Breastmilk vs. Formula: The Power of Choice and the Thin Evidence for “Liquid Gold”

In today’s world of women’s rights, choices, and equal opportunity, infant feeding has fallen to the wayside. There’s no emotional choice for women--breastfeeding is a requirement to be a responsible mother. Formula feeding is the McDonald’s of yesterday, as popular literature and societal pressure ingrain in our mind. Yet the actual benefits of breastfeeding are shockingly thin, begging the question of how we’ve stripped women of one of their most intimate decisions.

Fair warning: this article is comprehensive. Its goal is to illuminate facts so women can make their own data-informed decision, not to promote one over another. This article is for men to be equally informed, to remind their partner of the facts while she’s riding a hormone roller coaster.

Read on or skip to pertinent sections:

  • The guilt from the medical industry and society
  • The history of formula vs. breastfeeding recommendations through the 1900s
  • How breastfeeding physically works
  • The claims as to why breastfeeding is better
  • The counter-arguments to why formula feeding can be better
  • Recommended reads and resources

breastfeeding hat

Guilt from the Medical Industry

At your first pregnancy checkup, your doctor suggests you take a breastfeeding course at the hospital. You leave the course with the headline burned into your eyeballs: “Breast is Best. It’s all-natural. What do you feed baby pigs? Pig milk. What do you feed baby cows? Cow milk. What do you feed human babies?”

Fast forward. You roll off a 24-hour labor exhausted, sleep deprived, drug-filled, elated, swollen, bleeding, and disoriented. Every 2 hours, a nurse takes your vitals, measures the pee you’re collecting in the special toilet bucket, checks your bleeding and hemorrhoids, changes your doubled extra-long pads, pushes your stomach to help retract your uterus as you scrunch up in pain…and asks to see The Log.

The Log is where you note every feeding attempt, at least every 2 hours. Baby must eat or he’ll get dehydrated. If he loses more than 10% of his body weight, you won’t be discharged. Every nurse’s shift brought in a new technique: they squeeze your boob to get nipple geometry right (c-hold, u-hold, football hold, cradle hold) for a latch and hold your baby’s head against your boob. I’ve never had so many people squeeze my boob. I ended up getting blood blisters on the tips of my nipples in the first 12 hours of giving birth.

Once in awhile during feeding, you keel over in pain from your stomach. You rejoice for about 1 second--you know your baby latched. One of nature’s cruelest jokes is that breastfeeding releases oxytocin, which induces uterine contractions to help it retract post-birth. That 1 second of joy immediately gives way to labor-like contraction pains and sharp nipple pain.

Of the 5+ nurses and 3 lactation consultants I saw in the hospital, no one told me I had blood blisters until I was discharged 2 days later. They led on that it was just bruising and would get better. I had the script memorized: keep trying, it gets easier, it’s all natural, use lanolin cream. There wasn’t one mention of formula; I felt that if I uttered the word, I’d be wheeled into counseling before being discharged. This was a leading hospital in Silicon Valley that delivers 350 babies a month.

Guilt from Society

From the time you do you first Google search, you’re bombarded with baby registry ads for discreet breastfeeding covers, breast pumps, co-sleepers. Your workplace, in this modern age, is equipped with nursing rooms. You feel obligated to use them. And, as an educated woman, you want to get back to work and prove that women can do it all. You hear stories about breastfeeding as a terrible right of passage. “I breastfed until my baby was 2 years old!”

The 2nd websearch result for “breastfeeding benefits” even claims better friendships, that "Women are supposed to be sitting together, nursing and taking care of babies." Who wouldn’t want better friendships?

After being discharged from the hospital, I desperately sought advice from female friends. Nearly all responses were the same:

Breastfeeding isn’t natural but there’s just so much guilt! I can recommend a good lactation consultant. Are you drinking enough water? Are you eating lactation cookies?

I’m so sorry breastfeeding isn’t working out.

Well, formula is pretty good nowadays.

Every response was tinged with the notion that breastfeeding is best. Ladies, we’re walking a shaky line, admitting breastfeeding didn’t come naturally, acknowledging the immense guilt to do it, yet talking as if it’s the prime choice.

