Susan Burger wrote (quotes indicated by <> brackets):

<Just like having a surgical delivery prevents the normal bacterial colonization that is supposed to happen during birth, so does just a little formula prevent the normal colonization of bacteria in the infant gut and among the many thing the authors of that abysmal study did not consider in their outcome measures is how that changed those bacteria.>

That would indeed have been interesting, but I understand why the researchers might not have chosen to do it - it would have added very significantly to the expense, difficulties and complications of the study, all for the sake of getting information that we wouldn't really have been able to do much with in practical terms (since, at this point, we know very little about the details of just *how* changes in the gut microflora translate into practical outcomes). 

What I was extremely pleased to see was that they *did* take the trouble to look at what you might call practical, end-of-the-day outcomes - infection rates and allergies, in this case. Not that it was much help in this case due to the sadly low uptake rate of the study, but it was good to see researchers taking the trouble to look at how formula supplements in the early days affect the outcomes that parents are, at the end of the day, going to want to know about most.

<Furthermore, one only has to look at the HIV epidemic to see a more immediate and profound impact of a little bit of formula damaging the gut sufficiently to allow transmission of the virus.>

Good point, though fortunately not one that comes up too often in countries where replacement feeding is AFASS. But I'm still curious as to whether you have any outcome studies for small amounts of formula supplementation in the general population? It seems to me that this is an area where there's a lot of theory, but not much evidence, and what evidence we do have available doesn't really support the very strict stance against any degree of formula supplementation (other than in specific situations such as HIV-positive mothers).

<What flabberghasts me is why, when the vast majority of research funding is spent tinkering with minute changes in formula and the last time I calculated it some negligible percentage of all research dollars on infant feeding goes to research on breastfeeding and and even more negligible percentage of US Tax payer dollars goes to that research.>

That's interesting - could I have your source for research funding going on formula changes?

<Why on earth would you not want better research to avoid the 10% weight loss to begin with, better research and funding for making human milk available and I mean even in the grocery store if need be (heretical as that may sound), and better research on how to fix the very real problems of insufficient milk supply? >

I'm not sure why you think anyone here wouldn't want that. Of course we do, but it's not an either-or - it's also important to look at new ways of helping mothers with continuation of breastfeeding, and that's what this study did. If you're a paediatrician working with mothers and newborns on a day-to-day basis, it's probably going to be a lot easier to set up a study into a way of increasing breastfeeding rates among those mothers than it would be to do lab research into mammary tissue function or breast milk storage. 
 

<  Yet no one complains about mothers going through 7 or more rounds of fertility treatments. >

Not wanting to get too far off topic here, but I don't think that's actually true. Anecdotally, from what I've heard, women having fertility treatments seem to be just as plagued with remarks like "Just adopt!" as struggling breastfeeders are with remarks like "Just give a bottle!"


<And -- since I thought it was so obvious, I didn't mention it -- one of the biggest flaws in study design is to give a treatment to a population that didn't need it to begin with.  It was such a huge elephant in the room that I didn't think it needed to be mentioned.>

Well, the whole point of the study was to look at whether there might be *benefits* in supplementing in this population. From the previous article by the study authors that was posted here, and from Janelle Aby's comment on Alison Steube's post, it seems that their concern was the number of situations they'd seen in which a mother was successfully urged to avoid early supplementation, only to become so disillusioned when her infant ran into problems with jaundice/more severe weight loss that she would give up breastfeeding completely. So they started wondering whether a strict stance on supplementation was backfiring, and whether the use of limited formula supplementation would work as a strategy for stopping women from getting to that point of desperation and hence actually make women *more* likely to keep breastfeeding.

And, you know, the other elephant in the room here that so many Lactnetters don't seem to want to talk about... it *actually worked*. Contrary to all dire predictions about supplementation playing havoc with breastfeeding chances, the mothers whose babies had early limited formula supplementation ended up giving far *less* formula overall in the first week, and being far *less* likely to give up breastfeeding or to be supplementing at three months. So much less likely that the results were statistically significant even in such a small study. 

Now, of course that one small study isn't evidence enough in itself to base a protocol on, or to toss all previous research out of the window. And, yes, there's certainly room for discussion of whether it would be better to use donor human milk rather than formula for supplementation. But why are so many people so unwilling to consider that, at the very least, we seem to have a potentially promising intervention here that is well worth further research, and that perhaps some of the currently-held beliefs on the undesirability of supplementation *may*, just *may*, not be quite as correct as many of us thought?


Best wishes,

Dr Sarah Vaughan
MBChB MRCGP

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