Known Effects of Low Income Conditions and Tobacco Smoking on Health of Children, often Confused with Effects of Bottle Feeding:

It is important to know some of the health effects of low-income existence and smoking, which are crucial in understanding the basic differences between breastfeeding and bottle-feeding households.  Bear in mind that those two groups differ greatly according to income levels, with bottle-feeding mothers being very disproportionately of low income, according to the Surgeon General’s own data for the U.S. and according to studies in the U.K. and Australia. ( , Section 1.2.s.1.a)  According to a major study funded by the U.S. Public Health Service, “Disparities in childhood asthma can be directly tied to several factors which disproportionately affect lower income children and children of color, including substandard and over-crowded housing, poor ambient air quality (often related to living near freeways, ports, or industrial sources of pollution); exposure to pesticides, particularly among migrant families but also children attending schools close to fields where pesticides are sprayed; and attendance in older schools with poor indoor air quality.  Lower income children are also more likely to face barriers to quality health care to treat and control their asthma.  Obesity and its consequences, such as diabetes, are widespread in this country, especially among poor, ethnic and racial groups. Children covered by Medicaid are nearly six times more likely to be treated for a diagnosis of obesity than children covered by private insurance.” (282)

Many other studies have extensively documented adverse health effects of poverty on children, including not only frequency but also severity (including the severity that leads to hospitalization for respiratory diseases.   For children in low-income households, frequency of delayed immunization is three times the average, and asthma and bacterial meningitis are twice as common.  “In the first year of life after the neonatal period, death rates are double to triple those of other children;after the first year, death rates due to disease are triple to quadruple among low-income children…. A study in Toronto demonstrated that children living in socioeconomically deprived areas were far more symptomatic than the adults in these areas from exposure to ambient air pollution in their neighborhood…. Several studies have linked pesticide exposure in childhood to increased rates of leukemia and brain cancer.” (284)   It should be noted that pesticide exposure would be increased not only in agricultural areas but also in crowded, low-income conditions where insects such as roaches would be more likely to be a serious problem.  Strong correlation between low-income neighborhoods and childhood obesity has been found recently in a study cited by the NIH. (284b)


In trying to explain the reasons why lower-income children “suffer disproportionately from almost every disease and show higher rates of mortality,” poor housing, lower-quality nutrition, and reduced access to quality medical care are key factors that are focused on.  The lower an individual is in socioeconomic status, the more likely he or she is to experience adverse environmental conditions, such as exposure to pathogens and carcinogens. (285)  The reader should bear in mind that the adverse outcomes alleged by the Surgeon General to result from not breastfeeding are known to result from conditions that are typical in low-income households, and bottle feeding is very disproportionately common in the low-income households.


According to the U.S. CDC, in 1995, infants born to non-Hispanic white mothers with less than 12 years of education were 2.4 times as likely to die in the first year of life as those whose mothers had at least 16 years of education. ((285b) Highlights page)   Other statements from that same CDC page, connecting adverse health outcomes in children with the socio-economic conditions that tend to characterize bottle-feeding households: (1) Overweight was also inversely related to family income among non-Hispanic white adolescents; "Poor white adolescents were about 2.6 times as likely to be overweight as those in middle- or high-income families."  (2) During 1994–95, poor and near-poor children under 6 years of age were only about one-half as likely to have seen a physician in the prior year as middle- or high-income children.  (3) Children 1–14 years of age living in low-income areas were more than twice as likely to be hospitalized for asthma as those in high-income areas during 1989–91, suggesting to the CDC they may have been unable to receive outpatient care that could prevent such a hospitalization.  (Think about how this could be the real explanation for the connection between bottle feeding and hospitalizations for lower respiratory tract diseases, even while various studies found no association between bottle feeding and non-hospitalization cases of such diseases; there is a standard term -- used by the CDC -- for hospitalizations that could have been prevented with proper earlier care:  "avoidable hospitalizations.")  (4) In 1995 poor adults were about four to seven times as likely (depending on ethnicities and genders compared) as high-income adults to report that their health status was fair or poor; although this reporting applied specifically to adults, the same factors of reduced quality of personal care, hygiene, diet, housing and medical care that affect health of adults would almost certainly affect their children as well.  (5) (Bearing in mind that prenatal care serves important purposes in promoting the health of the infant) the CDC points out, "Pregnant women who have more education are more likely to start prenatal care early and to have more visits."


