This paper breaks a cardinal rule of infant feeding research by not starting with the obligatory opening line that breastfeeding has like a zillion health benefits & that EBF for 6 months & continued BFing for 2 years plus is recommended by the WHO. We already love it!
They propose that BF promotion efforts have had the unintended consequence of stigmatising formula feeding leaving mothers who do not or cannot bf feeling that they have failed in early attempts at motherhood which could have adverse effects on their emotional health
To date there is no experimental work testing whether feeding methods engender stigma or what form this stigma takes or the impact of whether a feeding method was planned/unintended on perceptions. This paper seeks to determine the nature & scope of formula feeding stigma (FFS)
So FFS we say it is time to END FFS NOW!

Love the abbreviation 😆
I digress... in keeping with the rebel nature of this paper, they go on to draw attention to the problems in determining causality in the associations between feeding methods and outcomes
They draw attention to the PROBIT study (which examined the impact of a BF promotion effort in 1990s Belarus on health & educational outcomes), sibling studies comparing BF & FF siblings and studies looking at intention to BF on health... Haven’t we pointed this out before too!
Taken together these studies provide evidence that many of the purported benefits of BF are driven by maternal advantage and access to resources rather than by breastmilk itself
They argue in the absence of medical evidence that formula feeding causes harm that feeding decisions should be based on the unique medical and psychosocial factors pertaining to each family and we need to understand the reactions families might encounter if they use this option
Existing non-experimental research suggests that formula feeding may be associated with stigma or a ‘discrediting mark’ with those who formula feed being seen as selfish, inappropriate or even dangerous...
Some have argued that breastfeeding is now less of a recommendation based on solid medical evidence and more of a ‘moral imperative’ or requirement for being viewed as an acceptable mother ...
Mothers report being stigmatised for formula feeding often by other mothers and by health care providers and mother men and women report viewing bfing women as better mothers than women who bottle feed...
Experiencing such stigma can lead to negative emotions and may contribute to perinatal mental illness such as depression and anxiety...
Fear of stigma can deter parents from using formula when it is clearly indicated or from receiving adequate info about safe formula feeding practices and undermine parental confidence...
Our comment: does stigma impede info sharing or do BF promo policies banning group demos of safe formula feeding practices or info about formula being on public display contribute to stigma? Current policy acts like formula needs to be kept from public view. Pretty stigmatising.
The paper argues the need to explore the nature of potential FFS in order to understand how best to promote the health and well being of babies and care givers.
And the point out that self report and observational data are not sufficient to determine whether feeding method causes negative reactions to care givers who formula feed or whether other factors are involved...
See what they did there... they have data that seems to support their hypothesis but before rushing headlong into drawing premature conclusions, they put their hypothesis to the test ... That’s how it should be done!
They propose that FFS may vary as a function of the intended feeding method rather than the actual feeding method (and cite other literature suggesting that socially undesirable behaviour provokes more negative reactions when it is viewed as intentional)
So they propose that feeding intentions may moderate FFS with women who intend to formula feed being more likely to encounter stigma than those who intended to bf but ultimately use formula
So they created 2 tests

Experiment 1 exposed participants to a social medial post from mothers who were identical apart from their feeding method (formula feeding, breastfeeding & a control where feeding type was not mentioned). The feeding methods were described as intentional.
And they asked participants to rate their perception of maternal competence, likability, dedication, communality, dominance and selfishness. They also asked them to rate infant crying time, eating satisfaction, weight, developmental milestones and sickness.
They recruited 300 USA based participants via Amazon Mechanical Turk. They collected demographic data but it was not found to influence results.
The results supported the expectation that FFS would result in negative perceptions of mothers who FF. FF mothers were viewed as less competent, less likeable, less dedicated and more selfish. On these variables there were no differences between BF and control.
For communality and dominance rather control mother was s viewed as more communal and less dominant than either the BF or FF mothers and there were no differences in perceptions of BF and FF mothers on these variables
The results also supported the prediction that FFS would affect perceptions of infant wellness. There was no effect on crying time or eating satisfaction. But the FF infant was expected to weigh less than the BF infant (weight gain seen as an indicator that the baby is thriving)
There was no effect on infant milestones but there was an effect on infant sickness with the FF infant rated as being sick more frequently and severely than the BF infant or control infant and the BF infant being sick less frequently and severely than the FF or control...
This suggests that in this specific incidence FFS was reflected by both pessimistic expectations for FF babies AND optimistic expectations for BF babies.
Taken together, the results provide evidence of FFS but they are mindful of the need to replicate novel findings before drawing firm conclusions (notice how they don’t rush to a conclusion without collecting more data - you don’t alway see it in infant feeding research)
So experiment 2... tried to replicate experiment 1 and added in another variable: feeding intention. Would mothers who intended to BF but ended up FFing be viewed more positively than the mother who always planned to take the ‘sub-optimal’ approach...
What about mothers who intended to FF but ended up BF? Perhaps judgements about FFing are more driven by judgement of the mother’s willingness to adhere to expectations of intensive mothering than by concerns about infant well being?
This time they recruited 400 participants using the same approach. The new materials were identical to those used in the first experiment but added in intentionality. So what happened to the results...
When women’s feeding choices were intended, FFing mothers were viewed as less competent than BFing mothers... but the opposite was true when it was unintended (e.g unintentional BFing mothers were viewed as less competent than unintentional FFing mothers)
Unintended FFing mothers (That is those who intended to BF but ended up FFing) were not viewed more negatively on maternal competence than those who intended to BF and did so.
For likability ... intentional formula feeders were rated as less likeable than intentional breast feeders. Unintended breastfeeders were rated as less likeable than unintended formula feeders.
Unintended BF mothers and intended FF mothers were rated as equally likeable as did intended BF mothers and unintended FF mothers.
Similar pattern for maternal dedication - FFing mothers who didn’t intend to FF were rated as more dedicated than those who intended to FF. BF mothers who didn’t intend to BF were viewed as less dedicated than those who BF intentionally.
And no difference between unintentional BF mothers and intentional FF mothers OR between intentional BF and unintentional FF mothers.
Same pattern for communality with intended BF being rated as more communal.
Same pattern for dominance where intentional FFing mothers were rated as more dominant than intentional BFing mothers. No difference between those who intended to BF but FF and those who intended to BF and BF or between intentional FFers and unintentional BFers.
A similar pattern emerged for maternal selfishness except that unintentional BFing was rated as less selfish than intentional ffing.
Results for infant outcomes were less consistent. No effect on crying time or meeting developmental milestones.
For those whose feeding choice was intended, babies were rated as heavier than those who were unintended.
For infant sickness there was a perception that babies who were FF were more likely to get sick than babies who were BF. Those who unintentionally ff were perceived as being more sick than those who were intentionally BF but less sick than those who were intentionally FF
Intentionally BF babies were thought to be less sick than untintentionally BF babies BUT unintentionally BF babies were still expected to be less sick than intentionally or unintentionally FF babies.
Does anyone else’s head hurt? Let’s sum up ...

