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Am Fam Physician. 2002;66(7):online-only-

to the editor:American Family Physician has produced many excellent articles promoting and supporting breastfeeding and its benefits to infants and their mothers. However, I was dismayed by the cover illustration for the article, "Gastroesophageal Reflux in Infants and Children,"1 which showed a baby being bottle-fed. This article1 discussed the pathophysiology and treatment of gastroesophageal reflux disease (GERD) in infants but did not mention breastfeeding or its effects on GERD. It appeared that the underlying assumption in the article is that babies are formula fed. Treatment recommendations do not take breastfeeding into account, and, if these recommendations are followed, may cause a physician to recommend action that could interrupt successful breastfeeding.

While I realize that some parents will make the choice to artificially (formula) feed their infants, it is important that breastfeeding be supported as the norm for newborns and infants. Using the image of an infant formula feeding on the cover of a major publication such as American Family Physician undermines the work of the American Academy of Family Physicians (AAFP) in establishing itself as a leader in promoting breastfeeding and the unique role that family physicians play in breastfeeding support and education.

In September 2001, the AAFP Congress approved its new policy on breastfeeding, and the AAFP published a position statement on breastfeeding. I serve on the AAFP Breastfeeding Advisory Committee along with several other family physicians who worked hard to produce a document that provides recommendations to assist family physicians in advocating for breastfeeding in their offices, hospitals, and communities. Family physicians are asked to avoid the direct or implied endorsement of artificial baby milks (formula), yet the image of the bottle-feeding infant is seen four times in this issue. We need to be more vigilant so we don’t confuse our audience.

Editor's Note: Dr. Tobolic's point is well taken, especially in light of the AAFP’s policy and position paper on breastfeeding. Readers may remember that we featured “Initial Management of Breastfeeding” as the cover article for the September 15, 2001 issue, along with an invited editorial by Dr. David Meyers, highlighting the Academy’s position.

The cover illustration was inadvertent and unintentional, especially if it could somehow be misconstrued as supportive of bottle-feeding or reflect negatively on the Academy’s position. Had it occurred to me that this might have happened, I would have altered the cover art. In fact, I have asked the coordinator of our medical illustrations to avoid depicting bottle-feeding in the future. He wondered, however, if we had depicted a breastfeeding baby whether that illustration might have unintentionally conveyed the misperception that breastfeeding was a risk factor for gastroesophageal reflux in infants. Be that as it may, I appreciate Dr. Tobolic's keeping us on our toes. We will continue to do what we can to promote breastfeeding in America.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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