Saturday, January 5, 2013

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. 


  1. I felt it was pretty clear in Facts for Life that the advice on using donor milk only applied to low birth weight babies in the current facts for life. In the section on artificial feeding it says, "The best food for a baby who cannot be breastfed directly is milk expressed from the mother's breast, given from a clean, open cup. Even newborn babies can be fed with an open cup. If it is necessary to feed a baby with a nutritionally adequate breastmilk substitute, it should be fed to the baby by cup."

    No mention of donor milk at all. This same section in the 2002 addition states that the next preferred option is milk from another healthy mother a couple of times, while this isn't even mentioned as an option in the 2010 version.

  2. In your quote under the subtitle 'The current WHO stance', did you not notice that the quote contains the order of preference to infant feeding as this so called 'myth' of hierarchy which you claim never existed? There are evidence based reasons why this hierarchy exists and a good all round knowledge of human lactation and the components formula would tell you why even if this 'list' does not exist in short hand that it does exist in reality in much detail.

    You can look at documents available from Unicef or ennonline on Infant feeding in emergencies to see how strict the protocol is on what to feed infants when the infrastructure no longer exists for choice in infant feeding.

    Other bullshitometers are out there and mine is ringing away on this blog post.

  3. Hi Rabbit in the Moon. Thanks for your input. Just wanting to clarify your suggestion: I believe you're referring to the first quote immediately below the heading in question--the one starting with the words "18. The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed..." I correct? The text's a bit ambiguous, but my own reading of this paragraph is that it doesn't seem to state any particular hierarchy, but rather is just listing the options and saying "Which one to choose will depend on the circumstances." I could be wrong in my interpretation, of course. :)

  4. Interesting. Having looked into this myself in the past and found the same documents and references as you have, I'd assumed that the 'fourth best' hierarchy *had* been WHO policy back when that document was written in 1989, and had been changed since then in response to HIV muddying the whole idea that donor milk was automatically better than formula. I still think that's the likely explanation for the different and contradictory statements. And I completely agree that the 'fourth best' line should be dropped - it clearly isn't the case any more, even if it was once.

    By the way, there is actually no evidence that donor milk is better than formula for anyone other than premature babies, because the two just haven't been compared in other infants. My guess is that it's probably at least somewhat better, but probably not to the extent of being worth going to huge effort to get hold of it, particularly not if that means taking the risk of using milk from an unscreened mother.

  5. You know, I hadn't even thought of the HIV thing. You're right, that could well be the reason for the contradictory statements.

  6. Someone recently pointed me to this article.

    I thought you might be interested in seeing UNICEF Canada's page on breastfeeding, which includes a summary of their brief given to Health Canada in 2011 in response to its draft updated infant feeding policy.

    Here is what UNICEF has to say:

    1. Annie, thanks for this. It seems UNICEF Canada has come out with a clarified statement which encompasses donor milk, including the recent trend in unregulated milk donation: "UNICEF Canada encourages the expansion of regulated human milk banks and guidelines for safe wet-nursing, as donor human milk from a milk bank or wet nurse is the most acceptable alternative for an infant who cannot be fed breast milk from his or her own mother, with formula as the third choice." I'm inclined to agree that (screened/regulate) donor milk is good stuff... although I'd question the practicalities of wet nursing outside of remote/traditional societies.

  7. It seems to me that the hierarchy is totally pointless, as any one of the choices listed, plus unmentioned others (like distinctions among different formulas, goat milk straight from the goat, sterilized goat milk, camel/yak/sheep/different cow breeds/rat milk--remember that Simpsons' episode?) could be optimal, depending on combinations of circumstances far too numerous to specify. Off the top of my head, I can think of:

    - infectious and non-infectious health conditions of mother, baby, potential wet-nurses, and others in their households (who might be infectious, or need a lot of care, or need particular living conditions or diet restrictions)

    - availability of medical diagnosis/testing or treatment for any relevant medical conditions

    - typical microbial and mineral (e.g. lead, fluoride, calcium) content of locally available water

    - difficulty of sterilizing water for consumption and for washing the containers and utensils used to store, prepare and serve the baby's nutritional beverage

    - availability of refrigeration

    - typical nutritional adequacy of the local diet at various times of year

    - availability of potential wet-nurses (e.g. must have the baby taken to her in her fields for every feed, lives next door and is home all day, lives in another village and must have the baby come to live with her)

    - other demands on the mother's time and strength besides caring for the baby

    - likelihood of disasters that would impact food and water supplies and/or population movement (e.g. war, drought, earthquake, flood)

    - cultural and religious influences

    1. At the individual level, I'd agree that which is the "best choice" is going to come down to individual preference a lot of the time. For example, donor milk which is fresh and easily procured would be one thing, but I wouldn't personally be comfortable with unregulated donor milk or milk that had been frozen for long periods of time. And if, for example, procuring donor milk is going to involve dragging around in the car for hours on end to collect the stuff, then the impact on family life has got to be considered as well... same as with exclusive pumping, which is a very, very labor intensive way to mother.

      I have to say though, I'm struggling to think of any circumstances in which straight goat's milk could be top of any sort of hierarchy, yikes! Feeding this to infants as a main drink has resulted in organ failure and death due to protein and sodium overload--not good. I think homemade formulas are bad news, but even a homemade formula would be better than straight goat's or cow's milk.

  8. This comment has been removed by a blog administrator.

    1. (Oh dear... bit of random blog spam made its way in....)

  9. 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 schemesBaby Milk Formula

  10. You stopped too soon when quoting the text...


    (Formula is mentioned "fourth" (actually it is not even mentioned with breastmilk but has its own paragraph and it specifically says that children not breastfed should be closely followed as the represent a risk group (just by that, you can understand that Formula is the last (and fourth) choice)
    Exercising other feeding options

    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 unsuitable 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.

    19. For infants who do not receive breast milk, feeding with a suitable breast-milk substitute – for example an infant formula prepared in accordance with applicable Codex Alimentarius standards, or a home-prepared formula with micronutrient supplements – should be demonstrated only by health workers, or other community workers if necessary, and only to the mothers and other family members who need to use it; and the information given should include adequate instructions for appropriate preparation and the health hazards of inappropriate preparation and use. Infants who are not breastfed, for whatever reason, should receive special attention from the health and social welfare system since they constitute a risk group."

  11. Actually the quote you have added does mention formula in paragraph options (it suggests cup feeding). The next paragraph provides more detail about the choice and risk. I think when reading any WHO document it is worth noting that they are talking about the world and many countries don't have access to clean water so yes the infant is at risk.

  12. Nomes, I am inclined to agree. The fact that the same document talks about cup feeding kinda highlights a point that I and others have made elsewhere--that WHO advice tends to be tilted towards poor and remote environments where sanitation is poor. In these kinds of environments, cup feeding can save lives because cups are so much easier to sanitize than bottles. In rich countries, the advantages of cup feeding are likely to be outweighed by the mess, inconvenience and waste (and I speak as someone who has actually done cup feeding…!)