The History: American Association of Pediatrics and The La Leche League

From human evolution to the 1800s, wet nurses were common; women often had 10 children (not as many survived), and it was guaranteed there was another lactating mother in the family village. In the early 1900s, evaporated milk spawned baby formula--and by the 1950s, only 30% of babies were breastfed.

In the ‘50s, the La Leche League was founded as a group of Catholic mothers. Their name was inspired by a shrine "Nuestra Señora de la Leche y Buen Parto," meaning "Our Lady of Happy Delivery and Plentiful Milk.” They published “The Womanly Art of Breastfeeding,” in which the 1st edition talked about Eve: “Her baby came; the milk came; she nursed her baby.

In the ‘90s, the American Association of Pediatrics backed the La Leche League in recommending 6 months of exclusive breastfeeding, which the National Organization for Women claimed would put undue burden on working women.

Babies of the ‘80s were primarily formula fed; babies of the ‘90s and today are primarily breastfed. Although the eras of formula-fed and breast-fed babies have flip-flopped, each generation turns out just fine.

From a series of TV and print ads from 2003, from the US Department of Health, claiming "Babies were born to be breastfed":

Ice Cream Breastfeeding ad

The reality: Breastmilk Takes 3-5 Days to Start Producing

Breastmilk takes on average 3-5 days to start flowing after birth. You initially produce a couple teaspoons of colostrum, which is a natural energy drink and all your infant needs in the first few days of his life. Translated: There’s no need for formula, breastfeeding is the natural way to do it. In reality, your baby will survive, but they will lose weight and be inconsolable for days if you don’t supplement with formula.

The absolute best piece of advice I got was to have formula and bottles on hand whether you plan on breastfeeding or not. Your baby will be hungry and crying 24/7. You can still breastfeed so they can latch and stimulate milk production by sucking, but also give them a bit of formula to make your first few days tolerable.

I’ve never known such boob pain as when I started producing milk. My boobs were hot, engorged, heavy, and I could barely lift my hands above my head. But my nipples were in so much pain that I could barely pump long enough to relieve the pressure. (Word to the wise: don’t hug a just-given-birth mother. Shoulder pats are the way to go.)

The reality: The Breastmilk Feedback Loop and Boob Issues

Breastmilk production is a positive feedback loop: the more in frequency and duration you pump, the more you produce. I came home with horribly cracked, bleeding, blood-blistered nipples. I couldn’t attempt to feed without bawling, half in pain and half from the hormone high. I desperately wanted to hold my baby and cuddle without dreading him.

Yet, I persevered for exactly 1 month, my goal. I wasn’t pumping frequently enough because of pain, so my production was low. I got clogged milk ducts from the blister scabs. A clogged milk duct will make your boobs red, swollen, and needs to be treated to let milk out. Treatment is exfoliating your nipple. Yes, you take a wet, rough washcloth and cry as you exfoliate your blistered, dry nipple, in order to pump. That hot shower you want to take to relax? A hundred glass shards impaling your chest. Other boob issues include mastitis, a flu-like infection caused by blocked ducts, and thrush, a yeast infection passed back and forth from boob to baby’s mouth.

I went through 3 cycles of pumping less to heal, then pumping more to bring up supply, then becoming too tender to pump more, then lost my supply, and then repeated. We supplemented half formula during the whole time.

The Claim: Breastfeeding leads to higher IQ

Statistically insignificant. A study in 2015 made waves when it claimed that breastfed babies have on average 8 points higher IQ. Popular media picked it up and squeezed every last drop it could for the case for breastfeeding. The problem with any pregnancy study, though, is they’re studies, and at best only point out correlations, not causations--you can’t do a randomized trial with pregnant women. The most quoted, largest breastfeeding study done, the PROBIT trial in 1996, was based on correlations.

The 2015 study followed mothers who exclusively breastfed for 6 months and then continued in combination with food for 1 year. In any first world country, however, the only people who can afford to be home and breastfeed exclusively are middle- to upper-class, educated, usually white families, who are more inclined to raise kids who score higher on IQ tests. There’s so many confounding factors that the actual IQ benefit is statistically insignificant.

The Claim: Breastfeeding gives immunity

Not entirely. Breastfeeding provides passive, not active immunity. Humans are the only mammals whose antibodies pass through the placenta pre-birth, not through breastmilk. There are antibodies in human breastmilk, and while your baby’s mouth, throat, and stomach still have a coat of your breastmilk right after they’ve eaten, it can help fight infection, but those antibodies don't pass through to baby's blood system. This passive immunity is good if you have a preemie. But in reality, it amounts to about 4 out of 100 babies having 1 less incidence if diarrhea a year.

