Are three breasts better than two?

As we all know, toddlers like to switch sides when nursing--sometimes to the point of driving Mummy mad. Why have one breast when you can have two? Little Seal, however, seems to feel that even two breasts are not enough--she not only switches from right to left incessantly, but has also developed a bizarre habit of rooting around in my armpit and screaming in protest at the fact that I don't have another mammary gland for her under my arms (what a mean Mummy).

One day recently when she did this, my mind suddenly flashed back to something I'd read a while back about how a lot of women have rudimentary breast tissue in the underarm area, which is why swollen armpits are common when your milk "comes in." A google search soon plunged me into the bizarre world of multiple breasts.

Turns out the swollen-armpit thing is just the tip of a large and varied iceberg. Somewhere between 1% and 6% of all women have some degree of supernumerary breast tissue. In most cases (polythelia) this is just under-the-surface tissue, but in more extreme cases (polymastia) you have actual nipples as well--sometimes forming very noticeable extra breasts. These are most often found along the "milk lines"--pathways stretching from the groin up into the armpits. Litter-bearing mammals, of course, normally have milk-bearing teats up and down these lines; at some point in the evolutionary process our mammalian predecessors lost all of these except two. Charles Darwin considered the appearance of multiple breasts in humans to be an example of atavism--the survival or reappearance of a primitive trait in a more "highly-developed" species, like, for example, the occasional human baby that is born with a tail. (Could Little Seal's armpit-rooting be a kind of vague instinctive memory left over from the time when our furry ancestors actually had functioning breasts going up and down their abdomens? Who can say?)

The "throwback" theory is lent credence by the embryonic development. One of the eeriest things about pregnancy is the way the embryo's development over the weeks and months seems to repeat evolutionary history in miniature--the unborn child develops a tail which then falls away, and later grows a coat of fur which is then shed and reabsorbed, and so on. Over the first couple of months, "milk lines" in the fetus develop into mammary ridges, but in around the ninth week all these ridges recede and disappear except for the two which later become the "breasts" we are familiar with. In a few embryos, presumably, the surplus ridges do not fully disappear and instead continue to develop into rudimentary breasts. The atavism theory has appeal, but it doesn't seem to fully explain the extra-breast phenomenon, given that such tissue can also appear outside the milk lines--on the legs, in the groin and even on the sole of the foot.

As I mentioned above, it's not unusual for women to report swollen armpits at the very start of breastfeeding, and droplets of milk leaking from the armpits are far from uncommon (judging from all the questions on Yahoo Answers--that perennial mecca for people with weird and embarrassing body-related questions). In extreme cases, extra breasts have been known to have fully functioning nipples and produce useful amounts of milk.

An often cited case from 1827 refers to Therese Ventre of Marseilles, France. Her mother had a supernumerary breast beneath her normally positioned right breast. Ventre had a supernumerary breast beneath her normally positioned right breast. Ventre had a supernumerary breast on the side of her left thigh. This breast enlarged during puberty, and when she became pregnant, it produced milk. It was offered to her infant who took it willingly. She apparently nursed five children during her life from all three of her breasts. (Southern Medical Journal Supernumerary Breast Tissue: Historical Perspectives and Clinical Features, Department of Pathology and Laboratory Medicine, Emory University School of Medicine)

In our own time, however, extra breast tissue is more likely to cause issues with breastfeeding. In several cases, women presenting with swelling under the arms have had the sites biopsied, only to reveal that the lump is merely extra breast tissue and that milk is now leaking uncontrollably from the site of the biopsy--a "milk fistula." Breastfeeding Materials advises that such milk is likely to dry up on its own, just as any milk supply will ultimately dry up if there is no suckling; however, in this case here, the mother's milk fistula did not cease until she finally weaned her baby. Presumably, her accessory breast and normal breasts had enough tissue in common that they shared the same feedback mechanism, and stimulation of the regular milk supply thus tended to stimulate the milk production in the armpit as well. Who knows? In any case, the good news is that this troublesome extra tissue was removed through surgery, leaving the mum free to nurse her future babies if she wanted.

