Recent paper confirms that benefits of breastfeeding have been overstated

exaggerate

I have been arguing for years that the benefits of breastfeeding have been exaggerated far beyond what the scientific evidence could justify. In large part that exaggeration has occurred because of a massive marketing effort on the part of lactivists who repeated “breast is best” so often that it became conventional wisdom even though it wasn’t true.

It’s been 5 years since the publication, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons by Colen and Ramey that found the purported benefits of breastfeeding nearly all disappeared with corrected for confounding variables like socio-economic status and ethnicity. Multiple papers by other authors debunking various claimed benefits of breastfeeding have since been published.

“…[E]xclusive breastfeeding at discharge from the hospital is likely the single greatest risk factor for hospital readmission in newborns.”

A recent paper tactfully titled Is the “breast is best” mantra an oversimplification? summarizes the evidence that the benefits have been overstated and the risks ignored.

The authors note:

Recommendations about breastfeeding — absent critical analysis and removed from context — may overvalue its benefit…

The benefits of breastfeeding for infants have long been touted as numerous and supported by overwhelming evidence…

Massive public health campaigns citing data for the many benefits of breastfeeding have been launched with the goal of increasing the breastfeeding rate…

In recent years, an increasing number of researchers, physicians, and authors have begun to question whether, in the United States, the benefits of breastfeeding children are exaggerated and the emphasis on breastfeeding might be leading to feelings of inadequacy, guilt, and anxiety among mothers…

The authors review the existing scientific evidence in order to bring clarity to the discussion. They start by confirming the well known but small decrease in upper respiratory infections and episodes of diarrheal illness, but they find little support for most other claimed benefits, especially long term benefits.

IQ:

Several studies conducted in developed countries have linked breastfeeding to positive cognitive outcomes in children, including higher intelligence quotient (IQ).

These effects are conflicting, however, in studies that include sibling analysis and ones that control for maternal IQ. In the 2013 WHO meta-analysis, breastfeeding was associated with an increase of 2.2 points on normalized testing when only high-quality studies were included. A 2015 meta-analysis identified 4 high-quality studies with a large sample size and recall time

Obesity:

The relationship between breastfeeding and obesity later in life is debatable. A large, systematic 2014 review of 15 cohort and 10 cross-sectional studies found a significantly reduced risk of childhood obesity among children who were breastfed (adjusted OR=0.78; 95% CI, 0.74- 0.81). However, the review included studies that controlled for different confounders, and smaller effects were found in studies in which more confounders were taken into account.

The 2013 WHO meta-analysis found a small (approximately 10%) reduction in the prevalence of overweight or obese children, but cautioned that residual confounding and publication bias were likely. At 6.5 and 11.5 years of follow-up, PROBIT failed to demonstrate a protective effect for exclusively or “ever” breastfed infants. Sibling analysis similarly fails to demonstrate a statistically significant relationship.

A 2015 meta-analysis of 23 high-quality studies with a sample size >1500 children and controlled for important confounders showed a pooled reduction in the prevalence of overweight or obesity of 13% (95% CI, 6-19).57 The protection in this meta-analysis showed a dilution of the effect as the participants aged and an inverse relationship of the effect with sample size.

Breastfeeding is, therefore, unlikely to play a significant, if any, role in combating the obesity epidemic.

NEC (necrotizing enterocolitis)

In preterm infants, breastfeeding has been associated with a lower rate of necrotizing en- terocolitis. In the 2007 Agency for Healthcare Research and Quality report, the association was found to be only marginally statistically sig- nificant, and the authors warned that, first, evidence is old and heterogeneous and, second, present preterm formula is much different than the formula used in earlier studies of preterm infant nutrition and necrotizing enterocolitis. A 2012 Cochrane review included newer stud- ies in its analysis but reached the same conclusion on the quality and heterogeneity of available evidence, with a NNT of 25.

