Ethical Analysis of Public Health Policy
Ethics in Breastfeeding
Cari M. Cooper
Feb 23, 2014
MPH 560- Public Health Ethics
Dr. Shalah Watkins-Bailey
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Table of Contents
Introduction…………………………………………………………………………….Pg. 2
Basics of breastfeeding
History of breastfeeding………………………………………………………………..Pg. 2
Breastfeeding benefits…………………………………………………………………..Pg. 4
Benefits for mother and society…………………………………………………………Pg. 4
Breastfeeding recommendations and rates……………………………………………...Pg. 5
Ethical concerns for not breastfeeding and for breastfeeding
Synthetic process and lack of bonding with bottle-feeding…………………………… Pg. 7
Problems with infant formula………………………………………………….……… Pg. 8
Susceptibility too illness and problems in bottle-feed infants…………………………. Pg. 10
Conclusion …………………………………………………………………………….. Pg. 11
References ………………………………………………………………………………Pg. 12
Basics of Breastfeeding
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While breastfeeding may not seem the right choice for every parent, it is the best choice for
every baby. ~ Amy Spangler (quotegarden.com, 2014.)
All mammals are capable of breastfeeding their offspring. Mammals are characterized by
having a backbone, some type of hair or fur, and are warm-blooded with females who nurse their
babies with milk. There are over 4200 species of mammals, with humans being included in this
group of species. All mammals, including human females, naturally produce milk that contains a
blend of water, proteins, fat, carbohydrates, minerals, vitamins, cellular content and antiinfective agents. Although all mammals produce breast milk, each mammal’s milk is individual
and is perfectly suited for the growth and development of that particular species. Each mammal’s
milk correlates to the rate of growth of their specific species. The growth of breastfeeding in
humans is the slowest of all mammals. (Pregnancy.org, 2013.)
In this paper, I will explore the benefits of breastfeeding and the ethical viewpoint as to why it
is unethical to not breastfeed your infant when all possible.
Obviously, breastfeeding is as old as the human species itself. According to Lawrence, the
author of “Breastfeeding: A Guide for the Medical Professional” - 5th edition, the writing’s
from before the time of Christ clearly spoke of the importance of breastfeeding. However,
remnants of artificial feeding devices have been found in ancient infant graves. Until recent
times, breastfeeding remained the primary method of infant feeding. Human milk meant the
difference between life and death for infants. Although from the beginning of time breastfeeding
was the easiest, healthiest way to feed an infant, breastfeeding has actually gone in and out of
“style” and at times has been thought of as a job for the lower class. Wet-nursing is the practice
of a woman breastfeeding a baby who is not hers but for a woman who is unable or who does not
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want to nurse the child herself. The first record of wet nursing was in the third millennium B.C,
and comes from a Sumerian lullaby. “The nursemaid joyous of heart will suckle him” is this
lullaby sung by Shurlgi, the wife of the ruler of Ur, to her son. There is history of wet nurses
from ancient Egypt, many who were slaves. Wet-nursing saw it’s biggest “heyday” during the
eighteenth century in France. By 1780 in France, the Paris police issued a statistic, “only 1,000
of the 21,000 babies born that year were nursed by their own mothers.” Infant mortality rates
rapidly increased and showed a direct correlation to how much one was willing to pay their wet
nurse, (Hrdy Blaffer, Sarah, Dec, 1995). Swedish naturalist, Carl Linnaeus, who was the first to
sort out the animal kingdom and was also the first to classify humans, took a stand against wetnursing by lecturing and campaigning against it sometime between 1735 and 1758. In the year
1752, Linnaeus wrote a treatise entitled "Step Nurse," declaring wet-nursing a crime against
nature. Even the fiercest beasts nurse their young, with the utmost tenderness; surely women who
resisted their mammalian destiny were to be ranked as lowlier than the lowliest brute, (Lepore,
Jill, 2009). In 1762, due to doctors, philosophers and legislators agreeing that mothers should
nurse their own babies, breastfeeding ones own children was the main infant feeding method
until the end of 1880’s. Bizarrely in the late 1880’s, there was word from physicians that
American woman were running out of breast milk. In 1887, one doctor wrote, "Something is
wrong with the mammary glands of the mothers in this country." Seems quite coincidental that
at the same time the first artificial infant foods were becoming commercially available. Through
the early 1900’s some women breastfed and some gave their babies the new infant formula,
however by the middle of the twentieth century the majority of American woman were feeding
their babies formula. From then on breastfeeding rates went up and down for the most part. In
1997, the American Academy of Pediatrics issued a policy statement on "Breastfeeding and the
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Use of Human Milk," declaring human milk to be "species-specific" and recommended it to be
the exclusive food for the first six months of a baby's life, to be followed by a mixed diet of solid
foods and human milk until at least the end of the first year. (Lepore, Jill, 2009).
