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. 

Mother's milk--and others' milk--in Japan

Any sharp-eyed person reading this blog will probably have noticed that I am raising my daughter, Little Seal, in Tokyo. I've never really talked about Japanese breastfeeding culture on this blog--probably because, in the self-perpetuating metaworld of the Internet I blog primarily about stuff I read about online (in English). Nevertheless, the "Japanese breastfeeding experience" has been one factor shaping my attitudes towards breastfeeding and breastfeeding advocacy; here are a few things that might be interesting to outsiders.

What Causes Low Milk Production?

Many mothers worry that they may not produce enough milk for their babies. Well-meaning friends and relatives share their own experiences or stories they have heard from others in an effort to prepare expectant mothers for the worst. Even before their babies arrive, mothers may hear alarming reports:

• "I tried to breastfeed, but I couldn't make enough milk."

• “My milk never came in."

• "My milk suddenly dried up!"

• "Your mother had to supplement, so you will, too."

Most mothers have heard at least one of these reports before their own babies arrive. The good news is that the majority of women can produce all the milk their babies need for healthy growth and development. More often than not, concerns about milk production are simple misunderstandings of normal newborn behavior or breastfeeding management issues that can be fixed. Rarely, a woman may have a physical or hormonal condition that makes it difficult to build or maintain milk production. One study suggests these conditions occur in about 5% of the population of women (Neifert, 2001). The following sections outline some of the medical causes of low milk production:

Maternal Conditions Related to Low Milk Production

Insufficient Glandular Tissue: During puberty, progesterone and estrogen signal the growth and development of the mammary (breast) glands. Active growth of ductal tissue takes place during each menstrual cycle. In rare instances, the glands do not grow or develop fully during puberty, and insufficient glandular tissue, known as breast hypoplasia, may result (Neifert, Seacat, & Jobe, 1985). Some women with insufficient glandular tissue may have breasts that are unusually shaped or appear not to be developed at all. Some women may have breasts that seem to be fully developed but have a limited capacity to produce milk because fatty tissue is present, but glandular tissue is not sufficient. During a normal pregnancy, glandular tissue continues to develop, and there is usually (but not always) a noticeable change in breast size, increased sensitivity or tenderness, visible veining on the breast, and darkening of the areolas. Some signs of breast hypoplasia are:

• “oblong”, tubular shaped breasts

• “flat,” underdeveloped breasts

• widely spaced breasts (more than 1.5” apart)

• breast asymmetry (one breast noticeably larger than the other)

• very large or “puffy” areolas

• absence of noticeable breast changes during pregnancy or after birth

Any or all of these signs do not always indicate that a woman is unable to produce milk, but they should prompt women and their health-care providers to be aware of potential problems and have a plan of action to overcome them. Women with signs of insufficient glandular tissue are encouraged to develop a breastfeeding management plan with an International Board Certified Lactation Consultant (IBCLC) before they give birth.

Breast Surgery: Milk ducts may be cut, and nerves can be damaged as a result of surgery. The milk ducts may "re-grow" (recanalize) during pregnancy as the breast changes rapidly in preparation for lactation. Mothers who are unable to produce enough milk to meet the needs of a first baby may have better milk production with the next child as a result of breast development that occurs with each pregnancy. Sometimes, chest surgery or injury may result in nerve damage that affects the milk ejection reflex, or rarely, it may cause damage to the glandular tissue of the breast and result in a decreased capacity to produce milk. Mothers who have had breast, nipple, or chest surgery or injury may find the evidence-based website, Breastfeeding After Breast and Nipple Surgeries, to be helpful and encouraging.

Hormones: Many mothers with a hormonal imbalance such as Polycystic Ovary Syndrome (PCOS) have reported trouble producing enough milk for their babies. To date, PCOS, other hormonal disorders, and related conditions such as insulin resistance and infertility are not well-understood in terms of how they may affect milk-production. Some women may produce excess milk, while others struggle to meet their babies' needs. There are medical treatments which may help maintain balance and an adequate milk supply. A woman who thinks she may suffer from a hormonal imbalance should discuss her concerns with a health-care provider and develop a breastfeeding management plan with an IBCLC before she gives birth.