A confounding factor is the World Health Organization reports much lower infant morbidity in babies exclusively breastfed for at least 6 months. This is almost entirely due to 3rd world countries where a clean water source is an issue.

Despite the claims that breastfeeding reduces gastrointestinal issues, allergies, and asthma, each of these has seen a rise in the US since the ‘90s, the exact time period when breastfeeding campaigns changed the tide. Food allergies, of all things, rose 18% in the 1990s.

But, if your baby does have allergies and a sensitive stomach, breastfeeding is a safe bet.

The Claim: Breastfeeding reduces infant obesity

It can. If you’re reading this article, you want to do the best for your kid and I highly doubt you’ll raise an obese child. On a sidenote, “sensitive stomach” formulas use corn syrup and sugar instead of milk lactose and whey protein. We used only regular formula.

The Claim: Breastfeeding reduces SIDS

Maybe, but it’s small. A study of 1000 infants found that breastfeeding even partially through 2 months halved the risk of Sudden Infant Death Syndrome. The study interviewed parents’ behavior in infants whose deaths were categorized as SIDS. There may be truth to this study, but correlation questions arise again, since it wasn’t a randomized control study.

The SIDS rate in the US is about 0.054%, under 4,000 infant deaths a year. It's a catch-all for infant deaths that can’t be explained and happen during sleep. The one sure way to reduce SIDS is to keep your baby sleeping on his back.

The Claim: Breastfeeding is cheaper

Maybe. Formula costs $1000-$2000 a year. But media doesn’t itemize the costs to breastfeed, which isn’t free. If you’re working and pump, you need to rent or buy a pump (as long as ACA is around, insurance covers base pumps, but they aren’t ideal if you have supply issues). Hospital-grade pump rentals cost ~$100/month, plus the bags to store milk, the bottles, the nipple pads since you’ll leak, lanolin cream, hot compresses, new bras, nursing covers. If you’re exclusively feeding direct boob-to-baby, you’re probably missing the opportunity cost of working salary.

The Claim: Breastfeeding helps you lose pregnancy weight

Sure. Breastfeeding burns up to 500 calories a day, and you’ll lose weight if you don’t eat more. On the flip side, if you’re an active, fit person already, breastfeeding will get in the way of your gym plans. I was much happier working out on my own. Breastfeeding means early on, you can’t be away from your baby or pump for longer than 2 hours at a time.

The Claim: Breastfeeding helps you recover from pregnancy faster

True. Oxytocin is secreted during labor to induce contractions and also secreted when you’re breastfeeding to help your uterus shrink back to normal size. The claims are “uterus back to normal” in 6 weeks instead of 10. I’m skeptical of 10 weeks. I believe that being active as soon as possible after birth will do as much good.

The claim: Breastfeeding reduces postpartum depression

Maybe. Oxytocin is also a “happy” hormone, helping you psychologically forget the pain of labor and helping you bond with your baby. In theory, it can reduce postpartum depression. However, if breastfeeding doesn’t come easily, it can exacerbate tendencies toward PPD. I was much happier enjoying the time with my baby not in pain and having my body return back to normal.

The claim: Breastfeeding helps you bond with your baby

Yes, if breastfeeding comes easily. If it’s hard, I assure you, my time with my baby was spent in dread, not bonding. I had a much better relationship with my baby after I switched to formula.

Counterpoint: Formula feeding splits childcare with Dad

In the age of women’s equality, the single biggest factor for career and wage disparity is childcare. If you formula feed, feeding can truly be split between Mom and Dad. The extra sleep you get will go way further toward physical recovery and reducing postpartum depression and baby blues. My husband and I alternated feedings, so early on we were both getting up to 4 hours of sleep at a time, and engorged boobs don't exactly make you excited to work out.

Counterpoint: Formula feeding means cortisol won’t pass through breastmilk to your baby

The stress hormone, cortisol, passes through breastmilk. If breastfeeding is hard and you feel the crush of guilt to continue breastfeeding, your baby is feeling it, literally. Note that the above article actually bends this in a positive light, claiming “The findings lend further support to the idea that 'breast is best' and that formula milk does not provide the same nutritional benefits as breast milk.” Societal pressure once again.

