Yes, we still need strollers

Stroller, prams, pushchairs, buggies--they're a part of childrearing, whether you love them or hate them. And an awful lot of people do seem to really hate them. Dislike of buggies is one of the top complaints among those people who have a hostile attitude towards parents and children in public spaces--whenever the breeders vs. childfree-by-choice wars break out online, you can guarantee that there'll be lots of moaning about stroller-users bashing people in the ankles or pushing them off the kerb.

Big ("SUV") strollers, expensive strollers and older kids in strollers come in for the most criticism. "These things get bigger every year!" "Just carry your kid already--and once they can walk, make them walk!" Sometimes--in one of those unholy alliances that only the Internet makes possible--the child-hating-by-choice people are joined by the attachment parenting brigade, who say things like "Oh, I agree! I don't know why people use strollers; we almost never used ours, just carried her everywhere in a sling! It's soooo much easier than a bulky buggy!"

Now, I like a good sling myself too. But strollers are a necessity for most of us at least some of the time. So, taking a hint from Privilege Denying Doula for a moment, I'll say why I think so.

1. Not every baby will tolerate slings
Some babies really, really don't like being worn--and it's not always a case of "Oh, but you just need to find the right sling!" Some babies just prefer the stroller. No, seriously. They do.

2. Not every parent can use slings
Some mothers have disabilities even before they get pregnant; others develop problems due to pregnancy and childbirth, which can do a number on your body. Mothers who have developed chronic back ache, who have symphysis pubis dysfunction, who are recovering from surgery or whose pelvic organs are falling out don't need to aggravate these issues by lugging the baby, baby gear and all their bags around for hours on end. Which leads me to...

3. Prams carry stuff
I love slings for short trips, but for whole days out or when doing errands on foot...? The problem is, you don't just have your child; you've also got a diaper bag, change of clothes, toys, maybe snacks or drink. PLUS groceries and shopping... or maybe bags of dry cleaning and recycling... or maybe a bag of library books and the boots you're taking to the menders... perhaps raingear and umbrellas... or a picnic lunch... I have actually tried doing trips like this with a sling rather than a pram, and discovered that the hassle of occasionally having to search for an elevator is actually a lot less miserable than staggering round like a packhorse for hours and hours.

4. Prams let you catch a break
A child falling asleep in the pram is your cue to slip into a cafe or restaurant for a quiet lunch with your friend or partner, or even just a nice half-hour to have a coffee and knit/read by yourself. You really cannot enjoy this kind of moment with a baby glued to your front; you can't eat in comfort because you have tyrannosaurus-rex arms (= you struggle to get your hands near your face), and you can't drink anything hot for fear of dropping it on their head. If they're on your back, you can't sit back in your chair and relax. Ugh!

5. Kids who can walk sometimes need strollers too
A lot of people love complaining about walking-age children in strollers. "Let them walk! They need exercise!" Yes, but. The four-year-old you briefly spied in a stroller yesterday was almost certainly not there all day long. Most likely they walked for ages, and then took a little rest in the buggy when their legs started to give way. A stroller makes it possible to cover substantial distances without driving; nobody moans about a four-year-old being driven from A to B in a car, even though said child is getting no more exercise than a child in a stroller (less, actually, since the strollered child probably did much of that journey on foot); Show me a person who says "Well, my little one was out of the buggy by 21 months! I believe in making children walk!" and I will show you someone who flippin' drives everywhere. Which brings me on to...

6. If you don't have a car, your stroller IS your car
The whole notion of "babywear only, skip the stroller and then make them walk once they're toddlers" is actually quite doable for most people who drive most places. You can dump all your stuff in the car, drive from place to place, and when you get out, bring just those few things you need right now; a baby can fall asleep in the carseat and you unsnap the bucket and carry it into the restaurant; an older child can take a nap in the car on the way home.  If you don't drive it's a different story. It is often not possible to carry a baby, diaper bag and errand stuff/shopping round for hours on end while covering considerable distances on foot; nor is it practical to do everything at a small child's pace. And your toddler will have nowhere to rest or nap. I think, to be honest, this is what's at the crux of all those furious online arguments about strollers in public places. The demographic which is most hostile to having children in their midst tends to be concentrated in densely populated urban areas... however, it is precisely those areas where parents tend to need their strollers the most.

7. Not all strollers are created equal
I'm not sure where this whole "Strollers keep getting bigger all the time!" idea has come from--haven't the people who say this ever seen a tank-like 1950s pram? Now those really are strollers you could haul a week's worth of coal home in (and of course that's just what people did). Teeny umbrella strollers are great for older kids, but tiny babies need to lie flat. And if you're a city parent who uses your stroller a lot, it is perfectly reasonable to spend $$$ getting an good one; cheap strollers will steer awkwardly, rattle your child around when they're trying to nap, and rapidly wear out and need to be replaced. False economy. I'm not sure why it's considered so morally abhorrent to spend some money on something which one is going to use hard every day and be seen with for hours at a time. Nobody bitches at the person who invests in a decent winter coat rather than the cheapest anorak they can lay their hands on. (Just one thing: if I'm brutally honest, I do think that some of the strollers used by some parents are bigger than they need to be. I think the best urban stroller is mid-size: big enough to carry your gear, small enough to be reasonably agile.)

Closing thoughts
Much as I love my Beco--it's practical, fun and sometimes life-saving--I'd be disappointed if the existence of slings started to become yet another excuse for stroller bans, hostility towards pram-users in public spaces, or failing to make accommodations for strollers such as ensuring elevator provision. Hating on parents with strollers won't make us and our offspring disappear--it will just drive us into cars, which won't help anyone. Of course it is possible to "manage" without either prams or cars--in remote villages in Nepal and Sierra Leone and so on, women trudge around with babies, firewood, water and farm produce strapped all over them. I wouldn't want to live that way, and women in Nepalese villages probably wouldn't live that way either if they had any choice in the matter. At least Nepalese village women have the option of leaving toddlers in the care of extended family members or older kids (who do most of the childcare in traditional societies). In developed countries, we have little choice other than to drag toddlers around with us on errands. Strollers are an important tool in making sure parents, especially mothers, can occupy public spaces easily and get their stuff done.

