Studies in Rhetoric & Communication

Contemporary Controversies in Infant-Feeding Policy and Practice

Amy Koerber

• Publisher: University of South Carolina Press
• Year: 2013
• ISBN:
  9781611172461
• Topic: Languages & Linguistics
• Subtopic: Rhetoric
• Index: Languages & Linguistics

Breast or Bottle? is the first scholarly examination of the shift in breastfeeding recommendations occurring over the last half century. Through a close analysis of scientific and medical controversies and a critical examination of the ways in which medical beliefs are communicated to the public, Amy Koerber exposes layers of shifting arguments and meaning that inform contemporary infant-feeding advocacy and policy.

Whereas the phrase "breast or bottle" might once have implied a choice between two relative equals, human milk is now believed to possess unique health-promoting qualities. Although it is tempting to view this revision in medical thinking as solely the result of scientific progress, Koerber argues that a progress-based interpretation is incomplete. Epidemiologic evidence demonstrating the health benefits of human milk has grown in recent years, but the story of why these forms of evidence have dramatically increased in recent decades, Koerber reveals, is a tale of the dedicated individuals, coalitions, and organizations engaged in relentless rhetorical efforts to improve our scientific explanations and cultural appreciation of human milk, lactation, and breastfeeding in the context of a historical tendency to devalue these distinctly female aspects of the human body. Koerber demonstrates that the rhetoric used to promote breastfeeding at a given time and cultural moment not only reflects a preexisting reality but also shapes the infant-feeding experience for new mothers.

Koerber's claims are grounded in extensive rhetorical research including textual analysis, archival research, and interviews with key stakeholders in the breastfeeding controversy. Her approach offers a vital counterpoint to other feminist analyses of the shift toward probreastfeeding scientific discourse and presents a revealing rhetorical case study in the complex relationship between scientific data and its impact on medical policy and practices. The resulting interdisciplinary study will be of keen interest to scholars and students of rhetoric, communication, women's studies, medical humanities, and public health as well as medical practitioners and policymakers.

1

Infant Feeding and Rhetoric

An Overview

The recent intensification and proliferation of pro-breastfeeding messages in the United States can be traced to a highly publicized policy statement that the American Academy of Pediatrics (AAP) published in 1997. The statement urged women to breastfeed for at least the first year of the infant’s life and stipulated that breastfeeding is “the reference or normative model against which all alternative feeding methods must be measured with regard to growth, health, development, and all other short- and long-term outcomes.”¹ This statement represented a dramatic shift from the AAP’s previous position on infant feeding and is perhaps the most significant rhetorical event in the recent history of infant-feeding controversies in the United States.

To justify the organization’s dramatic shift in stance toward human milk and breastfeeding, the authors of the policy statement invoked a narrative of scientific progress. For instance, the statement begins with language that emphasizes the historical continuity of the organization’s stance toward infant feeding. The opening paragraph declares that the AAP has “from its inception… been a staunch advocate of breastfeeding as the optimal form of nutrition for infants” and that “the activities, statements, and recommendations of the AAP have continuously promoted breastfeeding of infants as the foundation of good feeding practices.”² The authors then proceed by attributing the academy’s new stance to “considerable advances that have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, in the mechanisms underlying these benefits, and in the practice of breastfeeding.”³ A 2005 revision of the earlier statement places a similar emphasis on scientific progress, claiming to reflect the “significant advances in science and clinical medicine” that had occurred since the 1997 statement.⁴ Based on the language used in this narrative, we might surmise that the medical community has always supported breastfeeding but recent advances in understanding specific health benefits have intensified that support. Although the current recommendations differ from older recommendations, such language suggests, the difference is incremental and by no means revolutionary.⁵

A similar emphasis on scientific progress and newly discovered evidence was echoed in many of our focus-group participants’ perceptions of current breastfeeding information.⁶ In the words of Rebecca, who was expecting her first child at the time, “now there are more studies going on and more information out there about the benefits of breastfeeding.” Another participant, Mary, had two young children when she participated in our focus group and had exclusively breastfed both children until the age of six months. Mary expressed a similar faith in the currently available scientific knowledge about breastfeeding: “That’s just magical about breast milk. It’s just so amazing. My friend went on a website, and she says there’s, like, a jillion benefits. They’re coming up constantly with all these benefits of breast milk.”

