Reply to commentary on ELF study

There was a study published a little while ago showing that early, limited formula feeding (ELF) was associated with increased breastfeeding rates in older infants, and not by a little bit. Although it was small, I was impressed with the results, and they changed my thinking about the use of formula. Using formula vs. breastfeeding is often portrayed as a black or white issue. This is partly due to the research, which often only compares exclusive breastfeeding with exclusive formula feeding, despite the fact that many women use both methods at the same time. Perhaps by not polarizing the issue, we can do a better job of helping women to breastfeed for longer?

This is not the view that is supported by a writer from Best for Babes. She wrote a post criticising the study, but it is clear that she is a proponent of 100% exclusive breastfeeding and does not have a background in science or clinical research. Just because a study contradicts what you expect, doesn’t make it flawed. I was so annoyed by her responses, that I wrote my own counter-response. Her statements are in bold.

Prior research shows that use of formula without medical indication strongly undermines breastfeeding.

The researchers hypothesize “adding the early use of limited volumes of formula in addition to breastfeeding before the onset of mature milk production would have high potential for reducing breastfeeding discontinuation for some mothers by ameliorating milk supply concern”. I understood that this approach has not been tested before in an intervention study. The fact that the study results, what answer a very specific research question, contradict general advice about breastfeeding is not a flaw, that’s just what the results show.

The wrong criteria for newborn weight loss

The researchers probably were not allowed to use a clinically relevant loss of weight without providing the standard treatment of care as it would have been deemed unethical. Anyone can give a healthy infant formula, but an infant that has lost more than 10% of its weight should not be included in a research study unless it is first treated for its weight loss.

Why try this? We already know what works.

We still need more research. The BFHI is a hospital-based initiative to improve breastfeeding rates, but the individual parts of it need to be tested. If the results from this research study are repeated in a larger study, the Early Limited Formula (ELF) approach could conceivably be considered as part of the BFHI.

Sample size too small, no controlling for other factors

This was a pilot study, hence small study numbers. Controlling for other factors is relevant for observational research, but this was interventional.

One author has financial ties to formula companies

This is a potential conflict of interest, however often formula companies choose to do research with people who have experience in the field. It does not necessarily mean that the research is flawed.

Milk came in late for one quarter of the mothers.

This is exactly why ELF may work: by using formula to help infants who are extremely hungry due to late arrival of milk, they may breastfeed better, explaining why ELF is likely to be successful.

Using formula to supplement instead of human milk.

Formula is a good alternative to expressed breast milk, especially if women have a low supply or their milk comes in late. Expecting women to express breastmilk in the early postpartum period when they have a low supply or their milk has not come in seems unrealistic.

Undermining recent progress.
This study shows that breastfeeding rates improves if women who had difficulties feeding their newborns were encouraged to use infant formula for a limited time. Improving breastfeeding rates sounds like progress to me.

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