Mothers who intended to breastfeed had infants with better health outcomes even if they DIDN’T breastfeed!

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Hold the guilt! A new study shows — once again — that the purported benefits of breastfeeding are actually benefits of privilege. Breastmilk has little if anything to do with it.

That was already demonstrated powerfully in the 2014 Colen study, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons. The answer was “No.”

The authors looked at breastfeeding vs. bottlefeeding WITHIN families by comparing siblings who were fed differently. In that way they eliminated the impact of race and socio-economic status. When they did, there was no difference between breastfed and bottlefed children.

It isn’t breastfeeding that improves infant health; it is privilege.

Now an even more ingenious study has confirmed those finding, The best of intentions: Prenatal breastfeeding intentions and infant health. The authors correct for the impact of race and socio-economic status by focusing on intention to breastfeeding instead of breastfeeding itself.

The authors looked at more than 1000 women and categorized them based on whether they intended to breastfeed or not.

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They noted:

…Approximately one-third of mothers who intend to exclusively breastfeed are able to achieve this goal. There are several exogenous factors that may prevent mothers from fulfilling their intentions. For example, biological barriers include low milk supply, pain, infections (mastitis), or clogged milk ducts. The baby may have a poor latch, be an ineffective nurser, or have food intolerances… Some factors may act as both an influence on a mother’s intentions as well as her ability to realize those intentions. For example, maternal employment, lack of social support, limited knowledge, or limited access to professional support such as lactation consultants may first undermine intentions and then breastfeeding success.

In sum, prenatal breastfeeding intentions may be an important factor in examining the relationship between breastfeeding and infant health as they help us to overcome a key identification challenge in measuring the effect of breastfeeding on infant health: that the same characteristics that lead a mother to breastfeed may also lead to an infant having improved health. (my emphasis)

They looked at three infant health outcomes: ear infections, respiratory syncytial viruses (RSV), and antibiotic usage in the infant’s first year.

They found that women who intended to breastfeed had infants with better health outcomes even if they DIDN’T breastfeed!

An infant born to a mother who intended and did breastfeed had approximately 35% (or 0.165) fewer ear infections than infants born to mothers who had no intention of breastfeeding, but an infant born to a mother who intended and did not breastfeed had approximately 29% (or 0.136) fewer ear infections compared to the same omitted group. There is no statistically significant difference in ear infections between intending mothers who did and did not breastfeed.

Next, we examine the RSV outcome. Compared to infants whose mothers did not breastfeed and did not intend to do so, infants with mothers who intend and do breastfeed are 83% less likely to have an episode of RSV in their first year of life (a marginal effect of 0.056 fewer episodes). The coefficient for infants born to mothers who intended but did not breastfeed is not significant but suggests a qualitatively large difference (36% less likely to have an RSV diagnosis, which is 0.024 fewer diagnoses). This substantial percent difference (83% vs 36%) is likely due to RSV being a rare outcome; only 7% of mothers in our sample reported RSV.

Finally, we focus on antibiotic usage, and our analysis suggests that prenatal intentions are negatively linked to incidents of antibiotic use. The infants whose mothers intended and did breastfeed had 38% fewer incidents where antibiotics were used, compared to infants of non-intending mothers, while infants whose mothers intended but did not breastfeed had 40% (or 0.293) fewer incidents where antibiotics were used compared to infants of non-intending mothers. Both coefficients are statistically different from the omitted group, but the difference between breastfeeding and formula-feeding mothers who intended to breastfeed is insignificant.

What’s going on?

The authors investigated differences in nutrition knowledge and sources between groups of mothers and found that women who intended to breastfeed but did not were very similar to women who intended to breastfeed and were able to do so. Both differed in important ways from women who had not intended to breastfeed. It is the differences between mothers that are responsible for the differences in outcome, not breastfeeding.

The authors summarize:

[O]ur findings help to contextualize the finding that “breast is best,” and add nuance to a body of literature on the benefits of breastfeeding for infant health. Although we do not dispute that breastmilk is an excellent source of nutrition, our results suggest that formula offers similar health benefits for our relatively advantaged sample of infants, once we take prenatal intentions into account. (my emphasis)

The authors amplify their findings in an interview in the mainstream press:

“By sinking so much energy into getting moms to breastfeed, we miss something very important: That access to health care and the ability to take medical advice is critically important to a mother and her infant,” said Raissian. “By exploring factors influencing better infant health outcomes, information from the study helps contextualize the trade-offs that a lot of mothers have to make when deciding how to feed their children.”