Many participants echoed the policy statements’ emphasis on novelty and scientific progress by stating that they felt fortunate to have access to more and better breastfeeding information than their own mothers had. As stated by Connie, a young mother who was expecting her first child at the time of focus-group participation, “I just get more information that my mom didn’t know then. She, you know, I tell her and she’s, like, ‘Oh, I didn’t know that.’” Andrea, who had breastfed her first child until the age of six months and her second child until the age of five months, also said that she had access to much better information than her own mother had: “I don’t think she had near the information I have. I don’t think there was any way she could have.” And Nancy, who had exclusively breastfed her child until the age of five months, agreed: “I think for my mom, it wasn’t the thing in her day either. And she didn’t really care about it very much in the first place, but now there’s so much education about the pros of it, that I think that a lot of women consider it.”

Some focus-group participants were even more specific in their references to recent discoveries about the immune-system benefits of human milk. For instance, Mary went so far as to suggest that her husband’s asthma could have been prevented if only his mother had had access to today’s scientific knowledge: “So many things, and just all the time if you, you know, log on. And my husband, who was not breastfed …, he’s asthmatic and they found that it prevents asthma. And that colostrum, they call it liquid gold and that actually coats their body and it helps their developing body and they just need all that. He was allergic to milk. He had all these things wrong with him. And I think breast milk would have prevented it.”

These mothers’ emphasis on novelty and advancement hints at the presence of a persuasive mechanism that Jeanne Fahnestock calls the “wonder appeal.”⁷ Such an appeal, quite typical in public representations of and responses to scientific knowledge, might suggest that the recent intensification of medical recommendations in support of breastfeeding has been the inevitable end result of a slow and steady climb toward a truer and better state of knowledge.

These mothers’ comments, when considered alongside the narrative of scientific progress that is used to justify the medical establishment’s increasing faith in human milk, raise some questions that serve as a useful starting place for a rhetorical investigation of infant feeding in the contemporary United States: How did we get to this moment? What does it mean to say that today’s new mothers have more and better information about breastfeeding than their own mothers did? What kinds of breastfeeding facts are being established and communicated today, and why were these facts not available a generation ago?

We can begin to address such questions by sketching the contours of, as Judy Z. Segal says, a “rhetorically tilted medical history” of U.S. infant-feeding policy and practice as that history has unfolded from the mid–twentieth century to the present.⁸ Attempting to “open up differences inside medicine and create better access to them” and to “interrogate that which is dismissed as ‘what everybody knows,’” we can identify three distinctly different topoi, or rhetorical commonplaces, that have provided the basis for experts’ arguments about breast- and bottle-feeding since the mid–twentieth century: the topos of breastfeeding as foundation in the mid–twentieth century, the topos of breastfeeding as the norm in the late twentieth century, and the topos of formula as risky in the early twenty-first century.⁹

Topoi have traditionally been understood as the commonplaces that serve as a conceptual inventory that speakers or writers at a particular historical moment can use to build their arguments. A particular topos can serve as effective material for an argument because it resonates as common sense with a given audience at a given place and time. However, to say that each of the historical moments examined in this chapter is defined by its own topos is not to say that other ideas have ceased to exist or to have any credibility at that moment. Rather, the notion of topos as rhetorical commonplace is meant to capture the predominant assumptions that shape what can be said and most readily accepted as true at a given historical moment—the argumentative material that is most easily available and, consequently, might ring true with a given audience at a given moment. The etymologic origins of topos link it to notions of physical place or space (as in topography, the study of place or, more specifically, physical features of a geographic location). So, in a quite literal manner, we might think of topos as a “conceptual place to which an arguer may mentally go to find arguments.”¹⁰ Taking a rhetorical approach to history, then, we might assume that a historical period is shaped by the kinds of commonplaces or stock material that are most readily available to the speakers and writers who are poised to make arguments on a particular subject in a particular place or time.