Impaired Thyroid Function: Hypothyroidism is common in women and may affect “4-10% of women” in the postpartum period (Ogunyemi, 2011). Both Hyperthyroidism and hypothyroidism result in irregular production of the hormones T3 and T4 which act on the metabolism of the body. Women who are experiencing low milk production may benefit from having their thyroid hormone levels tested so that problems may be treated. Many mothers with these conditions will have improved milk production when their symptoms begin to resolve.

Hormonal Birth Control:  The use of combined estrogen/progesterone hormonal birth control is associated with low milk production. Many breastfeeding mothers are prescribed progestin-only hormonal birth control because it does not typically decrease milk production. However, it can be associated with a decrease in milk production in some women especially if started before 6 weeks postpartum. Women who are planning to breastfeed should discuss alternative forms of birth control with their health-care providers.

Retained Placenta: The detachment of the placenta signals a cascade of hormones that cause the milk to "come in" after the baby is born. Even a tiny piece of placenta left attached to the wall of the uterus may cause the mother’s body to “think” it is still pregnant. When the placenta does not completely detach as it should, progesterone levels stay too high to allow copious milk production. When the placenta is shed or removed, the mother's milk production is likely to increase (Neville & Morton, 2001). Retained placenta can be very serious. Health-care providers will explain warning signs to watch for, such as very heavy postpartum bleeding. 

Excessive Blood Loss: When an abnormal amount of blood is lost during childbirth or through postpartum hemorrhaging, the system that triggers the release of prolactin (the “milk making” hormone) in the pituitary gland may be interrupted, and inhibit milk production. 

Infant Conditions Related to Low Milk Production

Latch: A baby who is not attached well and positioned comfortably at the breast may be unable to transfer milk efficiently. An ineffective latch may result in:

• damaged nipples

• disorganized sucking

• fussiness at the breast(Genna, 2008)

A common solution for pain during breastfeeding is to ensure baby is positioned comfortably, stabilized, and given assistance to latch deeply. Sometimes, however, a change in position and a deeper latch do not resolve pain, and there may be a structural problem such as tongue tie, lip tie, or high palate. When breastfeeding discomfort continues despite position and attachment changes, an IBCLC can help with assessment, recommendations for feeding, or referral, if necessary, to other professionals that can assist with treatment.

Suck Dysfunction: If baby is not able to suck effectively and remove milk from the breast, the result may be low milk production. Suck dysfunction is associated with some medical conditions, early birth, low muscle tone, and other problems which should be addressed by a IBCLC or other health-care provider. Some of these babies may tire at the breast while feeding, while others may use their tongues ineffectively or have trouble coordinating the behaviors associated with feeding (Genna, 2008). Sometimes, position changes that increase “positional stability” for the infant (Colson et al, 2008) may be helpful. Some babies improve dramatically with age, but in many cases, close attention from a IBCLC or other health-care provider is also necessary.

Non-Medical Causes

Infrequent Nursing: In many cases of low milk production or slow weight-gain, the baby simply needs to nurse more often. Healthy newborns breastfeed an average of at least 10-14 times in 24 hours, and most babies must feed frequently in order to take in enough milk. Many babies who are not gaining weight well simply need more time at the breast, and some babies need encouragement in order to feed more often. A mother may help this process by offering the breast every 1-2 hours and paying close attention to signs that the baby is hungry or satisfied. When the breast is drained, the body responds by making more milk. Placing the baby directly onto the bare skin of the mother's chest facilitates intimate contact between the two of them and is associated with more frequent breastfeeding and greater milk production. All babies need unrestricted access to the breast in the first three weeks, when the body is “primed” to learn to make enough milk (De Carvalho, 1983). 

Many factors can lead to babies spending too little time at the breast:

• Early formula supplements can lead to less breastfeeding and lower milk production.

• Frequent visitors, traveling, or entertaining can reduce the time a mother spends alone with her baby, skin-to-skin, and breastfeeding. Early feeding cues can be missed if mother and baby are not together or the baby is sleepy or overwhelmed from being passed from person to person.

• Scheduling, delaying, or limiting breastfeeding restricts the amount of milk a baby is able to remove and how much a mother can produce.