SIDS (Sudden Infant Death Syndrome)

There is a statistically significant association between sudden infant death syndrome (SIDS) and feeding method. Infants whose cause of death is SIDS are approximately one half as likely to have been breastfed as matched controls…

The protective effect exists for any amount of breastfeeding and is stronger for exclusive breastfeeding, suggesting a protective role — not simply an association. Caution should be employed with this conclusion, however, because the studies included in the meta-analysis used univariate analysis primarily and did not control sufficiently for known confounders. In addition, the authors warn that publication bias might overestimate the association…

Assuming a protective role, available data suggest that more than 3500 infants need to be breastfed to prevent one case of SIDS.

Does breastfeeding save lives?

No clear association has been found between mortality and breastfeeding status in developed countries, except for the association with SIDS.

And breastfeeding has risks including dehydration, failure to thrive, weight loss, and hyper- bilirubinemia.

…[E]xclusive breastfeeding at discharge from the hospital is likely the single greatest risk factor for hospital readmission in newborns. Term infants who are exclusively breastfed are more likely to be hospitalized compared to formula-fed or mixed-fed infants, due to hyperbilirubinemia, dehydration, hyper- natremia, and weight loss (number needed to harm (NNH)=71). For weight loss >10% of birth weight with or without hospitalization, the NNH for breastfed infants is 13.

Many of these hospitalizations and events could be avoided with appropriate monitoring and medically indicated supplementation; the likelihood of long-term harm is low. Formula supplementation is often avoided if possible in hospitals to promote exclusive breastfeeding; however, several small randomized clinical trials have demonstrated that limited formula supplementation in breastfed infants does not affect the breastfeeding continuation rate at 3 and 6 months, and, therefore, might be a way to decrease in- fant rehospitalization.

The bottom line?

The evidence for infant breastfeeding status and its association with health outcomes faces significant limitations; the great majority of those limitations tend to overestimate the benefits of breastfeeding. Nearly all evidence is based on observational studies, in which causality cannot be determined and self-selection bias, recall bias, and residual confounding limit the value or strength of the findings.

Is breastfeeding advocacy harmful?

The “Ten Steps to Successful Breastfeeding” program of the Baby-friendly Hospital Initiative (BFHI; launched by UNICEF and WHO) has come under scrutiny because of an increasing number of reports of sudden unexpected postnatal collapse; fall injuries; modeling and encouragement of unsafe sleep practices; an overly rigid resistance to the use of formula supplementation; and the ban on pacifier use…

Some of the “Ten Steps,” such as the call for skin-to-skin care and 24-hour rooming-in, have well-established benefit yet, when performed without supervision, can have the rare but serious unintended consequences of sudden unexpected postnatal collapse (the incidence of which may be higher than that of SIDS) and unsafe sleeping practices.

Furthermore, despite evidence that early formula supplementation, when medically necessary, does not adversely impact the breastfeeding rate, the “Ten Steps” program advises that giving formula before breast milk comes in might “lead to failure to breastfeed.”

Similarly, the ban on pacifiers is contrary to available evidence. The use of pacifiers before last sleep is more protective against SIDS than breastfeeding (NNT=2733) …

What about the harms to mothers?

The literature that does investigate harm consistently finds that women who have difficulty breastfeeding or choose formula feeding report feelings of inadequacy, guilt, loss of agency, anxiety, and physical pain during breastfeeding that interferes with 1) their ability to bond or otherwise care for their infant and 2) competing work obligations…

What do mothers need to know? The authors offer compelling statistics about both short and long term benefits including:

Greater than 99% will not realize benefit from either the prevention of SIDS … or from improvement in long-term health measures …

Balancing the abundant, but often limited-quality, data on the benefits of breastfeeding and the sheer lack of data regarding the risks of advocacy represents a clinical and an ethical challenge for physicians. It is a challenge that can only be resolved through individualization of care and shared decision-making, in which the physician is expert on the benefits of breastfeeding, and the mother is expert on the personal circumstances to be weighed against those benefits.

Her baby, her body, her breasts, her choice!