Homemade formula and the Weston A. Price bust-up

It's always kind of interesting when crunchy people fall out with each other (you know, like elimination communication fans vs. let-your-child-sit-in-diapers-till-they're five-if-they-want-to people... that kind of thing). The latest bust-up--if you'll pardon the pun--concerns the Weston A. Price Foundation (WAPF) vs. breastfeeding advocates.

WAPF is a kind of nutritionist movement that's been around for decades, and which advocates for "traditional foods"--organic everything, lots of animal products and lots of fermented/home-processed foods, from konbucha to bone broth to a yohurt-like product called kefir. It also advocates making homemade formula. Some breastfeeding advocates have become suspicious of WAPF in recent times, claiming that WAPF proponents are too quick to push homemade formula recipes on struggling mothers, rather than getting to grips with their latch issues, tongue ties, lack of support and so on. In the most extreme form, some WAPF advocates have stated that WAPF homemade formula can be better than breastmilk... if the mother eats an imperfect diet, and especially if she's vegan. WAPF doesn't actually sell its formula, obviously (this formula has to be made freshly), but it does encourage followers to purchase ingredients from a sponsor company called Radiant Life, which sells $170-$400 kits containing one to six months' worth of the supplements and powders needed to make the formula at home.

I don't always agree with Best For Babes but I think their piece on the WAPF thing got it more or less right. Full-on malnutrition can affect breastmilk quantity and quality, but this is rare in developed countries. In spite of its hippy image, woo/crunchy stuff/pseudoscience is often big business, and WAPF may well be subtly encouraging homemade formula use because it's in its business interests to do so, no different to Similac or Cow & Gate. Women who want to breastfeed would therefore be advised to be wary. Incidentally, this is not really about whether we think formula is wonderful, evil or something in between; it's because it behoves us to maintain a proper degree of skepticism concerning the advice given by anyone who is trying to sell us stuff. I mean, I use disposable diapers and wouldn't want to live in a world where they didn't exist; however, I have no intention of getting my toilet-training advice from a Pampers helpline. After all, businesses are businesses, not charities; it ought to be possible for us all to take advantage of their products appropriately and take what they say with a good pinch of salt.

However, amid all this talk, there's actually been very little discussion of the homemade formulas themselves. So I thought I 'd talk about that.

How to make formula (quick explanation)
Bit of background: You can't give straight cow's milk to young babies as a main drink because it's pretty different from human milk. Too much protein, for a start. Also, there are two types of protein in all animal milks: casein and whey protein. Human milk is about 30:70 casein-to-whey, while cow's milk is more like 80:20. All that casein's hard for a baby's belly to digest. The resultant stress on the intestines causes microscopic bleeding, which can add up to quite a lot of blood loss. Now, there's hardly any iron in cow's milk, which tends to cause anemia, and that gradually accumulating blood loss makes things even worse. Cow's milk also has too much sodium, and not enough carbohydrates. (It's a similar story for goat's milk, by the way, despite the urban legends about how it's supposedly similar to mother's milk)

Formula companies therefore process cow's milk and add things and take things away to make it more similar to breastmilk. Not the same, mind you; many nutrients are better absorbed and more useable ("bioavailable") in breastmilk than they are in formula, and the storage and preparation of formula may cause loss of some nutrients. So in order for the formula-fed baby to get the same amount of, say, calcium as the breastfed baby, you may actually have to create a formula with more calcium in it than breastmilk.

Now, the WAPF formulas purport to do the same thing--just on a homegrown scale.The website lists three types of formula--cow's milk-based, goat's milk-based, and liver-based--and explains the ingredients and preparation method for each. There is also a nutritional chart comparing what's in them (maddeningly, however, it uses ounces which makes it difficult to compare with scientific data on formula composition).

Protein
Now, the WAPF cow's milk and goat's milk formulas are certainly better than the crude recipes your grandma might have used--the sort where you just watered down evaporated milk and then bunged in a bit of sugar. Like commercial formula, the WAPF recipes get you to "rebalance" the casein-whey ratio, by making a separate batch of curds-and-whey (remember Little Miss Muffet?) and then adding some of that whey into your formula mixture. The actual amounts of protein also turned out to be comparable with commercial formulas, when I checked. So far, so good.
UPDATE: I've had a chance to read through some of the materials linked to me by Becky (the commenter below) on cow's milk in the first year. Cow's milk protein in the first year irritates the intestines and causes occult enteric blood loss in babies, meaning that their stools contain unusually large amounts of blood when examined. This over time can add up to substantial blood loss, greatly increasing the risk of iron deficiency anemia, which is strongly linked with mild cognitive problems later on in life. In commercial formulas, these milk proteins are heat-treated, making them easier to digest and minimizing blood loss. As I discuss below, the WAPF milk-based formulas are already low in iron; the fact that they contain elements which could cause the baby to loose what little iron they have must be considered a further strike against using such concoctions. And I think this also ties in with what I talk about in the final section--that when it comes to infant formula, processing is generally a good thing.

Raw milk
It is concerning, however, to see that WAPF is advocating raw (unpasteurized) milk for babies. When a person consumes raw milk, there is a small but real risk of infection which can have very serious consequences including organ failure, as the Real Raw Milk Facts website explains--no matter how clean the milking barn is. And most adults who drink raw milk are only having the odd glass. A baby is getting many bottles of milk a day--the chances of coming across a bad batch sooner or later are going to add up fast.

Sodium
One reason you shouldn't feed straight cow's/goat's milk in lieu of formula/breastmilk is their high sodium levels--about 430mg per 36oz (compared to breastmilk's 180mg). Commercial formulas, when I did the calculations, ranged from 180-360mg per 36oz. So the sodium levels in WAPF's milk-based formulas--308-320mg--seem to be fine.

