Insisting breastfeeding matters to everyone, Dr. Meghan Azad shows why it doesn’t

One percent on white background. Isolated 3D illustration

The Fed Is Best movement has completely changed the conversation around breastfeeding.

True, they haven’t yet gotten lactation and health organizations to acknowledge outright that the benefits of breastfeeding term babies in industrialized countries are so trivial that they literally cannot be measured. But we (I consider myself part of the movement though I’m not part of the Foundation) have forced a re-framing of the conversation. And as I’ve written many times in the past, when you frame the discussion, you own it.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Breastfeeding matters to approximately 1% of babies in industrialized countries. There is no evidence that it has a substantive impact on 99%.[/pullquote]

A new piece from microbiome researcher Meghan Azad, PhD, offers an excellent example. In explaining why breastfeeding matters to everyone, Dr. Azad unwittingly shows why it doesn’t much matter.

The author begins with the fallback position into which breastfeeding researchers have been forced: the language of breastfeeding “goals.”

Research in the US has found that most women (60%) do not meet their own breastfeeding duration goals…

This reflects the lactivist understanding that intense pressure to breastfeed, such as the Baby Friendly Hospital Initiative, will no longer be tolerated going forward. That doesn’t mean that lactation professionals recognized the error of their anti-feminist ways, merely that they’ve modified their language.

“Look at us,” they invite. “We’re not pressuring women to breastfeed; we’re helping them meet their goals!”

That’s about as persuasive as the fashion industry absolving itself of the pressure on women to be thin by declaring, “We not pressuring women to lose weight; we’re helping them meet their weight goals!”

Dr. Azad then asks:

But is breastmilk truly better than formula milk for supporting infant health outcomes?

She answers yes, but puts so many qualifiers around it that she’s basically acknowledging that no, it doesn’t matter.

… [T]he magnitude of difference depends on a multitude of factors including genetics, the environment, socio-economic factors, medications, length of gestation (prematurity), and method of birth. Simply put, a healthy full-term infant born vaginally with no genetic risk factors may not benefit to the same extent from breastfeeding as a premature infant requiring multiple medications and interventions …

This is just another way of admitting to what I have been writing for more than a decade: in industrialized countries breastmilk can have lifesaving benefits for extremely premature infants (only 1% of infants born each year) but has negligible benefits for term babies.

When it comes to the rest of the world, Dr. Azad persists in promoting the fantasy that breastfeeding could save more than 800,000 lives per year. She fails to note that this is based on a mathematical model that has never been validated and the model itself erroneously assumes causation for every observed correlation. She also neglects to mention that the countries with the highest breastfeeding rates (98%+) have the highest infant mortality rates. If the babies who are already being breastfed are the ones who are dying, how could increasing breastfeeding rates elsewhere save them?

Then Dr. Azad pivots to tenuous “benefits” that have never been confirmed. As I recently explained, the ever more nebulous benefits of breastfeeding (the microbiome! epigenetics!) are a fallback position, an acknowledgment that the substantive benefits of breastfeeding have been largely debunked.

Breastmilk also contains many factors that directly enhance the infant’s immune system, regulate appetite and support their gut bacteria. For example, there are special sugars in breastmilk called human milk oligosaccharides (HMOs). HMOs are the third most abundant solid component in breastmilk, yet they are completely indigestible to the infant. The primary role of HMOs is to act as a prebiotic, or food source, for beneficial bacteria in the infant’s gut, such as Bifidobacterium longum subspecies infantis (B. infantis). This bacterium is specifically adapted to proliferate in the presence of HMOs, allowing it to prevent the growth of other potentially pathogenic bacteria by crowding them out.

And:

B. infantis and other gut bacteria (collectively known as the ‘gut microbiome’) also help train the infant immune system and produce essential vitamins, having a long-term impact on infant health and development. While there is still much to learn about what constitutes a healthy or unhealthy microbiome, we know that breastfeeding is among the most influential factors shaping this important community of ‘good bacteria’.

How does that affect the health of individual infants? To date, there is no evidence that it does.

Dr. Azad continues with ever smaller benefits:

Breastfeeding is also protective against breast cancer, offering a 4.3% reduction in risk for every 12 months that a mother breastfeeds over the course of her lifetime …

But pregnancy raises the risk of breast cancer by 16% over the following years. Yet the researchers who made that discovery claim that risk is so small that it shouldn’t be factored into the decision to have children. If that’s the case, why should a much smaller reduction in the risk of breast cancer from breastfeeding factor into the decision on how to feed infants? It shouldn’t.

But wait! Breastfeeding is important for the environment!

It is important to consider the environmental savings of breastfeeding as opposed to the environmental footprint created by formula feeding. It is estimated that more than 4000 L of water are required to produce 1 kg of powdered formula and that 86 000 tonnes of metal and 364 000 tonnes of paper end up in USA landfills annually as a result of formula packaging…

This is taken directly from the new nonsensical editorial in the BMJ that I wrote about only last week (Climate change: have you tried squirting breastmilk on it?).