Supernumerary breasts have, in some historical periods been associated with witchcraft--Anne Boleyn was rumored to have one, although that may say more about Boleyn's enemies than about Boleyn herself. In other times, extra breasts have been considered a sign of super-fertility (think of all those multi-boobed goddess figurines), but there's no evidence of this. On the contrary, there is some evidence linking extra breasts with elevated rates of certain congenital problems, especially abnormalities of the urinary tract such as "supernumerary kidneys, failure of renal formation, and carcinoma of the kidney."

So while the image of being able to feed a baby from multiple breasts is appealingly bizarre, it seems fair to say that in the real world, three breasts are definitely not better than two. Although most nursing toddlers and babies would probably disagree with me about that.

"We are a charity" is not an excuse for failing to listen to people

The National Childbirth Trust (Britain's largest parenting charity) is in the news again. It all started when pregnancy writer and blogger Linda Geddes appeared in a Radio 4 discussion about the NCT. As you'd expect from the author of Bumpology (a promising looking new book which adopts a science-based approach to pregnancy and birth), Geddes expressed some critical ideas about the NCT during the discussion, claiming in particular that the organization's classes gave her poor advice and unrealistic expectations due to their overwhelming ideological bias towards natural childbirth, discussed here and here. The interview might have passed without much comment had Kirstie Allsopp (a well-known British TV presenter) not tweeted about the show, echoing Geddes' criticisms and describing the NCT as "a very politicised, dogmatic and in my experience, scary organisation."

This is far from being the first time the NCT has been criticized for being overly obsessed with natural childbirth, breastfeeding at all costs and so on. Allsopp had another similar spat with the NCT last year, I had my own little go here, and this thread from Mumsnet gives a decent overview of the complaints that many NCT members have about the organization. Many women have fantastic experiences joining the NCT and participating in its classes and workshops because there are many great people who work with the organization. There are also a lot of crunchaloons who are giving the NCT a bad name. Every time the NCT is criticized in this way, the organization protests that the criticisms are unfair, that the organization is inclusive and is becoming more so, that they are making efforts to embrace different ways of giving birth and to expand beyond the "middle-class mothers" who make up their core group and so on. How genuine these protestations are is kind of questionable, however, as Pauline Hull of Cesarean Debate recently pointed out.

But there is one defense of the NCT which I'm constantly hearing, and it is really starting to annoy me: the defense that "These complaints are unfair. NCT is a charity, not a business, and it's staffed by volunteers, many of whom are mothers themselves. You can't expect it to be run perfectly."

Now, here's the thing. If you talk to anyone who has worked on the ground in, say, the developing world or among disadvantaged groups anywhere, they will tell you that this kind of attitude is at the heart of what is wrong with so much charity and philanthropic work--the idea that charities (unlike businesses or governments) do not have to be accountable for their actions or responsive to feedback, the idea that people receiving charity should be grateful for whatever they get (even if it's crap), the idea that that it doesn't matter if charities upset people because even badly-run charity work is better than nothing at all, and the idea that ITS MEEN to criticize anyone who works in a charity, because charity workers do nothing except from the goodness of their hearts and you surely can't have a problem with that, right?

Well, actually it's all a bit more complicated than that. Because the problem is, charities have their own agendas which are sometimes not completely altruistic--for example, trying to further their own political, social or religious views (fundamentalist churches "fighting AIDS in Africa" through abstinence-only education being merely one of the more egregious examples). Sometimes charities do actively harmful things to the people they are trying to help, often as a result of these agendas, which means that it's not always true that bad charity work is better than nothing at all. Sometimes, bad charity work is indeed better than nothing at all--but that doesn't mean that it couldn't be better, or that charities shouldn't be aspiring to do better. No private-sector business would be okay with the sort of feedback the NCT was getting from a lot of posters on that Mumsnet thread. Maybe the NCT could do with operating a bit more like a business--a process that starts with listening to the people you are supposed to be serving.