Iron
Breastmilk iron is unusually bioavailable--there doesn't need to be a lot of it. Formulas need more iron in order for baby to get enough. Commercial ones usually have around 3.5mg per 36oz in the case of low-iron formulas, and up to 14.5 mg in the high-iron types. WAPF's cow's milk and goat's milk formulas, however, contain only 1.4mg and 2.2mg per 36oz, respectively, which looks rather low to me. The WAPF does emphasize that parents should start egg yolk feeding at 4mo, which will certainly help, but I wonder how the baby is supposed to manage till then--or what happens if your baby just can't take a spoon at 4mo.

Vitamin A
Perhaps mindful of the low iron levels in its other formulas, WAPF have come up with a third formula--"Liver based." You make this one by grating raw liver into meat broth, plus vegetable oils and other things. This formula has more iron in it (and it's haem iron, which is well absorbed).

Unfortunately, the liver means it has potentially toxic levels of Vitamin A as well. 20,000iu of Vitamin A per 682 calories means 2,933iu per 100kcal; meanwhile, "Toxic manifestations have been reported in infants when the daily intake was 2,100 iu/100 kcal or higher." I can't really imagine that very many people are actually going to bring themselves to feed their baby a pureed liver concoction all day long, but I do think it's a bit scary to think that if you followed WAPF s instructions to the letter, you could risk poisoning your child. Of course, a few decades ago, mega vitamin doses were very much the thing; I remember my mum's Adelle Davis books recommending that readers take some truly scary amounts of Vitamin This and That. Since then, the pendulum has swung very much towards recommending low doses of vitamins only; high doses of Vitamin A in particular have come out very badly in recent times, including concerns about teratogenicity (birth defects) in pregnant women; that's why pregnant women are supposed to take prenatals (with special low Vitamin A) rather than normal vitamins.

Other nutrients
Most of the micronutrients in the formula seemed to be higher than comparable amounts in commercial formula, when I did a comparison. One or two--like Vitamin E--were lower. Other than the scary liver-Vitamin A thing, I can't see anything here that would cause acute toxicity.  Still, from a long-term perspective, I think I'd rather feed my baby something where the levels of all these nutrients have been balanced reliably and consistently to just the right levels, based on research by dietitians.

The advantage of manufacturing formula using artificial vitamin and mineral drops and powders is that if you want to add exactly such-and-such amount of, say, manganese, you can go ahead and do just that. When you use natural materials, anything you add tends to come packaged with other nutrients, which then throws the mixture's balance off. Like... okay, one can boost the iron content of a formula by adding liver. But that iron comes bundled up with way too much Vitamin A. Or, perhaps we could bump up the rather low vitamin E level by adding more vegetable oil? But then the mixture might face composition/texture problems such as excessive oil separation. We could add something else to deal with the separation issue... but then you're inadvertently adding other nutrients. And so on. And the more steps and ingredients you have, the more opportunities for errors. I just think it's going to be really, really difficult to produce a well-balanced and foolproof formula on a home-kitchen scale.

Margin for error
Honestly, though, in a way the recipes themselves are less scary than the comments below. People saying stuff like "We have been using the cows milk formula and have replaced the yeast with vitamin b and maple syrup..." "My bottle of yeast flakes was crushed entirely in my check-in luggage; is yeast flakes absolutely required for this recipe or can I do without it for 3 weeks?" "I have been feeding our adopted newborn the goat milk formula since he was 3 weeks old. I did not realize that I was supposed to wait on giving him the cod liver oil until he was 3 months old. Have I done something dangerous to his health?" "I increased the cream by a tablespoon because he is a big boy..." "How about coconut nectar from the company called coconut secret? Just ideas....." "I noticed that it had curdled almost, more like became gelatinous...is this suppose[d] to happen?" Seriously, people, why are you even asking these questions? This is your baby's lifeblood we are talking about, not a fun baking experiment. The newborn period is a time when most of us feel like we deserve a round of applause just for getting a simple meal cooked. Creating formula using all these elaborate rules when you are sleep deprived seems like an invitation to disaster (especially when one considers how many parents make errors even with commercial infant formula preparation).

The food that breaks the rules
Formula breaks all the rules of normal food. We all know these rules: "Cook food at home," "Use real produce," "Eat fresh food," "Try to eat foods with as short an ingredients list as possible" and so on. But formula is a food with a unique job to do: it's got to mimic a natural food (breastmilk) as closely as possible. So the processing that commercial formula undergoes and the long list of ingredients on the package are good things; they make the formula more like breastmilk and less like cow's milk. A simple homemade formula using fresh materials is likely to behave less like breastmilk, and is therefore less suitable for a baby.

To be fair, the WAPF's milk-based formulas (as opposed to the scary liver puree thing) don't look to me like they could induce toxicity in an infant, which fits in with the fact that many people do use these formulas and their babies seem perfectly alright...although to be honest, the impression I get from the comments on the WAPF page is that the greater part of parents using homemade formula are doing so as a supplement for a predominantly breastfed infant rather than as a full-time thing, which would greatly reduce the risks. In a situation where commercial formula and donor milk weren't available (and yes, this can happen: after the earthquake in Japan around the time I gave birth, formula started disappearing from the shops due to distribution problems and panic-buying) I have no doubt that something like the WAPF cow's milk formula, with pasteurized milk, would keep baby ticking over OK until supplies resumed. However, I'd really question the utility of using homemade formula by choice in peacetime conditions.

The optimal milk drink for a baby is breastmilk, but if a mother can't nurse or prefers not to, I think the next best thing is a commercial infant formula correctly made up. Buy a tin and follow the instructions on the label. Done. This is one of those pleasantly hedonistic moments in childrearing where the easiest approach is actually the best and safest too. Making your own formula falls into that interesting category known as "Putting a lot of effort into actually making your parenting worse." It's complicated, there's no evidence it's any better, and there's at least some indications that it may be less well balanced and riskier.