Breastfeeding infants, has many proven benefits for baby, mother and society as a whole.
Breastfeeding protects your baby in many ways. Colostrum. the thick yellow milk that a woman
produces right after birth of a baby is considered “liquid gold”. Colostrum is extremely rich in
nutrients and contains antibodies that protect your babies’ immune system. Although babies only
receive a small amount of colostrum from each feeding, this amount naturally matches up with
how much an infant’s tiny stomach can hold. Breast milk changes automatically as your baby
grows. By the third to fifth day of nursing, the colostrum turns into what is called mature milk.
Mature milk, although much thinner, contains just the right amount of fat, sugar, water, protein
as well as nutrients and antibodies your infant needs. Breast milk is easier to digest then cow’s
milk, especially for premature babies. Probably breast milks biggest benefit for the infant is the
ability to fight disease. Formula simply cannot compete with the chemical make-up of human
breast milk. There is ongoing research that infants who were breastfed have a reduced risk of
Type 1 diabetes, childhood leukemia, atopic dermatitis and lower rates of SIDS. Formula-fed
babies have higher rates of ear infections and diarrhea as well as higher risk factors of
developing Necrotizing enterocolitis (a gastrointestinal disease), lower respiratory infections,
asthma, obesity, allergies and Type 2 diabetes.
Of course, our first concern is in the babies best interest, however, breastfeeding also has
many benefits for the mother as well. Once mother and baby settle into a routine, breastfeeding is
easier; no bottles, nipples to sterilize, nothing to purchase, measure, mix or warm up.
Breastfeeding can save you a lot of money. The average cost between feeding supplies and
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formula can cost well over $1,500 annually. Families can reduce their household costs due to
lower health care because breastfed babies are proven to become sick less often. Physical contact
brought on by breastfeeding is beneficial to both mother and baby; the skin-to-skin contact
actually boosts the mother’s oxytocin, which can help calm the mother. Breastfeeding lowers the
mother’s risk of Type 2 diabetes, breast cancer, ovarian cancer and postpartum depression.
Researchers also suspect that breastfeeding helps reduce osteoporosis as well as weight loss.
Breastfeeding benefits society as a whole. Recent research shows that if 90 percent of family’s
breastfeed exclusively for 6 months, that nearly 1,000 deaths could be prevented. This research
shows that the United States would save 13 billion per year due to breastfed babies requiring less
sick care visits, prescriptions and hospitalizations. Breastfeeding is also good for the
environment; with less trash and plastic waste compared to infant formula supplies that
permanently impact the earth’s carbon footprint. (OWH, 2014).
So what are the actual recommendations for breastfeeding by experts and organizations who
have done the research on the subject? The American Academy of Pediatrics recent
recommendations are from 2012 and states: the American Academy of Pediatrics (AAP)
reaffirms its recommendation of exclusive breastfeeding for about the first six months of a baby's
life, followed by breastfeeding in combination with the introduction of complementary foods
until at least 12 months of age, and continuation of breastfeeding for as long as mutually desired
by mother and baby, (AAP, Feb, 2012). The Centers of Disease Control and Prevention, (CDC),
supports the AAP, and used their statement as their recommendations on breastfeeding. The
World Health Organization, (WHO), has similar recommendations when in comes to
breastfeeding but suggests to continue breastfeeding up to the age of 2 along with other foods.
The WHO recommendation states: Exclusive breastfeeding is recommended up to 6 months of
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age, with continued breastfeeding along with appropriate complementary foods up to two years
of age or beyond.
