On 21/05/2012 23:46, Pamela Morrison wrote:
> And I think you're asking us - as colleagues on LACTNET, not as your
> personal LCs - to agree with the rightness of the choice you made to
> feed your daughter formula a little before the age of 6 months on the
> grounds that there was unlikely to be a significant problem, and you
> seem to ask for recognition that there are a vast variety of different
> circumstances across families and that no single simplistic rule
> (against offering formula) can cover them all.
The second part of that is spot on - that is precisely what I'm trying
to get across. The first part, I think you've misunderstood. I was not
asking Maria's opinion on my actions because I felt any need for her or
any other Lactnetter to *agree* with my decision, but because it was a
handy example for challenging the dogma that donor milk is invariably a
better substitute for babies than formula.
You write below that 'it is the LC's job to provide the mother with
enough information so that she is aware of the impact that substitutes
for breastfeeding, and particularly cow's milk-based substitutes, are
likely to have on her baby's immediate and future
health/well-being/development'. I agree with that completely. What we're
disagreeing about is whether cow's-milk-based substitutes would
invariably have a higher risk of impact than donor milk substitutes. I
do not regard that as an evidence-based position at all. Yes, in some
circumstances they clearly do - we have good evidence that use of
pasteurised human milk in the NICU, rather than formula, reduces the
babies' risk of NEC. In many - I would go so far as to say most - other
circumstances that might come up, I think it's pure conjecture that this
is the case.
I'm going to repeat my previous question (though this time rephrasing it
to make it a general one - I think the fact that I used my circumstances
as an example has led to this getting completely sidetracked into a
belief that I'm only asking this as a way of getting personal validation
for my choice, which isn't the case at all): In the case of a breastfed
baby older than six months who requires supplementation, what reason
would there be to believe that donor milk would be better than formula
for that supplementation? (Let's assume that this is a situation where
the parents are not planning to stick to a cow's milk exclusion diet as
solids are introduced, so the baby is going to be getting exposure to
cow's milk protein anyway in other forms.) I honestly cannot see what
evidence there would be for advantages of donor milk over formula in
such a case. I'm happy for you to point out anything you feel I'm
missing here by way of evidence.
>
> It might be that we cannot endorse your choice because we are schooled
> in the WHO recommendations for infant feeding, ie exclusive
> breastfeeding for the first six months of life and continued
> breastfeeding with the addition of appropriate weaning foods for up to
> two years or beyond.
Pamela, I think you've put your finger on it. I think that, for many
Lactnetters, this could be precisely the reason. And I find that quite
concerning.
I'm a doctor; I know how incredibly important guidelines are in enabling
us to practice evidence-based medicine. It's simply impossible for any
practicing health care professional to read and evaluate all the
research that comes out in their field. Thanks to the designated groups
of specialists who do this for us and summarise the findings in
guidelines, we can have up-to-date information about best practice at
our fingertips for checking. But, as a doctor, I'm also well aware of
the limitations of guidelines.
Guidelines are as good as the evidence they are based on, and, even in
the best-researched of topics, there are inevitably going to be grey
areas where the existing evidence is too limited, too contradictory, or
too much of a mixture of pros and cons for it to give us a clear-cut
obvious answer about what course of action would be best *in a
particular circumstance*. When those grey areas come up, what we get in
the guideline is an opinion as to what we should do. Not an
incontrovertible fact; an opinion, from which others, studying the
identical evidence with equally sincere intentions, might quite
reasonably find themselves differing. And, while any properly-written
guideline is going to distinguish between levels of evidence and make it
clear when the recommendation given is such an opinion, it's easy to
lose track of this and assume that 'evidence-based' equates to
'incontrovertible evidence exists for every point mentioned on this
guideline, in every circumstance'. It doesn't.
On top of that, the WHO have the problem of having to come up with
guidelines that are simultaneously meant for worldwide applicability,
and appropriate for those living in the world's poorest, neediest, most
deprived areas. What this means in practice is that they simply can't go
into detailed consideration of the nuances of whether any particular
recommendation might or might not actually be helpful be in the kind of
vastly more privileged circumstances in which most Lactnetters live.
There are many countries in the world where it *is* unquestionably
important to avoid giving any formula, and so this becomes part of the
worldwide recommendations regardless of whether every single country
really needs to be quite so strict. (In case anyone rushes to
misunderstand that, I would like to clarify that I am not saying that
*breastfeeding* is unimportant in developed countries; I am simply
questioning whether every detail of the guidelines is really of
universal importance worldwide.)
What all of this means is that guidelines are invaluable, necessary...
and limited. They should *never* be regarded as the unquestioned
be-all-and-end-all. We should all be aware that even a guideline that
contains many recommendations supported by impeccably solid research
(such as the question of whether to breastfeed rather than formula-feed)
may well also contain recommendations for which the evidence is far
weaker or even non-existent. We should always be willing to think
critically about how the available evidence might or might not apply in
a particular situation - not just those situations where proved benefits
are small enough that practical considerations might outweigh them, but
those situations where the benefits haven't actually been proved and are
pure conjecture.
The question I posed above lies in precisely such an area; there simply
*isn't* any evidence that I can see that formula would be worse than
donor milk for supplementation of an older (6 - 12 months) breastfed
baby. So, would you really advise a mother in that situation that she
should if possible get donor milk rather than formula for supplementing
her child? If so, why? After all, that advice is not free of significant
potential disadvantages.
Now, those of you who answer the first question in the affirmative may
well have given careful thought to your reasons for doing so, and I look
forward to what I hope will be an interesting and thought-provoking
discussion about them. But, if an LC's reason for giving that advice
really is solely that she's 'schooled in the WHO recommendations' and is
thus giving what she sees as the standard approved answer, seeing no
further thought about the matter as necessary... then I think
something's badly wrong with that picture.
Best wishes,
Dr Sarah Vaughan
MBChB MRCGP
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