posted this study before because it really debunks the arguments that "those babies in those icky third world countries that don't have our wonderful modern sanitary systems need breastfeeding but our babies in our supersanitized modern countries don't really need it".  The relative increased risk of death from formula feeding was 5 fold higher than breastfeeding with latrines and no piped water.  The relative increased risk of death from formula feeding was 2.7 fold higher than breastfeeding with piped water and flushed toilets.  The risk of death was still higher even when sanitation was good.  Habicht J-P, DaVanzo J, & Butz WP. Mother’s Milk and Sewage.  Their Interactive Effects on Infant Mortality.  Pediatrics. 1988;81 (3) 456-520. 

So while there are many different risks associated with formula -- they do not drop to zero when you improve sanitation.  If you think about the fact that most respiratory infections are spread via droplets where toilets don't help at all and frequent handwashing may not help if someone sneezes around your baby -- you would probably see less of a difference between the impact in areas of poor and areas of good sanitation.  

So, we may explain to our clients that we have a human milk scarcity and provide evidence to help them make sensible decisions in view of the scarcity, but that doesn't mean that we shouldn't work hard to advocate for less scarcity or make up bogus hypothesis to argue that heavily processed cow's milk or soy or concoctions made with chicken liver are more appropriate for babies than human milk.

Sincerely, 

Susan E Burger, MHS, PhD, IBCLC

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