Breastfeeding enthusiasts will focus on the "association" between bottle feeding and bad health outcomes, but the CDC apparently recognizes that the bad health outcomes actually result instead from conditions related to the low education levels and low income that disproportionately go along with bottle feeding.



Smoking:  Smoking is known to be more prevalent in families in which infants are bottle fed.  According to the CDC, smoking cigarettes during pregnancy was found in a study to be strongly associated with lower socioeconomic status (and therefore with bottle feeding) among all racial and ethnic groups.  And also, among various associated health outcomes for infants of mothers who smoke are Sudden Infant Death Syndrome and asthma.  In the CDC's words, "In every race and ethnic group, the more education women had, the less likely they were to report smoking during their pregnancy."(285b)  Among non-Hispanic white mothers with less than a high school education (who are very likely to bottle feed), smoking during pregnancy was found to be 15 times as  prevalent as among white mothers with 16 or  more years of education (who are least likely to bottle feed).  (The difference was only 10 times when comparing lower- vs. highly-educated mothers in general.)  To read about the known correlation of educational levels with breastfeeding rates, see , Section 1.2.s.1.a.

smokgConfdr.bmpData from the U.K. shows the different rates of smoking across socio-economic groups; those socio-economic differences are known to equate with higher or lower rates of breastfeeding in the U.S., U.K. and Germany. 


The following is taken from the “WHO Report on Tobacco Smoke and Child Health,” 1999:   “…maternal smoking during pregnancy causes well-established, demonstrable harm by reducing birth weight and increasing infant mortality…  Parental smoking is an important cause of lower respiratory tract illnesses … during the first years of life…. Both asthma and respiratory symptoms … are increased among children whose parents smoke, on the basis of over 60 studies…. Over 40 studies with different designs have investigated effects of parental smoking across a range of outcomes from acute otitis media to surgery for glue ear. Pooled relative risks for these outcomes range from 1.2 to 1.4…. Overall, parental smoking, particularly by the mother, appears to be responsible for between a third and a half of all SIDS cases….  Children of smokers… have lower scores in cognitive functioning tests… and have more behavioural problems, including conduct disorders, hyperactivity, and decreased attention spans…. Tobacco smoke, whether voluntarily or involuntarily inhaled, includes numerous carcinogens.”   According to a Spanish study, pregnant women who smoke or inhale secondhand smoke put their children at risk for learning difficulties, attention-deficit/hyperactivity disorder and obesity. ( )


According to a more recent study cited by the NIH, "spending just 10 minutes in the backseat of a car with a smoker in the front increases a child's daily exposure to harmful air pollutants by up to 30 percent.  And cracking a car window doesn't help....  Exposure to PAH (found in tobacco smoke) has been linked to immune system problems, wheezing, IQ changes and allergy development, the researchers noted."(285a)


 According to, "African-American infants are twice as likely.... to die of SIDS as caucasian infants.  Other potential risk factors include:  smoking, drinking, or drug use during pregnancy, poor prenatal care, prematurity or low birth weight, mothers younger than 20, tobacco smoke exposure following birth ...." (287a)  Notice how extremely well this profile of risk factors for SIDS fits the profile of typical bottle feeding mothers:   low-income, smoking, young, often African-American, less likely to get prenatal care.  Is it any wonder that a higher percentage of bottle-fed than breastfed babies end up dying of SIDS?  And how likely is it that the SIDS cases normally result from bottle feeding rather than from other factors, including the apparent major genetic vulnerability of African-Americans, low-income conditions, immature mothers, and (especially) smoking, all of which disproportionately go along with bottle feeding?  See the many references to the recognized connection of smoking with SIDS in the previous paragraph as well as in this one. (Aside from blacks and Native Americans, SIDS affects about one out of 2000 U.S. children (287b))


Unmarried women breastfeed at about half as high a rate as married women. (Section 1.2.s.2)  “Adolescent mothers (most of whom are unmarried)… have less healthy babies overall than do older mothers.” (288)  This reinforces the connection between low income, bottle feeding, and adverse health outcomes, with low income life being the probable underlying cause of the adverse health conditions, and bottle feeding going together with the low income but not being a cause of the illnesses.