Further reading

*Best For Babes's take on the WAPF bust-up
http://www.bestforbabes.org/from-karo-syrup-to-goat-milk-the-formulas-may-change-but-the-booby-traps-remain-the-same

*More discussion at Unlatched
http://unlatched.wordpress.com/2013/04/02/the-weston-a-price-foundations-dangerous-breastfeeding-advice-should-not-be-ignored/

*Vitamin A toxicity
http://www.medceu.com/index/index.php?page=get_course&courseID=3903&nocheck

*Commercial formula composition
http://www.espghan.med.up.pt/position_papers/con_23.pdf

*Real Raw Milk Facts website
http://www.realrawmilkfacts.com/raw-milk-hot-topics

*Cow's milk induced intestinal bleeding in infancy
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1029246/pdf/archdisch00547-0084.pdf

We can't wait for clean water

I think it was that photograph that did it. Tinderbox, Craig Timberg's masterly work on the HIV/AIDS epidemic in Southern Africa was, as you might expect from such a subject, a book with a lot of very, very sad stories; however, there was only one that actually brought tears to my eyes. It was the story of Chandipiwa Mavundu who lost her baby Kabelo at age eight months. The book showed a picture of Mavundu standing in front of her Botswana home, holding a photograph of herself and Kabelo--the only photograph of him she owned. I'm trying to imagine what it must be like to be left with only a single battered snapshot of the baby you knew and loved and played with for eight months. How she must treasure that picture.

But Kabelo's death was not caused by AIDS; it was caused by a waterborne diarrheal disease. The water made Kabelo sick because Mavundu had been advised by her healthcare providers to bottle-feed him, to protect him from the HIV that lurked in her milk. Mavundu had no idea that the WHO were now recommending that HIV-positive mothers in developing countries breastfeed because the risks of bottle-feeding in such circumstances outweighed the risks of HIV.

I'm repeating this story here as a kind of "Lest we forget."On this blog, I quite often write posts that attempt to puncture what I consider to be bad science or misconceptions that overstate the benefits or importance of breastfeeding. As a result, it can be easy to lose sight of the fact that not all benefits claimed for breastfeeding are urban legends or exaggerations. Sometimes they are both real and life-saving.

What's the real killer--the formula or the dirty water?

In the last month or so, there's been a lot of coverage on the dangers of bottle-feeding in resource-poor settings, including the Guardian's discussion of the appalling behavior of formula manufacturers in Indonesia, and Save The Children's "Superfood" report, a 75-page paeon to the life-saving potential of "optimal breastfeeding" (early initiation and exclusive-for-six-months) in developing countries. It called for a number of strong measures to support breastfeeding, including obligatory WHO Code-compliance by formula manufacturers and stern-sounding warnings about the dangers of bottle-feeding on formula tins--even in developed countries. Needless to say, all this resulted in some lively discussion, including commenters on the Fearless Formula Feeder's Facebook page and a fierce debate on Mumsnet on whether the site should support STC's initiative as an official Mumsnet campaign.

Both breastfeeders and formula feeders alike on these sites expressed near-universal disgust at the tactics of Nestle, Danone and others in developing countries, and supported tougher measures against them (I couldn't agree more). Some posters, however, also expressed a bit of (understandable) annoyance at certain aspects of the "Superfood" report, which was perceived as having gone a bit too far in eulogizing breastfeeding and in failing to make adequate distinctions between the benefits of breastfeeding in poor countries and in rich countries. I'd broadly agree with this too (Suzanne at the The Fearless Formula Formula, by the way, has done a better job of setting out some of the "issues" than I could). And one point brought up by several commenters was "Look, what's the real killer here--the formula or the dirty water?"

Just going back to Kabelo for a moment: Kabelo's death probably could have been avoided had he been breastfed, sure. Yet there is no suggestion that there was anything lethal about the formula powder provided by Botswana's government. Kabelo's bottles only became deadly once the powder was mixed with contaminated water. Perhaps--and this is a commonly heard argument when this topic is discussed--rather than focusing our efforts so much on promoting breastfeeding in developing countries, we should be shifting our resources towards cleaner water instead--something that the "Superfood" report doesn't even mention? On the face of it, this seems like a very reasonable argument. After all, increasing breastfeeding would only benefit babies--what about other age groups? What's going to happen to those breastfed babies once they're weaned and exposed to dirty water anyway? Surely focusing on breastfeeding and ignoring the sanitation problem is merely delaying all these deaths, not preventing them. And making sanitation the key would help women in poor countries who have to formula feed--because they don't make enough milk or because they work as cleaners or shop assistants or maids (rather than as subsistence farmers).

Not a superfood.... but an impressive logistical system

Now, getting clean piped water and sewerage system into developing countries is a worthwhile endeavor, to say the least. No, not worthwhile--crucial and life-saving. NGOs and aid agencies think so too; indeed, many of these organizations devote their efforts to nothing else. But getting clean water and sanitation into developing countries is a long, slow, upward struggle. Many countries will not get there within our lifetimes. Meanwhile, we have babies dying from contaminated bottle-feeding right now. We need to be practical.

I don't believe breastmilk is "superfood." I mean, I find the very word "superfood" pretty risible--perhaps because I associate it with those Daily Mail articles touting one food after another (wheatgrass, quinoa, coconut oil, flax seeds, you name it) as the One True Elixir that, when consumed, will prevent cancer, cure acne, raise the value of your house by 15% or more etc., etc. However, I am impressed by the logistics of I like to call the "breast-to-mouth delivery system." This is, when all is said and done, a system in which the milk (with or without magical properties) is provided clean, without the need to be poured into a container or to sit at room temperature, and where the supply is not going to get watered down or stopped altogether because hubby decided to buy a transistor radio or a bottle of whisky instead. Even if it turns out that breastmilk itself has zero immunological properties and is in practical terms no different to formula coming out of a boob--well, a low-tech, readily available system that churns out clean formula correctly made-up and served in a germ-free container is in itself not to be sneezed at.