It isn’t breastfeeding that improves infant health; it is privilege.

That explains why efforts to promote breastfeeding have been spectacular failures when it comes to improving outcomes. With the exception of premature babies, breast milk doesn’t have many benefits at all.

There is no correlation between breastfeeding rates and infant mortality rates. Countries with the highest infant mortality rates have the highest breastfeeding rates and countries with the lowest breastfeeding rates have the lowest infant mortality rates. Increasing breastfeeding rates within a country has no impact on infant mortality or other health outcomes. The promised monetary savings have also failed to materialize.

The authors have elegantly demonstrated that breastfeeding is a proxy for privilege. It is intention to breastfeed that leads to improved outcomes, not breastfeeding itself.

  • rational thinker

    This may be a little off topic but I wanted an opinion on this, If a baby is exclusively bottle fed people will say to you “dont put a bottle in his mouth every time he cries” but then if the baby is exclusively breastfed these same people will advise you to “put your breast in his mouth whenever he cries” has anyone else ever noticed that?

    • The Bofa on the Sofa

      See, it’s just that boobs are magic. The more you breastfeed, the more they produce. But if you over breastfeed, they stop, because they KNOW exactly what the baby needs.

      All hail the magical powers of the boob!

    • Actually, my pediatrician was consistent–don’t put a [feeding thing–I gave my kids bottles and breast] for every cry. (Mind you, I ignored his advice the first three months for each kid, because they really did cry for food all the time.)

      • Mimc

        Yeah hunger was the only reason mine cried the the first three months. If he was uncomfortable he would whine and if he was sleepy he’d just fall sleep wherever he was (I miss that). A true cry was definitely hunger.

    • EmbraceYourInnerCrone

      Yes, they don’t seem to get that if you pay attention you learn what hungry crying is, as opposed to fussy “woe is me I am too tired to fall asleep” crying. I used to try a pacifier if I thought it sounded like the second type of crying, if it was hunger crying she immediately spat it out at me and commenced with the outraged FEED ME SEYMOUR crying. SOunds like people who advise “put your breast in his mouth whenever he cries” are suggesting using the breast AS a pacifier.

      • Merrie

        My first two kids, both EBF, absolutely had times when they wanted the paci and times when they wanted me and they would not accept the one they did not want. (Third kid never took a paci, and was also the only one we worked from the start to put down drowsy.)

  • The Bofa on the Sofa

    I still cannot conclude too much about breastfeeding studies unless they control for daycare attendance. Has this one done that?

    • Cartman36

      It says they “adjust for the type of intended child care (the mother herself, a relative, or non-family care)”. This seems broad. There can be a HUGE difference in cleanliness between child care centers.

      https://www.sciencedirect.com/science/article/pii/S2352827318300223?via%3Dihub

      • The Kids Aren’t AltRight

        So it could actually be that mother’s who intend to breasfeebr have the privilege to get their kids into cleaner daycare centers, and that benefit has been previously attributed to breast feeding.

  • demodocus

    Bah. Can we throw these studies in a lake?

    • The Bofa on the Sofa

      Those studies don’t take into account the fact that, for some women, breastfeeding is really, really, really important for their self-image and sanctity, and therefore, the conclusions are wrong regardless of what the data indicate.

  • Mel

    My first batch of teenage moms who I taught in high school are getting close to age 30 now. Some of their kids are in junior high now – and the rest are in grade school.

    My completely unscientific tiny sample size conclusion is that moms who want to be good moms for their kids have better outcomes than moms who are ambivalent about the type of mother they want to be.

    The difference is that of thoughtfulness about what a mother needs to do and the amount of energy used at being a good mother. The overarching theme for the moms with good outcomes is that they try to figure out what is best for their kid(s) and adapt accordingly. Some breastfeed exclusively; one lady breastfed her first exclusively but switched to formula for her second when it was clear her son wasn’t doing well on formula. They read to their kids. They get their kids to do homework.

    From a longer view, it’s not the processes that the moms pick – it’s the fact that the moms are thinking about what is best for their kids. After all, not terribly long ago good moms gave their babies formula, put them to sleep on their tummies to prevent choking, and let them run around in metal baby walkers to promote mobility. Two of those three choices are viewed as being counterproductive today – but the moms who chose them still did better.

    • The Bofa on the Sofa

      There is a saying you find in parenting books, “Trust your instincts, they are usually right.”

      And it’s true. That’s because, for most of the things we do as parents, there are really no wrong answers. The fact that you actually care enough to fret over the decision is enough to make sure you don’t do any harm.