In any case...take a look at the sort of complaints being levelled at the NCT in that Mumsnet thread. I mean, if most of the complaints about the NCT were things like "the venues for the classes are cramped" or "my email inquiry didn't get answered straight away," well... okay, maybe these issues would be somewhat understandable in an organization run by volunteer mums in their spare time. But I really don't see how complaints about instructors demonizing cesarean sections, epidurals and bottlefeeding in NCT classes have anything to do with its charitable status. There is no reason on earth why an unpaid volunteer can't give classes and workshops that offer a balanced view of birth and infant feeding; it's not as though it would cost more to do this. (And to be fair, many or most NCT instructors are offering reasonable and balanced advice; it's just that the NCT doesn't seem to be very good at weeding out the instructors who spend their classes beating the "obstetricians-are-out-to-get-you" tom-toms and telling mothers that they won't bond with their babies if they have surgical births, etc.)

If there are some NCT instructors who are saying things that are contributing to depression and anxiety in new mums, and if the NCT is failing to do anything about this because of its agendas and beliefs, then that is a problem, regardless of whether or not the organization is a charity or not. And the NCT needs to start engaging with this issue unless they want the complaints to continue and get louder.

Bullshitometer: Formula is the fourth best choice according to the WHO

The first Bullshitometer post I ever wrote (on the global average age of weaning) taught me that sometimes crunchy bloggers basically invent their own WHO sources. So I smelled a Bullshitometer post in the making regarding a certain bit of internet wisdom that has been doing the rounds on parenting blogs and message boards for quite a while--the whole "WHO says that formula is the fourth best choice" thing, which comes up most often when discussion focuses on donor milk--and especially milk donated via informal milksharing schemes.

There are lots of versions of this one knocking about. Jack Newman gives one version (stating that the formula-is-the-fourth-best-choice thing is WHO policy, but not giving any references) in The Ultimate Breastfeeding Book of Answers. I've also seen some really scary versions which actually rank goat's milk above commercial infant formula (yikes). The most commonly cited version, however, is a piece of text which is quoted as being the official WHO wording:

"The second choice is the mother’s own milk expressed and given to the infant in some way. The third choice is the milk of another human mother. The fourth and last choice is artificial baby milk (infant formula)."

This ubiquitous bit of text boasts more than 400,000 Google results. However, when it came to trying to find the original source--and yes, with the fanatical zeal of a stalker I really did click through every single link on seven or eight pages of results--all anybody seemed to have were links back to other breastfeeding-related blogs and pages containing the same bit of text, not to any original WHO document. 

I broadened my search and this time struck gold in the form of the famous "Watch Your Language! "essay by Diane Wiessinger, containing the following text.

"Breastfeeding is best; artificial milk is second best. Not according to the World Health Organization. Its hierarchy is: 1) breastfeeding; 2) the mother's own milk expressed and given to her child some other way; 3) the milk of another human mother; and 4) artificial milk feeds (4)." 

The footnotes give the source of this information as "(4) UNICEF, WHO, UNESCO: Facts for Life: A Communication Challenge. New York: UNICEF 1989; p. 20."Aha! I eagerly searched for the document, wondering if this document could be the source of that "The second choice is the mother's own milk..." bit of text--only to discover that "Facts for Life: A Communication Challenge" is not online and that the hard copy is out of print... which is not really very surprising, given that it was published in 1989.

The current WHO stance
The Who/Infant and young child feeding publications is the right place to hunt around if you want to find out what the current WHO stance on expressed milk vs. donor milk vs wetnursing vs formula. Here is what the WHO's "Global Strategy for Infant and Young Child Feeding" (2003) has to say.

18. The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother’s milk be considered un suitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances.

So, no apparent hierarchy, just a list of possible options and a suggestion that we make our own decisions. Which raises suspicions that the whole "WHO says formula is fourth best" thing might be just an internet urban legend that got started because someone glanced at the above paragraph and erroneously thought that the possibilities were being ranked in the order of best to worst, rather than merely listed.

