Dr Sasha Howard is a paediatric doctor working in the NHS specialising in endocrinology, which concerns growth, hormones and diabetes. Currently on maternity leave with her second child, and working on a PHD in the genetics of puberty, she is also the co-author of ‘Guilt-Free Bottle Feeding: Why Your Formula-Fed Baby Can be Happy, Healthy and Smart’, with Madeleine Morris. Here, she explains why breast is not always best.

The idea for the book Guilt-free Bottle Feeding’ came from (co-author) Madeleine Morris and me looking around us at our friends. What we saw were all of these normal, professional, very caring mothers, the vast majority of whom were using formula to one extent or other. Then we looked at the fact that every time you go to the GP or see a health consultant they ask if you are breastfeeding, and make you feel like slightly second-class parents if you are bottle feeding. It was like: are we really bad mothers? Should we have tried harder? Are we failures? Then we said: hang on a minute, if there are so many of us doing this, and feeling this way, why do we all feel so alone?

The first few months of being a mum can be lonely, and feelings of guilt and shame about giving your child formula can be a big problem for women. To know that there are other mums like you, who are also struggling with something that is perceived as so natural – so crucial to the best outcome for your baby – that’s enormously helpful. It is terrible the judgment you get for the choices you make as a mother, the vitriol that women throw at each other. It’s like everybody has to be in a camp – breastfeeder or bottle feeder – and let’s throw stones across at the other side. Why is it like that? I think that about all sorts of aspects of motherhood. But every mother and baby is different, and you have to find your own way through it.

The most recent NHS infant feeding survey figures on breastfeeding in the UK are from 2010. They say that in Britain, 80 per cent of us try to breastfeed; by time the baby is a week old 50 per cent have introduced some formula; by six weeks more than 70 per cent are using formula to some extent. By six months just one per cent is exclusively breastfeeding. So 99 per cent of us have introduced some degree of formula.

The World Health Organisation (WHO) says that both in the developed and developing world breast-milk is the best option for your baby for health and non-health factors, such as intelligence. But when you then delve into the detail a lot of it is not based on nearly such robust data as one might think. A lot of the huge systematic meta-analyses – the most reliable scientific studies – conclude that we cannot draw a clear conclusion because the data isn’t good enough.

There is this idea that all mums can breastfeed if they really try. There is a much-quoted figure that only one to five per cent of women can’t breastfeed, the idea being that the rest could if they tried harder. Madeleine and I looked at what that statistic was based on – and it’s actually a hugely distorted figure from one study in 1990, which looked solely at white middle class American women and found that only five per cent didn’t produce enough milk, and another 10 per cent couldn’t breastfeed for other reasons. Actually in this day and age for all sorts of reasons there are an awful lot of us who are finding very hard to breastfeed – whether it’s issues around going back to work and having nowhere private to pump; or body image issues – whether it’s from previous anorexia or previous sexual abuse – and for that woman breastfeeding isn’t a pleasant thing to do.

Our message is if all other things are equal, then breast milk is better than formula for its health-promoting properties. But if we try to take a more holistic view of the ‘breast is best’ message, then who are we talking about it being best for? Every mother and every mother and baby pairing is different. Each has a different set of circumstances. If a mum who is formula feeding is more relaxed, happy, more in tune with herself then actually she can be a better mum for her baby. For so many mums there are other circumstances that mean for them using formula, be it exclusively, or mixed with breastfeeding, produces a better outcome.

It’s not just a lifestyle choice, and to be told that we could do it if we tried harder is not helpful. We all need a lot of support, whether it’s breastfeeding, formula-feeding or mixed feeding. That support is often not available, whereas judgement and comment is rather over-available. There’s also this feeling that we all have to be perfect these days, that anything we do that isn’t primarily for our babies is selfish. How could you possibly do something that wasn’t with your baby’s primary interest first, even if that meant that your nipples are falling off? Is that right?

The biggest published study out there in feeding and IQ show there is about a two-point difference between a baby who has had breast-milk and a baby who has had formula. But if a mum who is breastfeeding is so miserable that every time she puts her baby to the breast she is weeping, that she’s dreading the next feed, that she’s crying with pain or very depressed afterwards, or can’t sleep – she is not going to be interacting with that baby.

If she was formula-feeding and that was the right choice for her and improved her sense of wellbeing, then she would be interacting with her baby more expressively, in a loving communicative way. Therefore quite possibly that baby’s outcome in terms of development will be better. Why can’t we be a little bit more honest and more sensitive to women’s individual needs and requirements?

I think there’s so much fear that by talking about formula and by trying to make women who are formula-feeding feel they are doing something that is OK, that somehow that is going to reduce the amount of women who would breastfeed. I actually think it would increase the number of women who breastfeed if the conversations around how difficult breastfeeding is or can be, were a bit more honest.

For some people it’s lovely but if someone could tell you before it happened that it might be the hardest thing ever, that you might have sweaty middle-of-the-night feeds where you’re both balling, but that you’ll come out the other side, that you’ll find a way through – and that you’re not alone; that there are countless other mums on sofas all over the world feeling the same way and it’s normal and it’s OK, and that you’re not failing – that might help us not feel such a failure when we find we can’t do it.