By responding to the needs of her baby when he indicates a desire to nurse, a mother eliminates the hazards of restricting access to the breast. A new family may benefit by limiting distractions and visits from well-meaning family and friends for a few weeks after birth. If people are eager to help with the new baby, the mother can suggest they provide some meals, run errands, or help with some housework. Nursing at the first sign of a hunger cue in the early weeks, can help protect milk production in the long term.

Lack of support: Many mothers experience a lack of support for breastfeeding from their communities. Well-meaning friends, family members, and even health-care providers may undermine breastfeeding by inadvertently giving inappropriate advice.  Some health-care providers have little or no training in human lactation and may not be providing the most accurate information about breastfeeding. Family members may want a turn to bottle-feed the new baby. Friends might not be familiar with breastfeeding and question how frequently the baby is at the breast. These situations may result in less breastfeeding and lower milk production.

Misunderstanding normal infant behavior: A fussy or unhappy baby is not always a hungry baby. Mothers and those around them may be concerned that a baby who is fussy or needs to nurse frequently is not getting enough milk. It is not uncommon for a newborn to nurse for 20 minutes and then be ready to nurse again 10 minutes later. The mother is often told, “He can’t be hungry; he just ate,” or “You’ll spoil him.” This kind of advice can lead to giving supplements when they are not needed. Instead, a mother may need to be reassured that her baby is getting enough milk at the breast.

When Supplementation is Necessary: Sometimes babies do not gain weight at the minimal expected rate for health and development and need temporary additional nutrition. Ideally, a supplement should be the mother's own milk or donor human milk. In the early days, if a supplement is necessary, mothers should be encouraged to hand express and supplement with their own colostrum as demonstrated in this video from Stanford School of Medicine: Hand Expression of Milk. Sometimes, a mother is not yet producing enough milk to feed as a supplement and uses formula. Whether a mother supplements with donor human milk or formula, she should be encouraged to express her milk in order to maintain (or increase) her milk production. Because formula takes longer to digest, many babies who are taking supplemental feedings exhibit less-frequent hunger cues. Over time, a baby receiving this kind of supplement may feed less frequently, and if the mother is not also removing milk as frequently as her baby would normally demand, decreased milk production may result. 

If a mother does not breastfeed and/or express her milk frequently or fully enough, an unproductive cycle can develop quickly; baby fills up on formula and spends less time at the breast. Baby spends less time at the breast, so the mother produces less milk. Mother produces less milk, so she gives more non-human milk, and so it continues until she is no longer making enough milk for her baby. This cycle can often be reversed if the mother instead makes sure to increase time at the breast, remove milk frequently, and use breast compressions while nursing.

If a baby needs supplemental feedings it is important to explore all of the possible maternal or infant causes of low milk production in order to help restore full breastfeeding. Supplemental feedings, while sometimes necessary, do not address the underlying cause of low milk production. Identifying the cause of the problem, if possible, may help determine the best solution. While supplemental feedings may be part of the plan of action, steps should be taken to ensure that the goal is that exclusive breastfeeding resume. 

If you need help making more milk, or if you are worried if your baby is not getting enough milk, an International Board Certified Lactation Consultant or community breastfeeding support worker may be able to help. Finding the support you need can help you reach your breastfeeding goals.

Related Articles

Losing Your Milk: What seems like dwindling milk can actually be normal changes in baby and you

Resources

Breastfeeding After Breast and Nipple Surgeries
Hidden Hinderances to a Healthy Milk Supply
Lowmilksupply.org
Making More Milk
MOBI Motherhood International

References

Akre J. E., Gribble, K. D., & Minchin, M. (2011). Milk sharing: from private practice to public pursuit.  International Breastfeeding Journal,  6(8). Retrieve December 12th, 2012 from International Breastfeeding Journal Website: http://www.internationalbreastfeedingjournal.com/content/6/1/8


Colson, S. D., Meek, J. H., & Hawdon, J. M. (2008). Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Human Development,  84(7), 441-449.