Plumbing is not a silver bullet either

As Timberg describes in Tinderbox, Mavundu's homeland of Botswana is no war-torn hellhole, but a peaceful and fairly prosperous African country which has never been at war, and which has decent infrastructure and governance and a very large middle class. So even after the WHO shifted policies towards recommending exclusive breastfeeding for HIV-positive mothers in poor countries, Botswana's government decided to keep going with its policy of telling such women to bottle-feed, confident that its networks of piped water, roads and electricity would keep formula feeding safe. 

Unfortunately for Kabelo and other babies like him, it turned out a bit of plumbing is not enough to ensure safe bottle-feeding. Flooding caused bacteria from underground latrines to leach into the piped water supply. Around 20-30% of the bottle-fed babies (but very few of the breastfed ones) in affected areas died in the outbreak, the fallout of which shook Botswana's confidence in its formula-feeding program. This kind of thing seriously calls into question the idea that we can make formula feeding safe by just getting a bit of simple infrastructure in. If even Botswana with all its advantages cannot really manage safe formula feeding when all's said and done, that doesn't bode well for the rest of the Bottom Billion.

Now, I have spent a fair amount of time in several Bottom Billion countries (Cambodia, remote bits of China/Central Asia and bush country in Papua New Guinea) because pre-baby I used to travel a lot. And I'll tell you what: it makes me bloody scared even to think about trying to prepare a baby's bottles in these sorts of environments. It's not just the lack of piped water. It's the difficulty of securing reliable supplies of formula in remote areas. The poor literacy and difficulty in understanding preparation instructions. The way everything gets dirty, constantly. The way there are flies and insects everywhere, and food and drink goes bad at unbelievable speed (no fridge-freezers here). The way in which men tend to commandeer family resources, and things that mothers and babies need tend to get "forgotten about" when the blokes want to buy alcohol and cigarettes. I wouldn't even want to bottle-feed a baby in most of China, where most people have piped water.

Babies (especially in the newborn phase) tend to snack on bottles, get bored, leave half the contents, then wail for another feed an hour later. But formula has to be thrown away within an hour of preparation to avoid dangerous multiplication of bacteria. Even formula feeders in developed coutnries--for whom baby milk represents only a small fraction of their spending--get frustrated at the amount of formula they end up throwing down the sink. Now imagine you're a poor family for whom formula represents a big, big hole in the family budget. How likely is that half-finished bottle to get thrown out after one hour... or two hours... or longer? Now imagine a kitchen with flies buzzing around and a bottle that wasn't properly sterilized in the first place. You're looking at a lethal health crisis in the making. Even when the water itself was reasonably clean to start with.

Delaying deaths and zero-sum games
The breastfeeding thing and the clean-water thing are not (or should not be) a zero-sum game. Just taking Save The Children as an example once again: if I thought that STC were using its breastfeeding-advocacy stance as an excuse to cut back on its development work in the domains of water and sanitation, I'd be pretty pissed off too. However, looking at the STC website I see no evidence that this is the case--STC has a long and distinguished history of sanitation work and there's no sign that this is changing. There's no discussion of clean water in the "Superfood" report because it's not the subject of that particular report.

And I don't think encouraging breastfeeding in dirty-water regions will just delay the wave of child deaths by a year or two. Deaths of kids under five are not distributed evenly across the five-year period; 43% of child deaths under the age of five take place during the neonatal period. Being confronted with contaminated water is a health risk for human beings at any age, but a toddler or preschooler has a much greater chance of surviving such risks than a newborn does. In terms of "lives saved per $1,000 spent," I would argue that increasing breastfeeding in poor countries therefore offers very substantial bang for your buck.

Not a superfood, but...
Breastmilk may not be a superfood, but it does appear to have some useful and proven immunological properties, such as the way certain compounds work to reduce the risks of diarrhoea and pneumonia. Sorry, but even I accept this as fact (and I'm really, really far from being a magical-thinking lactofanatic). So does Joan Wolf, author of Is Breast Best, by the way; she states that "Breast-feeding’s advantages are most plausible in reducing gastrointestinal infection... Research has shown how antimicrobial proteins in mothers’ milk, specifically secretory IgA and lactoferrin, act as protective agents in the gut." Significantly, breastfeeding in resource-poor environments also dramatically lowers a baby's risk of developing pneumonia--a non-waterborne disease--and breastfed infants in poor countries who do get pneumonia tend to suffer from it for shorter periods of time.

Now, I would say that a baby can manage pretty comfortably without IgA/lactoferrin action in a developed environment where there are few life-threatening infections (the PROBIT study--the nearest thing we have to a randomized control study of breastfeeding in a developed country--found no breastfeeding advantage for pneumonia; there was an advantage for gastro episodes, but such illnesses are seldom really dangerous in developed countries). But in a sewage-infested slum or swampy stilt village, baby needs all the help he or she can get. The size of the disease burden in poor parts of the world needs to be fully appreciated. I remember how when I was traveling, I could count on one "fairly serious illness" for every time I visited a Bottom Billion country--dysentery (with heavy bloodloss) from Xinjiang, a massive, weeping tropical sore on my leg that lasted for months and gave me a high fever from Papua New Guinea... I could go on.

Let's not throw the breastmilk out with the dirty drinking water
I started this blog with the aim of questioning some of the myths and misunderstandings about infant feeding that float around the internet. In fact, a number of skeptical and science-based parenting blogs, websites and individual voices have been questioning some of the excesses of the breastfeeding advocacy movement in recent years. This is an important trend. Nevertheless, we need to be careful that we don't fall into the trap of assuming that because some of the claims made about breastmilk/breastfeeding are bullshit, this necessarily means that any claims made about breastmilk/breastfeeding must be bullshit.