These connections to notions of place and physical location make the topos concept especially appropriate for conducting a rhetorical investigation of expert controversies on a subject such as infant feeding. The exact formulation of the concept has of course changed and evolved since Aristotle’s time, but the current understanding is that topoi serve simultaneously as a means of decorum (that is, reinforcing conventional ideas) and as a means of invention (that is, making new ideas possible). In other words, as speakers and writers build arguments from these old materials, they put them together in new ways that can and often do result in new ideas. Thus, viewing scientific history through the lens of topoi entails an understanding of progress in which the kind of novelty that is so greatly emphasized in current infant-feeding rhetoric is seen as deeply rooted in old ideas. This makes the topoi concept especially well suited for reconsidering the narratives of scientific progress and the “wonder appeal” that are prevalent rhetorical features of current infant-feeding discourse. In so far as such arguments are built, at least in part, from conceptual inventories that are already available, we must temper our judgments about the actual novelty of ideas that are touted as the latest and greatest. In the case of infant feeding, each of the three topoi examined in this chapter has shaped what kind of knowledge can be produced and how that knowledge can be communicated to various audiences at a given historical moment. We might say such ideas have literally formed the topography of the rhetorical landscape that has surrounded infant-feeding controversies at each of these historical moments. Whereas subsequent chapters will look more closely at the rhetorical events that have led these three different commonplaces to emerge, change, and evolve, this chapter’s aim is simply to introduce the three topoi as they have existed at different historical moments and to expose how each one has embodied its own unique set of assumptions for framing experts’ arguments about breast- and bottle-feeding.

An important theme that emerges is a decades-long, ongoing shift in the ways that science has been invoked by advocates of both breastfeeding and bottle-feeding. In fact, each of the three topoi might be said to embody a different set of possibilities for the type of scientific evidence that can be used in making arguments about infant feeding and a different set of rules for how such evidence can be invoked. In the mid–twentieth century, the preponderance of scientific evidence worked in favor of the formula industry. Starting in the late twentieth century, and continuing into the present, the situation has changed in ways that seem to be making the available scientific evidence more favorable to breastfeeding advocates; that is, breastfeeding advocates have been able to use scientific evidence in ways that support an increasingly sharp distinction between human milk and formula. Even as this change has occurred, however, the pressure on those who advocate breastfeeding has continued to increase, so that breastfeeding advocates have been required to make increasingly strong arguments to support their claims that human milk is superior to artificial substitutes. Examining how each of these three topoi has coincided with a different set of possibilities for invoking scientific evidence in the breast–bottle debate offers additional texture to the narrative of gradual, incremental scientific progress that is apparent in official policy language and also in the remarks of focus-group participants.

Mid–Twentieth Century:
The Topos of Breastfeeding as Foundation

Because breastfeeding as foundation is the oldest of the three topoi, medical historians have already done much of the work necessary to understand how arguments about breast and bottle were made and received in the historical era defined by this topos. Such historians generally agree that the question of which feeding method was best for babies was subject to a great deal of uncertainty in early and mid-twentieth-century infant-feeding science.¹¹ As a result, although early and mid-twentieth-century medical experts might have outwardly expressed their support for breastfeeding, they construed breastfeeding as a model that formula producers should emulate as they sought to perfect their products and that mothers should emulate if they chose to bottle-feed with formula. In fact, as medical historians suggest, although official medical policy throughout the twentieth century has consistently expressed support of breastfeeding, by the 1940s most U.S. physicians had come to accept the idea that mass-produced artificial formulas derived from cow’s milk could be a suitable, or even superior, substitute for human milk.¹² This belief created a rhetorical landscape in which breastfeeding and human milk often ended up being compared unfavorably to their artificial substitutes. Historian Rima D. Apple suggests that by the middle of the twentieth century many physicians were so enthusiastic about artificial formulas that they began to believe them superior to human milk, a belief that was reinforced by a number of studies that seemed to prove human milk unreliable because its vitamin contents were variable.¹³ Thus, most of the mothers of the women who are the targets of today’s medical discourse likely heard from their physicians that bottle-feeding with infant formula derived from cow’s milk was an adequate, or superior, substitute for breastfeeding.¹⁴