De Carvalho M, Robertson S, Friedman A, & Klaus M. (1983) Effect of frequent breast-feeding on early milk production and infant weight gain. Pediatrics, 72(3)


Genna, C. W (2008). Supporting Sucking Skills in Breastfeeding Infants. Sudbury: Jones and Bartlett Publishers.


Kent, J., Mitoulas, L., Cregan, M., Ramsay, D., Doherty, D., & Hartman, P. (2006). Volume and frequency of breastfeedings and fat content of breastmilk throughout the day. Pediatrics, e117(3).

Lieberman ,T. (2011). Booby Traps Series: Postpartum hemorrhage and retained placenta – Two birth-related causes of low milk production. Best For Babes. Retrieved December 12th, 2012 from Best for Babes Web Site: http://www.bestforbabes.org/booby-traps-series-postpartum-hemorrhage-and-retained-placenta-two-birth-related-causes-of-low-milk-pr


Marasco, L., PCOS and Breastfeeding. Retrieved Decemeber 12th, 2012 from Hcp.obgyn.net website: http://www.obgyn.net/displayarticle.asp?page=/pcos/articles/childers-chats Neifert, M.R., (2001). Prevention of Breastfeeding Tragedies, Pediatr Clin North Am., 48, 273-297.


Neifert, M.R., Seacat ,J.M., Jobe, W.E., (1985). Lactation failure due to insufficient glandular development of the breast, Pediatrics, 76(5), 823-8.


Neville, M.C., Morton, J. (2001). Physiology and endocrine changes underlying human lactogenesis II. J Nutr., 131(11), 3005S-8S.


Ogunyemi, D. A. (2011). Overview. In Autoimmune Thyroid Disease and Pregnancy.

Retrieved April 8, 2012, from Webmed LLC Web Site: http://emedicine.medscape.com/article/261913-overview


Pennington, S. S., Abrams, A. C., & Lammon, C. B. (2009). Physiology of the Endocrine System. In Clinical Drug Therapy (9th ed., p. 341). Philadelphia: Lippincott, Williams and Wilkins. (Original work published 2001)


The Academy of Breastfeeding Medicine Protocol Committee (2005). ABM Clinical Protocol #13: Contraception During Breastfeeding


West, D., & Marasco, L. (2009). The Breastfeeding Mother’s Guide to Making More Milk. McGraw-Hill.

Insider info on Kate Middleton's pregnancy--a BFWOBS exclusive!

A few days ago, people all over the planet were overjoyed to hear of the news that the Duchess of Cambridge and future Queen of England Kate Middleton, was expecting her first baby--a baby that will one day occupy the throne of England.

As the world's focus intensifies on what is quite literally the most important news event since Bill Clinton boned Monica Lewinsky, BFWOBS can bring you some thrilling insider information about what is set to become the most watched pregnancy on the planet, which hopefully will fill in the gaps until poor old Kate is released from hospital and can be photographed again.

Royal traditions
Family protocol at the House of Windsor dictates that the mother-to-be must carry the baby in her "uterus" for around nine months. Rumor at the Palace has it that this could cause Kate's stomach to "become larger" during her pregnancy. While it's not known how Kate plans to give birth, an insider source at the Palace has revealed to BFWOBS in an exclusive interview that the birth will almost certainly be either a vaginal delivery or a cesarean section: "I can confidently state that the Duchess will be having an elective med-free, home cesarean waterbirth, either with or without an epidural. There's no doubt this will be a very special experience for her."

Kate Middleton "could be carrying conjoined twins"
Experts say that there is a distinct possibility that Kate could be carrying conjoined twins, a rare condition in which two babies are joined together at one or more parts of the body. "Cases of conjoined twins have occurred occasionally throughout human history, and the Royal Family have refused to release any ultrasounds, so it's entirely possible that Kate could be carrying them. Also, she comes from Buckinghamshire where there was a case of conjoined twins reported back in the mid-1960s, which surely increases the odds," said a Pregnancy and Baby Expert we spoke to. The Palace has refused to comment on the conjoined twins rumor, leading to a further flurry of media speculation about possible constitutional ramifications.