  • GeorgiaPeach23

    I’m 5 days post partum. My infant needed formula in the hospital for compelling medical reasons. Now he won’t nurse, and my rational brain knows “fed is best” but internally I feel like total shit. I read this blog and know better but the emphasis on exclusive BF from all sides — including my post partum discharge instructions! — makes me feel like a bad mom already. Plus pumping every 3 hours is so much extra work.

    Nothing I learned in the BF class or the hospital LCs is helping. Every day my darling boy screams at my nipples and it breaks my heart into a million pieces. I want to just stop trying. I’m so emotionally vulnerable right now and I resent the lactation push so much. It makes me feel so isolated.

    • rational thinker

      When your son is all grown up years from now how he was fed as an infant is the last thing he is going to remember. This is YOUR baby not anyone else’s and you know what’s best for him. Do you really want to enjoy this time with him or resent it cause of worrying about what other people who don’t have to care for your son think?. Babies cry cause they are trying to tell us something, and crying when he sees a breast means he is trying to tell you something. Now my advice to you is go get the discharge papers about benefits of breastfeeding. Now hold them up and tear it down the middle, and for extra credit throw them into the fucking fireplace. The lactation industry lies about so many things to get or guilt trip moms into breastfeeding and they make a lot of money while doing it. There will always be people who will have comments about how you should parent, just remember these people get off on making you feel bad cause they have no self esteem themselves. After a few days of formula feeding or probably even a few hours your son will be a different baby, he will be full, content, and very happy, even sleep better. Next asshole that has a remark about how you feed your baby just say you wanted the best for him, and maybe tell them that breastmilk does not even have vitamin D in it. Also when you go out and some stranger starts talking to you and asks you if you are breastfeeding respond by asking them if they like anal sex or when they had a bowel movement last, they will shut up real quick. If you ever need support or just to talk due to the pressures of being a new mom there are a lot of good, well informed people on this blog that will be glad to talk to you and most of us have raised children so we can relate to the pressures of being a new mom. ******sending you internet hugs*******

      • demodocus

        Bonfire! or at least the a match and a driveway!

      • GeorgiaPeach23

        Awesome advice. Motherhood def needs more fire (and cowbell).

        • rational thinker

          Glad you are doing better. If you have to pump then just pump but you still may get comments from the hard core lactivists. His facial muscles may not be strong enough yet and maybe that’s why he preferred the bottle. Give him a week or two then try latching him again. Always remember it does not matter how you feed your baby just that you are feeding him. Also remember a happy mom= happy baby.

    • It’s so, so easy to feel terrible over stuff like breast v formula when you’re vulnerable, and postpartum-with-first-baby is pretty near the top of “vulnerable” in many ways. With my first baby, I felt scared when she got her two-month shots even though I KNOW that vaccines are safe and effective, and my former boss felt terrible about stopping lactation at 3 months even though she knew it would be best. I can think of other examples where I or other new moms agonized over something even when we knew better.

      The good news is that irrational feelings pass pretty quickly. My boss’s son did great on formula, and she felt so much less pressure. My kid screamed while being jabbed and got a mild fever after her shots, but was otherwise fine and protected from lots of nasty diseases.

      Go ahead and give your baby the formula. After a few days of seeing him happy and full and you not going crazy, you’ll feel better. Give it a year, and you’ll be tempted to laugh at your angst–though you may still feel resentment against the lactivists, and that’s perfectly warranted.

    • demodocus

      As it happens, my first was bf’d and my second ff’d. (because I’m still touched out 4 years after 1st was weaned) And ya know what? They’re both bright and mischievous monkeys. BF’d kid likely has ADHD, FF’d kid is probably typical, though at 2, she’s too young to be sure.

  • rational thinker

    I doubt this paper will have any affect on lactivists or the BFHI because what they push is not science or facts its an ideology. They will just deny everything in this paper or pretend it does not exist.

    • The Bofa on the Sofa

      Accuse the authors of having conflicts of interest.