Current breastfeeding rates have been making continued progress over the last ten years
according to the new statistics on breastfeeding rates from the year 2013. The percent of US
infants who begin breastfeeding is high at 77%; although there is still concern that infants are not
being breastfeed for as long as recommended. Of infants born in 2010, 49% were breastfeeding
at 6 months, up from 35% in 2000. The breastfeeding rate at 12 months increased from 16% to
27% during that same time period. There are still quite large discrepancies in regards of
breastfeeding rates form region to region and from state to state. Babies were breastfed in the
state of California at 91.6% and the rate in Mississippi was only 50.5%. Where the rates show
concern are how many infants are exclusively breastfeeding at the age of 6 months. Rates drop
dramatically with the highest being in the state of California and once again with a rate of 27.4%
and the lowest rate from Tennessee coming in at a sad 4.1%. Surprisingly, the Healthy People
2020 Objectives goals seem low in my opinion with hopes of those babies that were ever
breastfeed to be at 81.9% and those who will continue to be exclusively breastfed at 6 months of
age to be 25. %.
Ethical concerns for not breastfeeding and for breastfeeding
There are many reasons why not breastfeeding your infant is unethical. Now that I have
identified the many reasons to breastfeed, I will now explore the unethical practice of bottlefeeding your infant unless there is a concrete reason why the mother cannot such as lack of
lactation, required medication the mother must take or a transmittable disease that could be
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transmitted from mother to child through breast milk. The stakeholders in this topic follow an
order of main importance to less importance in my opinion. The main stakeholder must always
be the infant, with the mother and then other family members to lastly society as a whole. We
must direct our main attention to the main stakeholder, the infant, and focus on giving them the
best possible start to life.
Breastfeeding is natural and I personally do not understand why anyone would want to
deviate away from nature when it comes to something so simple yet detrimental to the health of
your infant. Infants start out with 5 basic reflexes that are only present in babies and disappear as
the child moves through infancy and up to the walking stage. The five basic infant reflexes are:
the tonic neck reflex, truncal incurvation, grasp reflex, parachute reflex and last but not least the
rooting reflex. The rooting reflex occurs when you stroke the baby's cheek. The infant will turn
toward the side that was stroked and begin to make sucking motions with the mouth. (Medical
Plus, 2014). Between the rooting reflex and the sucking reflex (also an infant reflex), these
primal reflexes are what makes a baby want to suckle and be nursed. According to Maslow’s
hierarchy of needs, eating comes second to only breathing. Giving our infants what is naturally
meant for them in the beginning of their lives just makes common sense. It would sound very
odd if parents were trying to alter fresh air, such as how society has decided to alter what comes
out of the human breast naturally for both convenience and profit (Simply Psychology, 2014).
Proper bonding that brings a healthy attachment between a child and a parent is found to have
a strong correlation to maintaining things such as mental health, reduction in a host of
personality disorders, reduction in the inability to tolerate intimacy and even less chances of
acquiring sexual disorders later in life. Although experts agree those who bottle-fed their infants
can obtain the same attachment, it will take quite a few adjustments to achieve what a breast fed
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mom does naturally. One of the main reasons attachments is typically higher with those who
breastfed is the amount of time it actually takes to nurse an infant. The average breastfeeding
session takes 20 minutes on each breast and is done 8-10 times in a 24 hour period, which equals
at a minimum that a breastfed baby is held at a minimum of six to seven hours a day. Since
bottle-fed babies use rubber nipples, which require much less oral energy, supplementation is
needed with the aid of a pacifier. (Which, now explains why my breastfed son never needed a
pacifier). Researchers say that you should never deny a bottle-fed baby a pacifier and if you do
this can actually lead to eating disorders, smoking and drinking later in life. Breastfeeding also
makes the development of dermal awareness so much easier. Experts believe skin-to skin contact
is an important part of our development as we learn to trust intimacy. Once again a breast fed
baby is automatically going to receive more skin-to-skin contact through the process of the
feeding sessions alone, therefore increasing their dermal awareness and trust of intimacy.
