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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