Tragic news--Baby will be "unable to walk or talk" for first year
Sadly, it appears that not everything about this pregnancy is set to go to plan. An acquaintance of Kate Middleton has disclosed that the baby Kate is carrying is likely to be incapable of walking or talking until it's around 12 months old. "Obviously this has come as a real blow to Kate," said our source, "but she's a strong person and will deal."

Join us at BFWOBS next time for....

Pictures of pregnant women with Kate's head crudely photoshopped onto them, accompanied by captions like "Shocking: What Kate could look like in her third trimester."

Advice on motherhood for Kate, given by random women we stopped in the street! Real live mums (just like you!) offer tips such as "Be prepared for sleep deprivation," "It's important to love your child and raise him or her in a good environment" and other similarly original remarks.

Special offer--Available only from BFWOBS! Are you looking for a commemorative gift item to mark Kate's pregnancy that is both useful and aesthetically pleasing? Well and good. If not, why not buy the Kate Middleton Pregnancy Commemorative Denture Cleansing Product Holder Mat Protector Stand, crafted from 100% genuine vinylette and decorated with a computer-generated image of what our future heir to the throne may (or then again, may not) possibly look like. $55.99 (batteries not included).

MORE pointless speculation!

Vote in the BFWOBS poll!
Do you think that requiring Kate to carry the baby inside her for the full duration of the pregnancy (while Wills gets off scot-free) is an outdated and sexist Royal tradition?

• Yes
• No
• I don't know
• I don't care
• I'm a grumpy republican... piss off

Skipping sippy cups?

No, you are not imagining things; that sippy cup really is designed to look like a pasty-white plastic tit. Needless to say, the only sippy Baby Seal would drink from was the one I was embarrassed to carry around...

It's become popular recently for breastfeeding mothers to skip the bottle and going straight to a sippy cup. However, some mums take this a stage further and go straight to an open cup. By the way, "some people" actually includes me... sort of. Since Little Seal hated bottles and was very slow to learn to drink from a sippy, I ended up more or less going straight to a little regular cup--supported/steadied by me in the early days, obviously. It wasn't until later that I discovered that "skipping the sippy cup" was a Thing.

Why are some people anti-sippy? Well, one point sometimes made is that they aren't necessary. The alternative name "trainer cup" implies that they are an essential step to learning how to drink, but this is of course nonsense; babies learned to drink from cups just fine before sippies were invented, and getting water out of a sippy involves an entirely different set of skills compared to drinking from an open cup. The real raison d'etre of sippies that they are spillproof and therefore a convenience to parents. Here in Japan, most daycare nurseries apparently insist that toddlers over 12mo use open cups only--a fact which amazes some Westerners when they first see all these tiny tots independently drinking from these little cups (without spilling... no doubt due to that mysterious ability that daycare workers have to get children to do things that they would never ever do at home).

Some lactivist-y people are anti-sippy because of fears that babies who start to enjoy the autonomy of wandering around with a cup will be more likely to self-wean early from the breast. Skipping sippies is relatively popular among baby-led weaners, which is a bit surprising, really; sippies actually allow early self-feeding and autonomy earlier and it's a rare baby who can manage an open cup independently at 6mo. However, mainstream pediatricians and dentists also tend to recommend skipping/severely limiting sippies. Extensive use of these cups has been linked with speech problems, possibly because in order to get liquid out of them--especially ones with valves--you have to push your tongue into a peculiar position which isn't used in the formation of sounds. And the very spillproof-ness of these cups can be a bit of a menace. Parents are tempted to put juice in and let toddlers wander away from the table with them (no way would you do that with an open cup, unless you like having disgusting sticky all over your house); sucking on the cup keeps kiddo quiet, so you let them have it a bit longer; and then you find yourself giving them a sippy with juice to stop them wailing in the car seat, and so on, and before you know it, the kid is spending half the day with a chewed-up plastic stub in their mouth and juice/cow's milk pooling around their teeth. The other thing about sippies is that they are often a bit... gross. They get all chewed-up, they have all these little cracks and crevices for germs to breed, they get thrown around and dropped and picked up and put in the mouth again and discovered under the car seat covered in two weeks' worth of fluff and lint and dog hair... you get the picture.