What exactly is in infant “formula?” In my opinion, the name alone sound like a science
experiment. For starters many brands of formula contain genetically modified products such as
high fructose corn syrup, which evidence links to higher rates of obesity. I found an article titled
“Chemicals As “Nutrients” In USDA Organic Infant Formula”, the writer consciously choose an
“Organic” formula whose label actually reads “Produced Without the Use of Potentially
Harmful Pesticides”, too analyze. There are several minerals contained in this specific can of
“Earth’s Best Organic Infant formula with iron.” Calcium Chloride is a salt of inorganic calcium
and chlorine, classified as in “Irritant” by the Dangerous Substance Directive by the EU index
(European Union laws regarding chemicals and safety). Calcium Hydroxide is also classified as
an irritant on the EU index. It is used in water and sewage treatment as a clarifying agent. And
lastly, Cupric Sulfate once again listed on the EU index as both harmful and an irritant. It is used
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as an herbicide, fungicide and pesticide. Moving away from minerals, this specific formula has
lots of other interesting ingredients such as Ferrous Sulfate, which is a byproduct of steel
production and again is listed as harmful and an irritant on the EU Index. The last ingredient
included in this formula that is listed in the EU Index is Manganese Sulfate, which is considered
harmful and dangerous to the environment. Potassium Bicarbonate has potentially toxic effects
on plants but according to the FDA is generally accepted for human consumption. Potassium
Chloride is mostly used to produce fertilizer, in medicine as a lethal injections, food processing
and as a salt free substitute. Potassium Chloride has the potential to cause gastrointestinal
discomfort, including ulceration when taken in supplemental form. Potassium Hydroxide, known
as “caustic potash,” has a strong base and is corrosive in nature. Sodium Selenite is considered
very toxic and dangerous to the environment. The material data sheet compares Sodium Selenite
toxicity to Sodium Cyanide, which at a 47.5-milligram dose could kill a 15lb infant. Zinc
Sulfate is also included and is again classified as harmful and dangerous for the environment.
The last concerning ingredient listed in this formula is called dl-alpha tocopherol, which is a
petrochemically synthesized blend of 8 molecules that is thought to disrupt the bodies endocrine
system. As bad as the ingredients are in infant formula, we also have to have some concern
towards the processing of these products as well. Although rare, infant formula can become
contaminated and be recalled. In September 2010, 5 million cans of Similac infant formula were
recalled. The recall was due to the possibility that the formula may contain beetle parts and
larvae from the manufacturing plant in Michigan. Although this would not cause any serious
harm to infants, it would likely upset infant’s stomach or cause them gastrointestinal discomfort.
The last concern I found regarding infant formula is evidence that soy formula can reduce male
testosterone levels. This study was done on a set of 80 identical twin marmoset monkeys. These
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monkeys were split into two groups of 40, one group was feed cow-based formula and the other
was feed soy-based formula. To the researchers surprise, the group that was exclusively feed
soy- based formula showed major suppression of ‘neonatal testosterone surge’ compared to the
control group that received cow-based formula. (Sharpe, Richard, Dr., (2014).
Sometimes an ethical decision is as easy as the benefits outweighing the risks. This is
definitely the case when it comes to the decision as to breast-feed or bottle-feed your baby.
Formula-fed infants face higher risks of infectious morbidity in their first year of life. These
health outcome differences can be explained in part, by the specific and innate immune factors
present in human milk. Breast milk produces IgA antibodies that provide specific protection
against pathogens in the environment as well as immune factors that provide protection against
infection. These antibodies can protect an infant from infections such as Hamophilus influenza,
Streptococcus pheumoniae, Vibrio cholere, Escherichia coli and rotavirus. Research that was
published as of 2009 that links formula to obesity and metabolic disease is quite astounding on
its own. Epidemiologic studies suggest that children who are fed formula are more likely to
become obese or develop type 2 diabetes. In meta-analysis, children formula fed in infancy were
22 times as likely to become obese as children who where breast fed as well as a 1.6 fold risk of
developing type 2 diabetes. Some studies are now suggesting an increase in risk for
cardiovascular disease, including higher blood pressure and less favorable lipid profiles but the
literature is currently mixed. Although the research is also mixed as well, some researchers have
found a modestly lower IQ score in formula fed children compared to their breastfed
counterparts. Case studies also show formula feed babies have an increases rate of SID’s. The
American Academy of Pediatrics explains the differences come from factors associated with
breastfeeding not breastfeeding itself. (Stuebe ,Alison, MD, 2009).