Sidenote: caffeine also passes through breastmilk. If you pump and save milk for later, it’s best to label milk by time of day and try to feed on a regular day cycle.

Counterpoint: We as a society undervalue the value of emotional health

If breastfeeding isn’t easy, you’re going to raise your cortisol levels, pass that to your baby, you’re likely going to argue more with your partner, your baby will pick up on that tension, and your family health will decline. I’m a huge proponent of emotional health in family and career. I’ve felt the incredible burnout from my career and seen its effects on my marriage and physical recovery from 2 ACL surgeries.

Counterpoint: Breastfeeding may actually cause long-term bone loss

Breastfeeding reduces estrogen levels, which affects calcium absorption. Though there’s few studies, at least one has shown that breastfeeding for 4 months reduces bone density by 4%. That bone loss was recoverable after breastfeeding stopped. However, women who breastfed for 9 months or longer didn’t recover their bone density after 18 months, when the study concluded. There's few studies in the area as to whether there really is long-term bone density loss, but it's worth pointing out as a possible factor.

Counterpoint: Formula has come a long way in the last 20 years

Most of the long-term studies are from the ‘90s. Formula now has DHA, lutein, Vitamin E, prebiotics, probiotics, and a blend of nutrients. Our generation of primarily formula-fed babies turned out just fine.

Counterpoint: Breastmilk is insufficient in nutrients past 6 months

Breastmilk is insufficient in vitamin D, iron, and zinc. This isn’t an issue in baby’s early days, since he’s using up stores from the womb. But unlike yesteryear prior to concrete, babies don’t get elemental iron from playing in dirt. You should be starting solid foods by 6 months anyways.

Breastmilk nutrition

From the book The Science of Mom: A research-based guide to your baby's first year

Counterpoint: Formula feeding is easier to track and log

It’s actually pretty cool and convenient to know exactly how much your baby’s eaten, especially in the first couple months. Apps are pretty awesome to track feeding, especially if you’re trading off feedings with your partner. Rather than waking your partner up at 2am to ask what time baby last fed, you can check a shared app. More sleep, more win!

Counterpoint: Sometimes technology wins

Vaccines, chemotherapy, glasses and contacts, statins for cholesterol. Sometimes technology is as good as or better than nature. Thank goodness we live in a world where we have an option other than breastfeeding.

So why on earth is breastfeeding so hard if it’s evolution?

In reality, if you had to do it, you would. I think a big portion is that we’ve lost the art of breastfeeding. I’m sure the support systems and homeopathic aids were part of our culture hundreds of years ago. Women also had many more children, and there was always a lactating female in a village. Wet nurses were common through the 1800s.

There’s theories that the more intelligent the mammal, the more difficult breastfeeding is, as has been observed in monkeys. Humans are have the largest breasts of any mammal, which is entirely impractical for the size of an infant’s mouth--but then again, as men have evolved to love big boobs, bigger boobs have won out the evolution game.

To make you feel better, infant feeding has been a struggle for hundreds of years. And we’re just riding the current generation’s cycle of promoting breastfeeding.

Don’t sweat it, but accept that you will sweat it

Accept the pressure. Be educated. Make decisions when the time is right for you. Despite researching and knowing all this, I honestly don’t know what I’ll choose with our next baby. There’s a ton of pressure and guilt. Remind your husband to remind you of these points when the time is right.

And if it works, it works

If breastfeeding works, great! If it doesn’t, go to the store and problem solved. All I wish for is equal ground so there’s no guilt either way. Whether your family’s solution is breastfeeding or formula, happy mom, happy baby, stressed mom, stressed baby. No guilt.

Recommended Reads and Resources

The references below are roughly ordered from articles and blog posts to science journals and studies. I highly recommend reading other womens’ articles--I cried through a few of them. One of the best medicines is to be emotionally understood, and it helps to have a virtual camaraderie.

This list isn’t meant to be comprehensive to promote breastfeeding or formula feeding. It’s skewed toward formula feeding because its information is much harder to come by. I’m an advocate of having comprehensive data so anyone can make their own informed decisions with a complete knowledgebase.