      Unfortunately, what happens too often (and I’ve seen it) is that someone hears that good advice, “Trust your instincts, they are usually right” and decides that it means that everyone else is wrong. No, that’s not how it works. There is more than one right answer. As long as you care enough to ask the question, you are doing things right.

      • guest

        I have friends that fret about being good parents because they were not raised with the best examples. I always tell them that if you are worrying if you are a good parent, you’re doing fine. Also, kids just need to be loved and cared for and not abused, every decision doesn’t need to be 100% right.
        I remind myself of this too when needed. 🙂

        • Merrie

          Yes, every other post in my due date club is someone fretting about some minute detail and worried that she’s a bad mom and I’m just like, you’re obviously a good mom since you’re trying so hard to do right by your kid.

  • Montserrat Blanco

    Thank you for this! The guilt should be banned. Surprisingly the best thing for a healthy and long life is… money. As in every single study out there, the best health outcomes are for wealthy people. Even in countries with universal health coverage the difference between life expectancy can be about 10 years between the poor and the rich.

    I suggest we simply raise minimum wage or try universal basic income, get everybody free education and free healthcare and just stop this nonsense of promoting breastfeeding and low rate CS. Instead of promoting breastfeeding give more money to low income families. We will do better.

    • Cartman36

      We should be cautious when a simple solution seems like the answer to a complex problem. It (usually) takes a certain amount of intelligence, maturity, dedication, and a willingness to delay gratification to graduate from college and thus be eligible for more higher paying jobs that require a degree. Better health and overall outcomes could be a be a reflection of those same traits and their associated behaviors rather than being caused by having money.

      • space_upstairs

        Yes, social class seems to involve at least 3 interacting factors: money, culture, and respect. If we give people money but still treat them like crap (no respect) and do not help them learn to relate differently to money and other assets such as health and education (no change in culture), we will probably not be doing them any long-term good. The same goes for attempting to give the disadvantaged only cultural instruction without the money to implement the advice or the respect that would make it all seem worthwhile: that’s the problem with lifestyle stuff like breastfeeding promotion and anti-junk-food campaigns. Probably the respect needs to come first, honestly supporting people and not looking down on people who have less and make different decisions partially on the basis of that. That might make people more respective to changing their culture, and then better able to use any money they are given.

      • LaMont

        The thing is, willingness to delay gratification (and other positive traits) are best fostered in an environment of safety. If you are financially unstable, you are less likely to live in a world where delaying gratification is possible or optimal in many cases. Your “dedication” can be interrupted by pressing needs more often than a wealthy person who won’t have to upend their life for a crisis. Giving money (and housing, and jobs) to people has worked out in many programs. We like to overcomplicate doing that because we think poor people in general deserve to be so.

  • Cartman36

    Am I the only one who is giddy with the anticipation of the impending lactivsit tears. But but but…. what about my sacrifice, waaahhhh!

    On a more serious note, this explanation just makes sense. My husband and I were VERY careful when we selected our daycare, we toured several and live in the same neighborhood as the owner who has her master’s in early childhood education. She hires primarily retired school teachers and they use a curriculum for the preschool age groups. Her employees clean the heck out of the center everyday usually with bleach water. I am completely serious when I say the floors there are cleaner than the floors in my home. My point is, my kids likely are more ready for school and have overall fewer illnesses because my husband and I have the resources to put them in this center versus dropping them off at an unlicensed facility run out of a filthy home. I’m not trying to make fun of other people (believe me I recognize that I was born on third base) but rather to highlight some of the other things that give my kids advantages that are the direct result of our means and doesn’t have a damn thing to do with how much breast milk they did or did not get.

    Dr. Amy – Thank you again for spreading this information. I am glad to see the caveats to breastfeeding benefits being discussed more and more. Thankfully i am done having babies but I want the ladies behind me to make the best choice for their family and not feel brow beaten by the breast is best message.

    • Sarah

      They’ll probably just reckon breastmilk is so powerful that you get benefits from even thinking about it.

      • Cartman36

        Don’t make me laugh when I am enjoying a hot beverage. LOL

      • Well, great! Think milky booby thoughts, then crack open that can of formula. Or, to paraphrase Michael Pollan: Be the kind of person who breastfeeds.

    • Madtowngirl

      The lactivists will probably double down and accuse the study of being funded by “big formula” or some such nonsense. It doesn’t fit their narrative, so it must be wrong. Watch Dr. Amy’s Facebook page, the usual deniers will be there soon. Probably with some lactivist parachuters as well. I’ve got my popcorn ready!