And breastfeeding enthusiasts also need to be more aware of their own responsibility in this process. I don't agree with everything The Skeptical OB says, but I think she had a point when she discussed in "Lactivism and reefer madness" how overblown claims by breastfeeding advocates can fuel cynicism and backlashes as people start getting cross and disbelieving everything lactivists say. I'm pretty sure the Save The Children report would have attracted more wholehearted support (including Mumsnet-campaign backing) and fewer "Yes, but..."-type reactions if it had not included demands for harsh warnings on formula tins in developed countries (which was absolutely guaranteed to piss formula feeders off--seriously, did nobody at STC think about this?), had distinguished more carefully between breastfeeding benefits in rich and poor countries and had refrained from using silly words like "superfood" and "silver bullet."

Evidence-based infant feeding politics is an area where it is incredibly difficult to get the balance right. I know this because I've rewritten this post about twenty times over the last week. It's difficult because: when we find data that indicates that "Breastfeeding is no better than formula feeding for XYZ" we have to try and present it in a way that doesn't undermine systemic support for breastfeeders or make it sound like breastfeeding mothers are wasting their time; when the evidence suggests "Breastfeeding is superior than formula feeding for XYZ," we then have to try and discuss this in a way that doesn't upset bottle-feeders. We have to try and support measures that keep babies in poor countries safe, without throwing rich-world formula feeders under the bus. We have to be skeptical without turning into bristly reactionaries. It's hard to get all this right. All we can do is keep an open mind (yet not so open that our brains fall out), keep our eyes focused on the data, and try our best.

In which I eat humble pie (and also agree to disagree)

Back in November 2012,  a couple of articles in the press by two well-known babycare writers (Miriam Stoppard and Robin Barker) inspired me to write a post called When mainstream babycare gurus go bad. Shortly afterwards, Ms. Barker herself actually emailed me. Here's our (very slightly edited) exchange.

Hi there, 

 For starters I am not well into my seventies, sixty-eight to be exact. Unlike many others who produce parenting tomes, I have thirty years of hands-on professional experience helping parents in the first three years. I also have had two children and two grandchildren who I spend a lot of time with.   Secondly, I am well aware that the piece on The Drum was extreme. Did I have a moment of aberration? Or is it indeed senile dementia? No, not really. 

I was asked to do the piece after one of the editorial staff on The Drum was horrified by the breastfeeding stats they saw published by whoever published them. I decided to put out some extreme ideas to see what the response might be. In actual fact, extreme though my ideas may have been, there was a poor response, judging by the number of comments published on The Drum – good responses on that site generate 400+ comments, my breastfeeding views, a miserly 100+. Most people couldn’t give a toss one way or the other. 

The thing I was interested in is this: the importance of breastfeeding is religiously trotted out by communities and governments alike yet the number of women breastfeeding much beyond an initial burst has not increased in over fifteen years and doesn’t look like it ever will. Does this matter enough to put in place some of the ‘extreme’ ideas (which I don’t necessarily support) I listed? I was keen to make the point that communities and governments would need take a radically different path – a path I am aware is almost certainly unacceptable – than what is currently being pursued if we are truly serious about the ‘importance’ of breastfeeding. 

The other thing I am always intrigued by is this: the less breastfeeding there is, the more infant food manufacturers stand to gain financially so why is it they emerge as the understanding compassionate goodies while anyone who goes out on a limb about supporting breastfeeding (zero financial gain)  becomes the enemy whose sole aim in life is to ‘make mothers feel guilty’. 

The general ignorance about infant formula is mind boggling: the experimental nature of the product - bearing in mind that for  babies not breastfed (currently the majority) it is, in their first four months or longer, their only food (so let’s hope the manufacturers get it right); the assumption by parents that ingredients generated from fish oil, egg yolk lipid, fungus, marine algae and inert plant yeast are equivalent to their counterparts in breastmilk; the now embedded notion that infant formula is an essential part of infant feeding; the push to make formula a necessity right through the toddler years; the subtle advertising of formula that undermines breastfeeding every step of the way are all aspects of artificial infant feeding the majority of parents appear to be unaware of. Depending which way you look at it, infant formula marketing has been a huge success, breastfeeding marketing mostly an abject failure. 

I think you say you have never read my book Baby Love. It is popular in Australia because my work entailed, unlike Penelope Leach and others you mention, seeing many parents (mostly mothers) and babies every day for many years. It was my job to help them in the particular circumstances they found themselves in. I helped many women to breastfeed through a myriad of difficulties, I helped many women through the distress of weaning, I guided many women in the best use of infant formula. My book reflects the numerous dilemmas and options available in caring for babies in the first year. I am above all uncritical, practical and pragmatic but that doesn’t mean I enjoy sitting back and seeing infant food manufacturers getting away with what they get away with, largely on account of the general apathy and ignorance concerning infant feeding, and the false notion that supporting breastfeeding is a whip to beat recalcitrant mothers about the head with. 

Please publish this on your blog. 

All the best,

Robin Barker plus all her marbles

My response:

Why yes, I did just randomly add a nice photo of some jellyfish. Jellyfish are pretty and make everything more awesome.

Dear Ms. Barker, 

First of all, my sincere apologies for the extreme delay in reply! I will be honest--I added an "email for inquiries" to my front page (thinking, "This will brighten up the blog a bit!") and then promptly forgot all about it since I had too many other things to think about... such is the life of the working mother, I fear. 

Anyway, thanks for getting in touch and for taking the opportunity to give me your own side of the story. First off... my comments about age were clearly (a) inaccurate (b) pretty discourteous, now I reflect on them (especially since I did after all start my blog with the hope of creating some science-based dialog, not flippant remarks or ad hominem attacks etc.). So, as they say, "Point well taken"; that was not a courteous way to speak at all, and I apologize. 