“Poverty tends to be associated with an increased incidence of malnutrition, and malnourished individuals are more susceptible to infectious diseases.  Overcrowding is known to promote the spread of infectious diseases.” (288a)  Aside from malnutrition, it is clear that low-quality foods (high in calories, fat, sugar and refined flour) are less expensive than foods of the kind (especially fruits and vegetables) that build good  immune systems and healthy bodies without obesity. The Surgeon General's Call to Action to Support Breastfeeding (p. 32) recognizes that low income leads to poorer health and health care, quite aside from any effects of breastfeeding.  Low-income families are more likely to live in noisy neighborhoods, near trains, airports or major highways, with the result that they have greater difficulty gaining the restorative benefits of proper sleep, in addition to poor air quality in such areas.


One possibility might be to try to “adjust” or "control" for those conditions, in studies attempting to compare health effects of bottle- vs. breast-feeding.  But there is probably no way to determine whether any such adjustments or controls are carried out competently; and that is a very important matter, given the complex and poorly-quantified nature of the effects of these confounders.  In the AHRQ-contracted report that the Surgeon General relies on as the principal basis for her claim of benefits of breastfeeding, many studies were reviewed; and there seems never to have been an attempt to determine whether “confounding” factors (which include low income and smoking) are appropriately adjusted or controlled for.  In the checklist form that was used for determining the merits of some of the studies (such as Gdalevich, 2001, and Collaborative Group, 2002, both of which studies received A ratings by the contractors), one of the questions is, “Did authors consider appropriate confounders and justification for adjusting or not adjusting for those confounders?”  “Yes” is the highest possible rating.  So, in those particular studies, it apparently didn't matter if the researchers didn't control for or made no suitable adjustment for confounding factors; if there had merely been apparent consideration of appropriate confounders, the study could (and often did) receive an “A” rating.  And it appears that even obviously inadequate consideration of confounders passes the test, as will be explained.  Other studies reported on by these contractors were graded A, B or C for assessment of confounders; looking at how those grades were assigned makes it appear that these contractors’ ratings for consideration of confounders were almost meaningless, considering how uncritically they gave out A’s and B’s.  For the studies on asthma done by Kull (2002 and 2004) and Wright (2001), the studies received A grades for confounder consideration even though they did not adjust for effects of low income conditions. (Remember from earlier in this section the effects of crowded housing, poor air quality, and less adequate nutrition that disproportionately affect low-income families, all of which affect asthma incidence.)  The Hauck study (2003) received an “A” for treatment of confounders in its SIDS study, even though it did not adjust for either income or smoking (see above about the very strong connection of SIDS with smoking).  Duffy (1997) received a “B” for consideration of confounders in its AOM (ear infection) study even though the authors didn’t even adjust for smoking, much less for low income.  In studies related to cancer prevalence, the Lee Sy (2003) and Jernstrom (2004) studies both received A grades for their dealing with confounders, even without making any adjustments for low income.  In addition to the contractors’ low standards of quality as indicated by their looking for nothing more than consideration of appropriate confounders in some cases, and their very lax grading standards in other cases, there apparently was not even any attempt to judge whether any actual adjustments were made competently.  