      • rational thinker

        probably

  • The Kids Aren’t AltRight

    I am combo feeding my 4 month old due to supply issues, and didn’t think I bought into breastfeeding propoganda that much; I have been reading your blog and even before that I noticed that the effect size and strength of the evidence of bf claims are nowhere to be found, which makes me doubt their conclusion. Yet, I just can’t shake the feeling that I am letting my baby down because she gets about 2/3s of her calories from formula. It is weird how effective the propoganda is.

    • Montserrat Blanco

      Your baby will turn out fine. You are a great mother. Hunger kills people. Inadequate calories for a baby is the worst thing you can do, this leads to developmental delays, hospital readmissions, more infections, etc, etc

      Supplement with formula and enjoy your baby! Those days will not come back! You are doing what is best for your baby. Do enjoy her.

    • alongpursuit

      I had a similar experience and my baby is one now. I made a maximum of 60 mL of milk in a day and I was a mess thinking that I had also failed my baby. I found this blog to be so reassuring and comforting in a very hard time for me. You are not alone.

      My baby is turning out fine. She only had one minor ear infection that healed quickly with antibiotics. She goes to daycare, so she has a runny nose most of the time (but so do all the other kids). She never had any gastro illnesses, skin problems or bad colds. She sleeps well, eats well and loves to play. No one could look at her and tell whether she was breastfed or formula fed.

    • PeggySue

      Sounds like you are doing A-OK. The people here are extremely knowledgeable, and also compassionate. Being a parent is tough business, and enjoying the baby sometimes gets forgotten. Please give that little girl a kiss, and try not to let the propaganda get you down.

    • MainlyMom

      That vague feeling that your letting your baby down due to less than perfect parenting never goes away. You get used to it tho! Trust me that if you didn’t attribute it to the formula you’d attribute it to something equally meaningless. Right now I’m feeling like I’m falling my kids because they both have anxiety issues. Next week I’ll remember they’re probably genetic issues and find something else to worry about.

      Congrats on your bundle of joy!!

      • The Kids Aren’t AltRight

        Omg, there are so many ways to let them down, aren’t there, lol.

        • Merrie

          Yeah, but you’re doing your best and trying to figure out the best way to do each thing and are concerned about your kid, which makes you as good as any parent out there and way better than many parents. Kid will be fine. As long as they’re happy and growing things are okay. If they’re not then you’ll figure something out!

        • With my three now 38, 36, and 35, I’m continually amazed they managed to survive ME

    • Mel

      Personally, I felt much more emotionally invested in breastfeeding while I was pumping for my son and while I was attempting to stop lactation than I did once I was able to stop lactating. The decision felt like a big thing – even though the benefits of breastfeeding for my son were over and the benefits of formula feeding him were clear as day.

      Since then, I’ve wondered if the anxiety/nervous energy/ constant focus I felt about breastfeeding was a throwback emotion left over from when moms who had poor supply needed to focus hard on figuring out how to maintain their supply while supplementing with whatever was at hand until their kid was weaned onto solids. Looking back, the feeling reminded me very much of the sense of helpless resignation I felt after my son was born. I knew Spawn was doing really well for a micro-preemie. He looked good. The doctors and nurses thought he was doing well. I found him enchanting and fascinating. All of that was true – but every day I was surprised on a gut-level that he was still alive when I saw him all pink and wiggling in his isolette giving his nurses hell. The feeling eventually morphed into “this is going to be one hell of a fight, but he’s got a chance” once he reached a developmental level that some preemies survived at without medical help – which was more than a little ironic because he was downright stable at that point.

      I wouldn’t be surprised if the same thing happens when moms know they aren’t producing enough milk to keep their babies going. Anxiety sucks – but it can be a powerful motivator to find a solution for the problem. We just haven’t had access to safe water and nutritionally balanced formula for as long as we’ve had babies and lactation problems so we’re stuck with body-level emotions that don’t match what our brains know.