Basically perceptions of mothers based are shaped by the intentionality of their feeding behaviour, not only by the feeding behaviour itself. So women who intended to BF but FF were viewed as positively as those who intended to BF and BF.
So if you tried to BF but couldn’t you get marks for effort
But unintentional breastfeeding is viewed just as badly as unintentional formula feeding so even doing the right thing for the wrong reasons gets you sent to the sin bin
So in conclusion FFS seems to have little to do with concern about babies’ welfare & quite a lot to do about judging mothers, which is consistent with previous work suggesting that negative reactions to ffing reflect requirements for ‘ideal mothering’ not infant nutrition
The results on infant outcomes seem to suggest that whilst it is believed that BF causes better health, that the intentionality matters suggests that there is an expectation that mothers who BF are good mothers and therefore cause better outcomes for their children
The authors suggest this has pressing implications for healthcare policy ...

FFS strikes in the vulnerable PP period when low levels of sleep & hormone fluctuations are high and a time when the risk of mental illness increases...
FFS may mean women continue BFing and not take medications that they are advised not to take having an adverse effect on their health.

FFS may make caregivers reluctant to give formula even in cases where BFing difficulties might lead to malnutrition, dehydration & even death
They also suggest that FFS may lead to self stigma and adverse emotional outcomes... they didn’t examine the impact of feeding intention on self stigma but we would point out that those who intended to BF but ended up FF have had an experience of not being able to do something
...that they may believe (because of BF promo) has significant advantages for their baby and their bond with their baby. Such an experience of “failure” may in itself have an adverse emotional effect.
Anyway, we digress again... the authors point out that intentionality does not point to any practical intervention for escaping FFS and it would be tiresome indeed for caregivers to communicate whether or not their feeding behaviours were intentional or not
Tellingly they also feel the need to stress that they are not taking a position against breastfeeding... but are arguing that care givers should be free to decide what feeding decisions are the best fit for them without the constraints of stigma
They also acknowledge that whilst their research points to the role of intentions in affecting FFS, future research might example the effect of a host of different rationales for unintended feeding methods
The study only looked at women who were exclusively BF or exclusively FFing. Future research might look at more ambiguous feeding choices eg feeding expressed milk in a bottle or combination feeding and the impact of FFS on fathers, transgender parents, adoptive parents etc
Future research could also look beyond public FFS and consider FFS from people who are closer to the family e.g. health care providers, grandparents, extended family and friends etc
Future research should also seek to look at different types of participant samples and it might be expected that FFS might vary based on the extent to which different social contexts embrace total motherhood ideals.
We would be particularly interested in the extent of FFS in midwifery, health visiting, primary care doctors, paediatricians and BF supporters.
An interesting paper and we are glad to see FFS as a recognised phenomenon. Now FFS can we stamp out FFS and focus on creating an environment where families can nourish their babies according to their own needs and feel happy and confident, whatever that decision might be.
Helpful steps might include

-A realistic stance on the impact of infant feeding on health
-Having info about all feeding methods readily available
-Being positive about nourishing a babies in comfortable, sustainable ways
-Focus on families, not feeding methods
And with that epic thread ... we bid you goodnight... but please... parents, lets discuss our experiences of FFS and anything else that this paper throws up for us!
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