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Although there is not a handbook on how to give your child the best start in life, experts such
as doctors, nurses, epidemiologist, researchers, government agencies, statistical analysts as well
as seasoned parents will most likely all agree that breastfeeding your infant is the most logical,
convenient and healthiest choice for both you and your baby. By choosing to breastfeed your
infant you are giving them many benefits such as instant immunity to disease and illnesses, a
better sense of security and intimacy, a reduction to other health problems later in life as well as
possibly a higher IQ. By purposely opting out of breastfeeding and using formula you are
increasing the chances of infant mortality, increased risk of disease and illness, possible
attachment problems that could mentally affect your child for a lifetime as well as adding
chemicals and additives found in formula to their diet that could cause discomfort, harm and
even contamination. I believe the choice is an easy one, when comparing the benefits to the
potential risks presented in this paper, that it is truly unethical to not breastfeed your infant if you
are able to.
“Breastfeeding is a mother's gift to herself, her baby and the earth. ~Pamela K.
Wiggins
(quotegarden.org, 2014).
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References:
About.com, Corley, Heather, (2014), Baby Food and Formula Recalls, Retrieved by
http://babyproducts.about.com/od/recallsandsafety/a/formula_recalls.htm
American Academy of Pediatrics, AAP, (Feb, 2012), AAP Reaffirms Breastfeeding Guidelines, Retrieved by
/about-the-aap/aap-press-room/pages/AAP-Reaffirms-Breastfeeding-Guidelines.aspx
Davis, Marie, RN, (2009), The History of Infant Feeding, Retrieved by
http://www.lactationconsultant.info/history.html
Egon Wildermuth, Hans Stark, Gabriele Friedrich, Franz Ludwig Ebenhöch, Brigitte Kühborth, Jack Silver, Rafael
Rituper (2005), "Iron Compounds" in Ullmann's Encyclopedia of Industrial Chemistry
GreenMedInfo, Founder, Ji Sayer,(March, 2012), Chemicals As “Nutrients” In “USDA Organic” Infant Formula,
Retrieved by http://www.greenmedinfo.com/blog/chemicals-nutrients-usda-organic-infant-formula
Hrdy, Sarah Blaffer, (2013), Natural History, Liquid assets, Vol. 104, Issue 2
Lawrence, Ruth A. and Lawrence, Robert M. Breastfeeding, (2009), A Guide for the Medical Profession. 5th ed.
Lepore, Jill, (Jan, 2009), New Yorker, BABY FOOD, Vol 84, Issue 45.
Medical Plus, Trusted Health Information for You, (2014), infant reflexes, Retrieved by
http://www.nlm.nih.gov/medlineplus/ency/article/003292.htm
McLeod, Saul, Simply Psychology, (2014), Maslow’s Hierarchy of Needs, Retrieved by
http://www.simplypsychology.org/maslow.html
Office of Women’s Health U.S. Department of Health and Human Services (OWH), (2014), Breastfeeding, Why
breastfeeding is important, Retrieved by http://www.womenshealth.gov/breastfeeding/why-breastfeeding-isimportant/index.html
Pregnancy.org, (2013), How do other Mammals Nurse? Retrieved by http://www.pregnancy.org/article/how-doother-mammals-nurse.
Quotegarden.com, (2014), Quotations about Breastfeeding, Retrieved by
http://www.quotegarden.com/breastfeeding.html.
Sharpe, Richard, Dr., (2014), Soy Formula Can Reduce Testosterone Levels, Retrieved by
http://leftinthedark.org.uk/PDF/Soy%20Formula%20Can%20Reduce%20Testosterone%20Levels.pdf
Stuebe, Allison MD, Reviews In Obstetrics & Gynecology, (Feb, 2009), The Risks of Not Breastfeeding for
Mothers and Infants, Retrieved by http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812877/
World Health Organization, (WHO), (2014), Health Topics, Breastfeeding, Retrieved by
http://www.who.int/topics/breastfeeding/ed
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