This article offers a quick big picture analysis of the formula dilemma. Yet the decision that exclusive breastfeeding is no longer possible often plays out in individual women's and families' lives in painful or distressing ways. I write to you about this more intimately here and here.

Women report four main reasons why they're unable to continue exclusive breastfeeding

In the research, parents report four main reasons why they need to supplement with formula or wean their baby from breastfeeding altogether.

Main reasons why breastfeeding women decide they are unable to continue exclusively breastfeeding	Most common underlying problem
1. Nipple or breast pain or damage	Nipple and breast tissue drag; breast inflammation
2. Difficulty coming on to the breast	Mammalian reflexes not switched on; breast tissue drag; landing pad encroachment
3. Fussing and crying at the breast	Nipple and breast tissue drag; conditioned dialing up at the breast
4. Low supply	Not offering the breast frequently and flexibly enough; poor milk transfer due to breast tissue drag

Why are rates of formula use so high when most women actually want to exclusively breastfeed?

In Australia, to give an example close to home for me, 96% of birthing women intend to breastfeed their baby. By the end of three months of their baby's life, only 39% are able to do so exclusively. This rate appears to have been more or less stable for many years.

The four main problems parents report, above, are not being effectively addressed because our health systems have profound blind spots about how best to help with breastfeeding problems. You can find out about this here.

Although the focus of unhelpful pathologising of breastfeeding women and their babies has shifted over the years (more here), overdiagnosis and overtreatment in the field of breastfeeding and lactation support has worsened throughout my life-time. This mirrors the growing international trend to overdiagnosis and overtreatment in health care more broadly, and is a symptom of our times of late capitalism, when unregulated market forces benefit those who are selling quick fixes, typically promoting them as 'evidence-based'.

Breastfeeding rates have not improved in a way that is commensurate with the dramatic increase in my life-time in numbers of providers offering services in the field of breastfeeding and lactation.

Why do families turn to formula rather than to donated human milk once they decide exclusive breastfeeding is no longer possible?

Many parents turn to formula rather than to donor breast milk when they decide they can't continue with exclusive breastfeeding, because

• Donated milk from milk banks is typically expensive and difficult to source

• Community-sourced breast milk may still bring inconvenience, complications, and risks which are unacceptable to some or many families, despite the importance of community-based initiatives to share human milk.

Health system solution #1 for decreasing formula use

I propose that our health systems and breastfeeding support professionals require training to identify and effectively help with the four main breastfeeding problems that parents report, above. This would prevent inappropriate diagnosis and treatment of various medical conditions (here) which the research shows typically doesn't help, results in side-effects or unexpected outcomes, and drives up costs. There would then be a dramatically reduced need for infant formula in our societies.

In the meantime, in the absence of political and health system will, we can only be grateful that the various formula preparations are safer now for feeding our babies than they were when I became a doctor in 1975.

Health system solution #2 for decreasing formula use

Similarly, if health systems were willing to invest in milk banks and the regulation of donated milk either in hospital or community settings, addressing affordability, convenience, and safety, then I believe almost all parents would choose donated human milk over formula. Again, this is not a problem caused by formula companies, but by political priorities and lack of government and health system investment.

Recommended resources

• You can listen to a podcast about how to minimise formula use in the first week of baby's life, at the same time as we maintain safety, with neonatologist Dr Danielle Freedman here. The transcipt is here.

• You can read about the timing of breast milk collection with respect to melatonin here and cortisol here.

• You can watch how to use the bottle in a way that most closely aligns to breastfeeding principles (known as paced bottle feedings) here.

Selected references

Australian Institute of Health and Welfare. 2010 Australian National Infant Feeding Survey: indicator results. Canberra: 2011

Australian Institute of Family Studies. Growing up in Australia: The Longitudinal Study of Australian Children, Annual Report 2006-2007. 2011.

Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, et al. Evidence for overuse of medical services around the world. The Lancet. 2017;390:156–168.

Douglas PS. Preventing overdiagnosis in the first months of life (abstract). BMJ Evidence. 2019:10.1136/bmjebm-2019-POD.1139.

Odom E, Scanlon K, Perrine C, Grummer-Strawn L. Reasons for earlier than desired cessation of breastfeeding. Pediatics. 2013;131:e726-732

World Health Organisation. Scope and impact of digital marketing strategies for promoting breast-milk substitutes. Geneva: 2022.

World Health Organization and the United Nations Children's Fund (UNICEF). How the marketing of formula milk influences our decisions on infant feeding. Geneva: 2022.

Armstrong N. Overdiagnosis and overtreatment: a sociological perspective on tackling a contemporary healthcare issue. Sociology of Health and Illness. 2020;43(1):58-64.