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.