Regarding your other points: I see that you yourself are not in favor of formula-on-precription-only (which I am relieved about, as I maintain that such strategies would be both dangerous and unnecessarily shaming to formula-feeding mums). I guess my own slightly waspish reaction also needs to be considered in the context of the debate surrounding infant feeding in recent years. Perhaps it has a lot to do with the rise of the internet as mums' main source of information, but the rhetoric of a lot of breastfeeding advocates seems to have become more and more extreme... and it's not unusual to hear people seriously advocating for such extreme measures as formula-on-prescription-only, forcing bottle-feeding mothers in hospitals to listen to lectures or to bottle-feed only in places where other mothers can't see them. So upon seeing your article and the mention of prescription-only formula, my overwhelming feeling was one of "Oh God, not Robin Barker too?? I'd always been told that she was one of the sensible breastfeeding advocates....!"

The exclusive-breastfeeding-to-six-months is, I'm afraid, also one of those things that tends to touch a nerve with me for personal reasons; I started solids a bit earlier than that as a carefully-researched decision, not because of commercial pressures, and tend to get a bit defensive when I hear governments using the six-month thing as a barometer to judge breastfeeding rates, because it makes me feel as though I'm being told that all the milk I was pouring into her somehow doesn't count. So I maintain that there are saner ways to measure breastfeeding rates in developed countries; perhaps measuring to four months, or having a definition of "exclusive" that included up to one bottle of formula per week or something. Who knows....

I do hear you on the fact that there are tremendous commercial pressures that exist behind formula and baby foods (though I don't know if it's true to say that there is no money to be made from breastfeeding either... lactation consultancy and so on have become pretty big businesses). I guess the trick is to try and find a balance between protecting breastfeeding AND making sure that women who want to or need to use formula are able to do so without feeling harassed. It's a difficult issue, that's for sure.

You are correct that I haven't read your book; I included it on my list of go-to resources on the advice of a couple of online friends who liked it a lot. I hope to get round to reading it soon (still working my way through quite a list of books right now, mind you) and if I find it a useful resource I'll do the right thing and put it back on the list. Let's face it, if I were to remove every book/resource whose author had at any time said anything I (slightly) disagreed with, I'd have a very short list indeed.

Anyway, I'd be happy to include your side of the story on the blog. Hope this is a constructive response--I like to think blogging is about having a conversation, rather than running a "bully pulpit"! Please enjoy the rest of the summer in Australia.

Best wishes

Breastfeeding Without BS

I'm publishing this particular exchange at full length not only because Ms. Barker asked me to in order to present her side of the story, but also as a little reminder to myself of the importance of maintaining courtesy when blogging--not just because behind the author, journalist or activist we are sniping at is always a real person with feelings, but also because I want this to be an evidence-based blog... and that means sticking to the evidence, not resorting to attacking other commenters on the grounds of sex, age, religion or anything else. Even when disagreeing with someone (and Ms. Barker and I definitely do disagree on several points here, including the validity of some of the ingredients in infant formula and the notion that breastfeeding is in retreat, at least in developed countries) we need to do so with courtesy and empathy for the other person.

Are three breasts better than two?

As we all know, toddlers like to switch sides when nursing--sometimes to the point of driving Mummy mad. Why have one breast when you can have two? Little Seal, however, seems to feel that even two breasts are not enough--she not only switches from right to left incessantly, but has also developed a bizarre habit of rooting around in my armpit and screaming in protest at the fact that I don't have another mammary gland for her under my arms (what a mean Mummy).

One day recently when she did this, my mind suddenly flashed back to something I'd read a while back about how a lot of women have rudimentary breast tissue in the underarm area, which is why swollen armpits are common when your milk "comes in." A google search soon plunged me into the bizarre world of multiple breasts.

Turns out the swollen-armpit thing is just the tip of a large and varied iceberg. Somewhere between 1% and 6% of all women have some degree of supernumerary breast tissue. In most cases (polythelia) this is just under-the-surface tissue, but in more extreme cases (polymastia) you have actual nipples as well--sometimes forming very noticeable extra breasts. These are most often found along the "milk lines"--pathways stretching from the groin up into the armpits. Litter-bearing mammals, of course, normally have milk-bearing teats up and down these lines; at some point in the evolutionary process our mammalian predecessors lost all of these except two. Charles Darwin considered the appearance of multiple breasts in humans to be an example of atavism--the survival or reappearance of a primitive trait in a more "highly-developed" species, like, for example, the occasional human baby that is born with a tail. (Could Little Seal's armpit-rooting be a kind of vague instinctive memory left over from the time when our furry ancestors actually had functioning breasts going up and down their abdomens? Who can say?)

The "throwback" theory is lent credence by the embryonic development. One of the eeriest things about pregnancy is the way the embryo's development over the weeks and months seems to repeat evolutionary history in miniature--the unborn child develops a tail which then falls away, and later grows a coat of fur which is then shed and reabsorbed, and so on. Over the first couple of months, "milk lines" in the fetus develop into mammary ridges, but in around the ninth week all these ridges recede and disappear except for the two which later become the "breasts" we are familiar with. In a few embryos, presumably, the surplus ridges do not fully disappear and instead continue to develop into rudimentary breasts. The atavism theory has appeal, but it doesn't seem to fully explain the extra-breast phenomenon, given that such tissue can also appear outside the milk lines--on the legs, in the groin and even on the sole of the foot.

As I mentioned above, it's not unusual for women to report swollen armpits at the very start of breastfeeding, and droplets of milk leaking from the armpits are far from uncommon (judging from all the questions on Yahoo Answers--that perennial mecca for people with weird and embarrassing body-related questions). In extreme cases, extra breasts have been known to have fully functioning nipples and produce useful amounts of milk.