The early twentieth century has received a great deal of attention from historians of medicine because this was the first time in medical history that a commercially produced, widely accessible alternative to human milk existed, and, in the early twentieth century, companies producing formulas were beginning to promote them to physicians and parents alike. Although, as Apple indicates, official medical discourse continued to espouse the view that breastfeeding was the ideal form of nourishment for babies, the increasing availability and quality of this commercial substitute around the turn of the century allowed them to assure their patients that, if they did not want to breastfeed or if they were unable to do so, bottle-feeding was an adequate substitute. At a time when faith in both medical science and artificial products was on the rise in the United States, this advice was readily accepted by new mothers eager to make the right choices about feeding their babies.¹⁵

Another factor that historians have noted is that in the mid twentieth century the formula industry stepped up its marketing efforts. Such efforts often targeted physicians and hospitals directly by providing them with free samples to distribute to their patients. The formula industry also became more heavily involved in funding medical research on infant feeding. A common feminist interpretation relates the early twentieth-century decline in breastfeeding to the increasing medical control over childbirth taking place at that time.¹⁶ Indeed, bottle-feeding seemed more compatible with the medical model of childbirth and childrearing that was gaining increasing legitimacy in the early part of the twentieth century. If a woman bottle-fed, she could report to the physician exactly how much milk her baby consumed on a daily basis, and both mother and physician presumably could know the exact nutritional composition of what the baby was being fed. Giving the physician this kind of control over infant feeding was an important factor in the process through which pediatrics defined itself as a profession in the early part of the twentieth century.¹⁷ By contrast, human milk and the practice of breastfeeding seemed more difficult to monitor. This imbalance created a situation in which breastfeeding and human milk came to be viewed as imperfect and unable to achieve the level of quality that could be achieved in artificial substitutes. As stated in one early twentieth-century medical publication that has been noted by medical historians, “it is easier to control cows than women.”¹⁸ Many medical studies at the time supported the belief that formula could be a superior substitute for human milk, particularly when administered as part of a physician-supervised feeding program.¹⁹

In rhetorical terms, emphasizing weight gain and protein levels appears to have enabled physicians to navigate the uncertainty that pervaded medical experts’ discussions of infant feeding in the mid–twentieth century. Because there was so much uncertainty about the best feeding method, it appears that early twentieth-century physicians often looked to criteria that could be easily measured and monitored to make decisions about infant-feeding research and management. Apple’s historical analysis suggests that early infant growth often was such a deciding factor. A central focus of physicians’ concerns, according to Apple, was the observation that babies who were exclusively breastfed tended to lose weight in the first few days after birth, probably because mothers typically produce only colostrum, rather than fully developed milk, in these first few days. Physicians at the time believed colostrum contained little or no nourishment, and their fears were reinforced by the observation of initial weight loss in newborns who were exclusively breastfed.²⁰

This historical literature hints at what I refer to as the topos of breastfeeding as foundation. But to understand how this topos functioned to enable certain kinds of arguments and preclude other kinds, we must look more closely at some examples of mid-...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Contents
• Series Editor’s Preface
• Acknowledgments
• Introduction
• 1 Infant Feeding and Rhetoric: An Overview
• 2 From “Wives’ Tales and Folklore” to Scientific Fact: Rhetorics of Breastfeeding and Immunity in the Mid–Twentieth Century
• 3 Articulating Knowledge and Practice: The Rhetoric of Infant-Feeding Policy
• 4 Viral Rhetoric: Breast and Bottle in Current Promotional Discourse
• 5 Rhetorical Agency and Resistance in the Context of Infant Feeding
• 6 Feminism, Rhetoric, and Breastfeeding: Some Concluding Remarks
• Appendix: Research Participants
• Notes
• References
• Index