The case for sippies
That said, when at 9mo Little Seal finally took to one of the sippy cups we offered (after I got frustrated one day and ripped the valve thing out... I felt vaguely guilty afterwards, as if I'd vandalized the cup, then an online search revealed that loads of parents do this), the dreaded sippy also turned out to be useful in its own way, and I can't quite imagine never using anything but an open cup with a toddler.

Why? Well, for one thing, kids don't seem to drink quite as much from open cups as they do from sippies. I've found it useful to "add in" a little drinking from the sippy at times when it just seemed like she needed more fluids. Also, I'm not sure how you are supposed to nightwean if you never do bottles or sippies; how do you give them a sip of water if they do wake up? Open cups of water in a dark bedroom when you're tired sound like a disaster waiting to happen. Finally, I'm told that car-using parents find a sippy of water useful when they are on the road.

Cups, cups, cups
Back when we were in the bottle-refusal trenches, I did briefly wonder whether the famous Doidy cup (a funny little open cup with tilted sides) might be the answer. I think I'm glad I didn't bother, since the impression I get from Mumsnet is that there are a lot of Doidies gathering dust in people's cupboards. The Doidy's tilted sides allegedly make it easier for babies to control the flow of liquid and thus drink independently; the reality seems to be that the vast majority of babies need some help with a Doidy until toddlerhood, much like with an ordinary open cup (as one Mumsnet poster put it "The myth of the Doidy cup: 4 month old baby sips delicately at the clever slanty cup of healthy beverage.  The actuality of the doidy cup: 15 month old baby tips contents of clever slanty cup all over own chest. Cries. Change clothing and repeat. Buy cup with spout.") Also, in my experience, babies spill from open cups mainly because a) they plonk cups down clumsily and b) they think it's fun to chuck water everywhere... not because they can't control the water flow. I think if you use any type of open cup with a baby, realistically you need to be prepared to help them out with it for quite a long time unless you like soggy children and drenched floors.

A lot of parents seem to be using straw cups these days due to concerns about sippies. If I could do things again, I think I would have given these a try with Little Seal. It's handy if a baby can drink from a straw early on. That said, the other issues of sippy cups--grunge/germs, temptation to let the kid sip juice or milk all day--still remain with straw cups, so I think there's still a case to be made for introducing an open cup in the first year as well. Also, I wonder how long it'll be before "they" (dentists, pediatricians, whatever) discover some sort of problem caused by sucking on a straw all day long...

My verdict
So, all in all, going straight to an open cup--for 90% of water consumption, anyway-- turned out to be quite a nice way of doing things. You do have to supervise more and have a little more tolerance for spills--but then, if you're only doing water in the cup, this isn't usually a real problem. And I love not having to drag grotty sippies around with me. Some restaurants only have thin glasses which a young child could bite through causing serious injuries (sturdy glasses are OK); in these cases I ask for a mug or a straw, or just feed water on a spoon. The other useful thing I worked out was to keep the cup out of reach, offer it at intervals and teach Little Seal to point to it when she wants to drink. If the cup is right there in front of a toddler, the temptation to dump the contents all over the floor (just to check that gravity is still working) can become irresistible.

The sippy in our house is only for water; cow's milk comes in an open cup. However, I suspect that using an open cup only for milk is probably only practical if you are doing extended nursing, with cow's milk as a sort of supplement; if I were only doing cow's milk/toddler formula, I think I'd use a sippy/straw cup--not sure a toddler would reliably drink enough milk from an open cup. I do think that the pediatrician's rule of "juice only in an open cup (with or without straw)" is a good rule to stick to, as it means that juice stays in its rightful place as something sipped occasionally at mealtimes, not an all-day pacifier. You see, as it happens I'm awful with the TV... you know, putting it on for a few minutes (cue mummy-guilt spasm) multiple times a day when I need to immobilize Little Seal or get essential stuff done, so I think I'm probably better off not having the temptation of juice or milk in sippies for keeping Little Seal quiet; I bet I wouldn't be self-disciplined enough to restrict usage.

To sum up; I think using open cups as the main drinking device for older babies and toddlers can work, but better to be a bit flexible and consider adding in a sippy or straw cup when it seems to make sense. Happy drinking!