An often cited case from 1827 refers to Therese Ventre of Marseilles, France. Her mother had a supernumerary breast beneath her normally positioned right breast. Ventre had a supernumerary breast beneath her normally positioned right breast. Ventre had a supernumerary breast on the side of her left thigh. This breast enlarged during puberty, and when she became pregnant, it produced milk. It was offered to her infant who took it willingly. She apparently nursed five children during her life from all three of her breasts. (Southern Medical Journal Supernumerary Breast Tissue: Historical Perspectives and Clinical Features, Department of Pathology and Laboratory Medicine, Emory University School of Medicine)

In our own time, however, extra breast tissue is more likely to cause issues with breastfeeding. In several cases, women presenting with swelling under the arms have had the sites biopsied, only to reveal that the lump is merely extra breast tissue and that milk is now leaking uncontrollably from the site of the biopsy--a "milk fistula." Breastfeeding Materials advises that such milk is likely to dry up on its own, just as any milk supply will ultimately dry up if there is no suckling; however, in this case here, the mother's milk fistula did not cease until she finally weaned her baby. Presumably, her accessory breast and normal breasts had enough tissue in common that they shared the same feedback mechanism, and stimulation of the regular milk supply thus tended to stimulate the milk production in the armpit as well. Who knows? In any case, the good news is that this troublesome extra tissue was removed through surgery, leaving the mum free to nurse her future babies if she wanted.

Supernumerary breasts have, in some historical periods been associated with witchcraft--Anne Boleyn was rumored to have one, although that may say more about Boleyn's enemies than about Boleyn herself. In other times, extra breasts have been considered a sign of super-fertility (think of all those multi-boobed goddess figurines), but there's no evidence of this. On the contrary, there is some evidence linking extra breasts with elevated rates of certain congenital problems, especially abnormalities of the urinary tract such as "supernumerary kidneys, failure of renal formation, and carcinoma of the kidney."

So while the image of being able to feed a baby from multiple breasts is appealingly bizarre, it seems fair to say that in the real world, three breasts are definitely not better than two. Although most nursing toddlers and babies would probably disagree with me about that.

"We are a charity" is not an excuse for failing to listen to people

The National Childbirth Trust (Britain's largest parenting charity) is in the news again. It all started when pregnancy writer and blogger Linda Geddes appeared in a Radio 4 discussion about the NCT. As you'd expect from the author of Bumpology (a promising looking new book which adopts a science-based approach to pregnancy and birth), Geddes expressed some critical ideas about the NCT during the discussion, claiming in particular that the organization's classes gave her poor advice and unrealistic expectations due to their overwhelming ideological bias towards natural childbirth, discussed here and here. The interview might have passed without much comment had Kirstie Allsopp (a well-known British TV presenter) not tweeted about the show, echoing Geddes' criticisms and describing the NCT as "a very politicised, dogmatic and in my experience, scary organisation."

This is far from being the first time the NCT has been criticized for being overly obsessed with natural childbirth, breastfeeding at all costs and so on. Allsopp had another similar spat with the NCT last year, I had my own little go here, and this thread from Mumsnet gives a decent overview of the complaints that many NCT members have about the organization. Many women have fantastic experiences joining the NCT and participating in its classes and workshops because there are many great people who work with the organization. There are also a lot of crunchaloons who are giving the NCT a bad name. Every time the NCT is criticized in this way, the organization protests that the criticisms are unfair, that the organization is inclusive and is becoming more so, that they are making efforts to embrace different ways of giving birth and to expand beyond the "middle-class mothers" who make up their core group and so on. How genuine these protestations are is kind of questionable, however, as Pauline Hull of Cesarean Debate recently pointed out.

But there is one defense of the NCT which I'm constantly hearing, and it is really starting to annoy me: the defense that "These complaints are unfair. NCT is a charity, not a business, and it's staffed by volunteers, many of whom are mothers themselves. You can't expect it to be run perfectly."

Now, here's the thing. If you talk to anyone who has worked on the ground in, say, the developing world or among disadvantaged groups anywhere, they will tell you that this kind of attitude is at the heart of what is wrong with so much charity and philanthropic work--the idea that charities (unlike businesses or governments) do not have to be accountable for their actions or responsive to feedback, the idea that people receiving charity should be grateful for whatever they get (even if it's crap), the idea that that it doesn't matter if charities upset people because even badly-run charity work is better than nothing at all, and the idea that ITS MEEN to criticize anyone who works in a charity, because charity workers do nothing except from the goodness of their hearts and you surely can't have a problem with that, right?

Well, actually it's all a bit more complicated than that. Because the problem is, charities have their own agendas which are sometimes not completely altruistic--for example, trying to further their own political, social or religious views (fundamentalist churches "fighting AIDS in Africa" through abstinence-only education being merely one of the more egregious examples). Sometimes charities do actively harmful things to the people they are trying to help, often as a result of these agendas, which means that it's not always true that bad charity work is better than nothing at all. Sometimes, bad charity work is indeed better than nothing at all--but that doesn't mean that it couldn't be better, or that charities shouldn't be aspiring to do better. No private-sector business would be okay with the sort of feedback the NCT was getting from a lot of posters on that Mumsnet thread. Maybe the NCT could do with operating a bit more like a business--a process that starts with listening to the people you are supposed to be serving.

In any case...take a look at the sort of complaints being levelled at the NCT in that Mumsnet thread. I mean, if most of the complaints about the NCT were things like "the venues for the classes are cramped" or "my email inquiry didn't get answered straight away," well... okay, maybe these issues would be somewhat understandable in an organization run by volunteer mums in their spare time. But I really don't see how complaints about instructors demonizing cesarean sections, epidurals and bottlefeeding in NCT classes have anything to do with its charitable status. There is no reason on earth why an unpaid volunteer can't give classes and workshops that offer a balanced view of birth and infant feeding; it's not as though it would cost more to do this. (And to be fair, many or most NCT instructors are offering reasonable and balanced advice; it's just that the NCT doesn't seem to be very good at weeding out the instructors who spend their classes beating the "obstetricians-are-out-to-get-you" tom-toms and telling mothers that they won't bond with their babies if they have surgical births, etc.)

If there are some NCT instructors who are saying things that are contributing to depression and anxiety in new mums, and if the NCT is failing to do anything about this because of its agendas and beliefs, then that is a problem, regardless of whether or not the organization is a charity or not. And the NCT needs to start engaging with this issue unless they want the complaints to continue and get louder.

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.