To summarize:  None of the studies relied on by the Surgeon General to support her case provide useful evidence if they don’t contain verifiably valid adjustments for the confounding factors that are known to cause the very same illnesses that the Surgeon General attributes to breastfeeding.   The report that she relies on for evidence (a) makes no attempt to determine whether controlling or adjustments have been done well, and (b) routinely gives “A” ratings for assessment of confounders when there is not even an indication of consideration of important confounders.  It is no wonder that the Agency for Healthcare Research and Quality distances itself from this contracted report, on which the case for breastfeeding so heavily relies, by stating conspicuously upfront, “No statement in this report should be construed as an official position of AHRQ.”  What is surprising is that the Surgeon General of the United States should launch a major national initiative based on little more than such poor-quality evidence, and in addition misrepresent that evidence as being the position of an agency of higher authority than is actually the case.   And it is especially bad that such poor evidence is used as a basis for launching an initiative that (in effect) promotes exposure of infants to levels of dioxins that are estimated by the EPA to be 86 times higher than the reasonably-safe upper threshold of dioxin exposure estimated by the EPA (35), when it is known that bottle-fed infants receive exposures many times lower than that. (36)  


That is probably an indication of what is going on here:  a strong bandwagon effect based essentially on emotion, which causes people to reach for almost anything that might seem to be evidence at first glance, and to accept it as valid even though a close look would reveal that it is not good evidence. 



The Surgeon General's response to the above rebuttal of her position promoting breastfeeding:  As of six months after the original presentation of this rebuttal to her in May of 2012, followed by two subsequent letters pointing out the wide exposure this is receiving and asking for her response, neither she nor her associates have responded to the contents of the above rebuttal.  


(282) Dana Hughes, DrPH, Mary Kreger, DrPH, et al.: Reducing Health Disparities Among Children:  Strategies And Programs For Health Plans. Produced with support from the Health Resources and Services Administration, U.S. Public Health Service,  At; also see Gallup Well-Being,  March 21, 2008  Among Americans, Smoking Decreases as Income Increases  by Rob Goszkowski   Am J Dis Child. 1984 Jul;138(7):629-32. Respiratory and gastrointestinal illnesses in breast- and formula-fed infants.  Myers MG,et al;    Effect of passive smoking on growth and infection rates of breast-fed and non-breast-fed infants.Yilmaz G, et al Department of Pediatrics, Keçiören Training and Research Hospital, Ankara, Turkey.

(283) Parker S, Double jeopardy: the impact of poverty on early child development. PediatrClinNorthAm.1968; 35:1227-1240.  Starfield B. Child health care and social factors: poverty, class, race. Bull N Y Acad Med. 1989; 65: 299-306.  Geltman PL, Welfare reform and children's health. Arch Pediatr Adolesc Med. 1996; 150: 384-389.   Palfrey JS. Community Child Health: An Action Plan for Today. Westport, Conn: Praeger Publishers; 1995

(284) Child Health Care and Social Factors:  Poverty, Class Race  Barbara Starfield, MD, MPH, Professor and Head, Division of Health Policy, Johns Hopkins University School of Hygiene and Public Health, presented at 1988 Annual Health Conference of the New York Academy of Medicine

(284b) Poor Neighborhoods Home to More Obese Kids: Study Researchers find link between weight and the economic and educational status of the community  By Robert Preidt  Friday, November 16, 2012, Medline Plus, U.S. National Library of Medicine, NIH

(285) Socioeconomic Inequalities in Health:  No Easy Solution   Nancy E. Adler, PhD (Vice-Chair, Dept. of Psychiatry & Director of the Center for Health and Community, University of California, San Francisco), et al., Journal of American Medical Association, 1993

(285a) Secondhand Smoke Very Unhealthy for Kids in Cars: Study  Backseat exposure to polluted air is worse than in restaurants, bars, casinos  By Robert Preidt  Thursday, November 22, 2012  HealthDay, Medline Plus of NIH   at

(285b) found at;  also, about SIDS connection, Golding J. Sudden infant death syndrome and parental smoking—a literature review. Paediatr Perinat Epidemiol 11(1): 67–77. 1997.  Other information connecting educational levels and smoking can be found in the following: Verbreitung, Dauer und zeitlicher Trend des Stilles in Deutschland, Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2007 May-Jun;50(5-6), p. 628  and also Breastfeeding Initiation and Duration:  A 1990-2000 Literature Review  Cindy-Lee Dennis, RN, PhD  JOGNN in Review, Vol. 31, Number 1




(288a)  Biology of Disease (a medical textbook), Nessar Ahmed et al., Manchester Metropolitan University, UK, Taylor and Francis Group, 2007