It's not quite so simple, though. Remember that 1989 "Facts For Life" publication alluded to above? Well, since 1989 the WHO has published some updated versions of the same publication (2002 and 2010). Here's what they have to say on the subject of what-to-do-if-you-can't-breastfeed-from-the-breast:

"Facts For Life" 2002:

"The best food for any baby whose own mother’s milk is not available is the breastmilk of another healthy mother. If breastmilk is not available, a nutritionally adequate breastmilk substitute should be fed to the baby by cup. Infants who are fed breastmilk substitutes are at greater risk of death and disease than breastfed infants.... The best food for a baby who cannot be breastfed is milk expressed from the mother’s breast or from another healthy mother."

"Facts For Life" 2010: 

"Bottle feeding and giving a baby breastmilk substitutes such as infant formula or animal milk can threaten the baby’s health and survival. If a woman cannot breastfeed her infant, the baby can be fed expressed breastmilk or, if necessary, a quality breastmilk substitute from an ordinary clean cup... A mother’s own milk is best for low-birthweight babies. However, not all of these infants are able to feed from the breast in the first days of life. For them, other options are available. In order of preference, they are: expressed breastmilk (from the mother); donor breastmilk (only if the donor is HIV-tested and the milk is correctly heat-treated); and infant formula. All of these should be given by cup, spoon or paladai (a cup feeding device), or medical tubes used by a trained health worker in a health facility." 

Well, that's... confusing. In its "Global Strategy for Infant and Young Child Feeding" the WHO merely sets out the different feeding options (wetnursing, donor milk, expressed mother's milk and formula) that are available without establishing any kind of hierarchy--indeed, "the choice.... depends on individual circumstances" seems to be explicitly stressing that there isn't any hierarchy. Meanwhile, in the 2010 "Facts For Life" the WHO states that expressed milk is superior to formula, makes no reference to wetnursing, and puts donor milk in a higher category than formula--but only if it's heat-treated and screened, and only for low-birthweight babies (for whom formula seems to pose greater risks). It's unclear what the WHO position is on, say, unpasteurized milk donated through informal milksharing schemes, or on whether these guidelines still apply for babies of normal weight. 

Bullshitometer verdict
First off the bat, I do think people need to stop reciting that much-quoted bit of text that starts with "The second choice is the mother's own milk..." given that nobody seems to know where it comes from and given that the most likely source I've found appears to be a document published in 1989 (which is an awfully long time ago) and not listed among current WHO publications.

But, leaving aside that particular quote, what about the general idea of "formula as fourth choice"--is this actually WHO policy? Frankly, the WHO's current policy on the hierarchy (or absence of hierarchy) regarding donor milk, expressed mother's milk, wetnursing and formula appears to be about as clear as mud, with two current WHO documents basically saying different things. I don't think that we can state explicitly that "The WHO says formula is the fourth best choice" until the WHO itself clarifies its stance--and that also means going into details like "What if it's a choice between unscreened breastmilk and formula?" "Is breastmilk that's been in the freezer for a year better or worse than formula?" "What about communities with high rates of HIV?" These little points make a difference when we are balancing the different benefits and risks involved.

What would I do if I couldn't breastfeed directly from the breast? Okay, I guess I'd do the exclusive-pumping thing. Mostly. For a while. I mean, I don't think I'd try to be the little hero who sets grandiose goals of exclusively pumping to a year and never using formula, because I wouldn't want to look back and feel like I spent a lot of time with the pump which I could have spent enjoying my child.  Since I'm not living in the year 1700, I won't be sending a child of mine out to live with a wetnurse (but wetnursing can be life-saving in developing countries). I would not be okay with using breastmilk donated by a milkshare scheme stranger or de-stashings that had been sitting around in someone's freezer for months on end, but screened milkbank milk or recently-pumped milk from a trusted friend would be warmly welcomed. Ultimately, how we choose to feed our babies when direct-feeding-from-the-breast is not possible (or desired) surely comes down to individual factors, including the environment we live in and our own tolerance levels for different types of risk. Simple hierarchies of A>B>C>D fail to express the complexity of these real-world decisions.