      • Ms. Sweaterfan

        I totally agree with this, and I often wondered if there was some evolutionary factor in play while I was continuing to exclusively pump day and night even though I hated it. Before giving birth I had all but decided to combo feed, but when my son was born I got stuck in this pattern of doing whatever it took to make EBF work. My particular problem was DMER, so stopping BF felt even more like a failure bc my supply was fine and my son was thriving. But eventually I had just had enough and decided to switch to formula at 4 months. I tried to phase out the pumping gradually, but the month or so when I was quitting and then when my body was readjusting to not nursing was brutal – probably worse than the nursing for me because of the combination of crazy hormones and the feeling of failure. When my hormones FINALLY got back to normal that was the first time I felt like me again after giving birth. Anyway, long story short, I don’t have the scientific expertise to know how it would work, but I’m convinced that that (sometimes irrational) determination to continue nursing has got to be some sort of leftover survival instinct from a time when EBF was the only safe option.

        • Cristina

          That makes so much sense! It also explains why some women who choose to never start usually have more a DGAF attitude.

        • Mel

          I hated the entire process of shutting down lactation. I had random feelings of guilt which morphed quickly into exasperated anger.

          See, I’d been hearing how missing a single pump was going to destroy my milk production forever (which I knew was not a thing based on dairy farming and a bit of common sense since infants go off-feed when sick without having mom’s lactation stop dead…), but no one thought to mention that fact that once lactation is established at 8-12 weeks postpartum stopping it is a long, drawn-out process.

          Well, no one besides my husband when I asked him how long it after a cow is dry that they stop milk production all together. I forgot to take into effect the fact that a dry cow is entering her 3rd trimester of pregnancy and I certainly was not preggers let alone really pregnant….

          So – yeah, I thought that I’d be able to stop production in a week or two if I went cold-turkey and only pumped for comfort. *snorts* Try six weeks! While I had a medically complicated newborn living in my dining room!

    • Merrie

      My combo fed baby is doing great. No noticeable differences between him and his EBF siblings. He was fully FF by his first birthday, though, and was the only one of my kids to self wean. I kept stepping down pumping because hey, this formula gig ain’t too bad, and pumping sucks, and then over time my supply wasn’t much and he was no longer interested.

      My oldest is now 7 1/2 and considering what we have been through so far and what is still ahead of us parenting-wise, breastmilk versus formula is really such a small slice of the parenting picture. It’s not worth the amount of emphasis we put on it. I think some of that emphasis comes from the fact that when you are in that spot with your first child this IS a big segment of your parenting journey SO FAR, but it’s all the blink of an eye in the grand scheme of things.

      • GeorgiaPeach23

        As a brand new mom of a son who just screams at my nipples: I really needed to hear this. Thank you.

    • demodocus

      My ebf’d and eff’d kids are cruising right along on their respective timelines, making all the milestones at roughly the same time of their lives. Except for being able to sit still; the ebf’d one has a harder time sitting still and listening than his younger eff’d sib.

      • Who?

        Yup my ebf kid still has trouble sitting still, except when he’s so focussed he doesn’t move for hours.

        He’s 27 in a week or so, does a couple of hours of fitness training every day, which takes the edge off, apparently.

        It’s almost like it’s temperament, or something…

  • As you have also pointed out, many women will be unable to accept this review–or indeed any other evidence–because that will mean that what they struggled and suffered for was trivial, and that their choices may have been more harmful than good.

    • alongpursuit

      You are entirely right! In my mostly terrible experience with lactation consultants I came to surmise that this is the reason they were so inflexible and unable to take my individual situation into account. It was all “breast is best” la-la-la (hands over ears) even when I was delirious from a breastfeed / formula feed / pump triple feeding routine around the clock and not seeing any increase in my measly supply at all. I want to write my hospital and encourage them to stop their involvement in the BFHI and include articles like this one. It’s a total ideology and no longer evidence-based and it needs to stop. Now.

  • fiftyfifty1

    I’m so pleased the narrative is changing.