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ELECTRONIC ARTICLE: Agneta Hörnell, Yngve Hofvander, and Elisabeth Kylberg Solids and Formula: Association With Pattern and Duration of Breastfeeding Pediatrics 2001; 107: e38 [Abstract] [Full text] [PDF]

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eLetters published:

"Associations" are not "Cause and Effect" relationships.

Mary Fay   (13 April 2001)

Re: "Associations" are not "Cause and Effect" relationships.

A Hörnell, "Y Hofvander, E Kylberg"   (27 July 2001)

"Associations" are not "Cause and Effect" relationships. 13 April 2001
Mary Fay, M.D. Send letter to journal: Re: "Associations" are not "Cause and Effect" relationships. mfay2{at}home.com Mary Fay	As the title of this article suggests, there is an association between feeding infants formula and decreased incidence of breastfeeding. This association is just that - an association - and not a cause and effect relationship. Formula feeding does not cause the decrease in breastfeeding; formula feeding occurs when mothers don't breast feed. Some food has to take the place of breast milk, but it is not necessarily true that the food causes the demise of breastfeeding. The only etiology of why mothers stop breastfeeding contained in this article is the mother’s belief the child needs more calories than the breast milk is supplying. Whether or not that perception is accurate isn't clear from the data supplied, so no conclusion can be drawn. It may be true that formula feedings will decrease breast milk production and end it when dealing with a mother-infant pair who are successfully breast feeding. If a mother introduces formula in place of a breastfeeding, the infant’s decreased need for breast milk will ultimately result in decreased output due to less time suckling. This is called "weaning," but is that occurring in the children looked at in this study? Are these children normal breastfeeders, or are these children in need of more calories, as their mothers perceive? This is extremely important information because the authors imply that practitioners may be able to increase the incidence of normal breastfeeding simply by counseling mothers not to use formula. If the infant and mother are healthy and normal, this will be true, but if the mother is not producing enough breast milk, or the child has trouble suckling at the breast but can take fluids more easily through the bottle nipple, it won’t. All too often I’ve seen a mother who is having trouble nursing successfully bottle feed a child who is too congested to stay on the breast. Bottle feedings are easier on the infant, and the mother’s perception about the child needing more is correct in that the child is frustrated by the slow feedings. Formula was not the problem. This sort of mistake about association vs. cause and effect happens so frequently in the medical literature as to be disturbing. Perhaps not allowing parents to use formula would insure more children receive breast milk, but whether or not the mother would be able to supply that breast milk or would be able to nurse a congested child who can’t latch on well enough hours in the day has to be considered. Physicians counseling mothers on feeding practices must never forget that guilt doesn't enhance the parenting experience, nor, in my experience, is it likely to promote breastfeeding. Unless you determine a child is receiving enough calories and nursing is normal, you can't make a blanket statement to a mother about not giving formula. If a mother feels the child is hungry or frustrated by breastfeeding, it's more important to address her fears than forbid her from using formula. She is probably right.
Re: "Associations" are not "Cause and Effect" relationships. 27 July 2001
A Hörnell, researcher and senior lecturer Dep. Food and Nutrition, Umeå University, Sweden, "Y Hofvander, E Kylberg" Send letter to journal: Re: Re: "Associations" are not "Cause and Effect" relationships. agneta.hornell{at}kost.umu.se A Hörnell, et al.	It is important to increase parents´ and health care personnel´s knowledge about factors that might influence the milk production. Bottle- feeding and pacifier use have been associated with decreased breastfeeding in most studies and there are several physiological ways in which bottles and pacifiers can intervene with breastfeeding (e.g "nipple-confusion", less suckling on the breast). This does not necessarily indicate a cause and effect relationship, since mothers might introduce bottles and pacifiers with the intention to decrease/stop breastfeeding. Some children can mix bottlefeeding and/or pacifier use and breastfeeding, and some can not. Unfortunately, it is not possible to know beforehand how an individual child will react. Therefore, it is important that parents who want to continue with breastfeeding and combine it with bottlefeeding and/or pacifier use, are made aware of the associaton with decreased breastfeeding, so that they will be more likely to react quickly if their child shows signs of not being able to cope. Our research facilitates individual counselling and support to parents based on informed choices - guilt and forbidding does not come into it.