The calories in breastmilk come from the increased amount of food that breastfeeding women must eat. In contrast to cows who need only consume grass to make milk, women need meat (produced by industrial farming), vegetables and fruit (produced by industrial agriculture) and fish (caught by practices that are destroying the oceans).

Moreover, how green is the plastic used in breast pumps? How green is the electricity and batteries used to power them? How green are nursing bras made with synthetic fibers? How green are special clothing, breastfeeding pillows and other breastfeeding accessories?

Dr. Azad concludes:

A cost analysis of common childhood infectious diseases that can be prevented through breastfeeding (gastroenteritis, necrotizing enterocolitis, respiratory tract infections, and acute otitis media) found that a 10% increase in exclusive breastfeeding until 6 months and sustained breastfeeding until 1 year could save the US healthcare system $312 million per year.

That sounds impressive until you consider that breastfeeding itself has become the leading risk factor for newborn hospitalization. An astounding 1 in every 71 exclusively breastfed babies will be hospitalized leading to approximately 40,000 preventable hospital admissions per year at a cost of hundreds of millions of dollars. That doesn’t even include the downstream costs of neonatal brain injuries from dehydration and severe jaundice.

The bottom line is that breastfeeding matters only to approximately 1% of babies in industrialized countries. There is no evidence — and Dr. Azad fails to provide any evidence — that it has a substantive impact on the other 99%.

  • Megan

    Can you cite the source for “An astounding 1 in every 71 exclusively breastfed babies will be hospitalized leading to approximately 40,000 preventable hospital admissions per year at a cost of hundreds of millions of dollars.”?

    • EmbraceYourInnerCrone

      https://pdfs.semanticscholar.org/f43d/71ee4b31dde05e6c509a27e52d39f2f4c63d.pdf

      “Exclusive breastfeeding is not only a major risk factor for
      hyperbilirubinemia but also for dehydration, particularly if nursing is not going well and weight
      loss is excessive [12, 22-25]. Significant weight loss from birth reflects feeding problems [8].
      Weight loss > 5% was observed in about 25% of breastfed infants during their first 24 hours of
      life [27]. Approximately one-third of breastfed term infants readmitted for hyperbilirubinemia
      (mean TSB level of 22.8 mg/dL) showed to have weight loss from birth > 12% [6]. “

      • Megan

        That’s an interesting study, but it has nothing to do with the claim that “1 in every 71 exclusively breastfed babies will be hospitalized leading to approximately 40,000 preventable hospital admissions per year at a cost of hundreds of millions of dollars.”

    • Daleth

      I’m interested in that cite too — the 1 in 71, I mean; once we know the rate, it’s not hard to extrapolate to the number of preventable hospital admissions (start with the number of babies born each year, multiply by the percent exclusively breastfed in the first month of life — which is when this type of readmissions happens — and apply the 1/71 or whatever rate to that).

      If it does come out to around 40,000 hospitalizations a year, which doesn’t seem like a stretch given that about 3.7 million babies a year are born in the US, then knowing what even a short hospitalization costs, hundreds of millions is not surprising.

      But anyway. While we await that specific study, here’s one looking at almost 150,000 healthy term and near-term babies, and finding that EBF babies have double the risk of hospital readmission as formula-fed babies, and also 32% more outpatient visits; and that 6.2% of EBF babies were readmitted: https://fedisbest.org/2018/01/exclusively-breastfed-newborns-double-risk-rehospitalized/

  • mabelcruet

    I called it 3 months ago! I knew it wouldn’t take long before molecular benefits were being touted as further proof of breast milk supremacy and become mainstream ‘facts’. My post from 3 months ago:

    “Epigenetics and the microbiome are old hat now. The next big ideas that they are seizing on are molecular metabolite variations to prevent childhood obesity; and oligosaccharide research, particularly 2′-Fucosyllactose which has prebiotic, antimicrobial effects, affects gut maturation, and is responsible for immune modulation. Leaky gut is real-get with the programme!”

    Nice theory, not much hard evidence.

    • The oracle has spoken.

      • mabelcruet

        I’ve got to get my continuing professional development points-I’ve been reading journals and doing reflective notes on ‘What I learned today…’ It’s like being back at school and doing homework!

    • Cartman36

      Yes, we should definitely focus on “molecular metabolite variations to prevent childhood obesity” and not the fact that there is a fast food restaurant on every corner, fast food restaurants and junk food sold to kids in our schools, places like hardware stores now sell candy, chips, and soda, a lack of safe play spaces and grocery stores in many neighborhoods, etc etc etc. #sarcasm

      I could go on and on and on but I feel like I sound like a broken record. Instead of focusing on the things that require the government and communities to put money and effort into fixing (i.e. food deserts) we make it the responsibility of mothers to solve complex issues like childhood obesity through a simple (and likely completely unrelated) process like breastfeeding.

      It makes me angry

      • mabelcruet

        It’s exactly like the paper written by Natalie Shenker, putting the blame on formula feeding mothers for environmental damage and climate change, rather than the huge multinational companies and government policies and inaction. The environmental impact of formula feeding is negligible compared to that, and to me it seems that the impact of molecular metabolites on obesity is likely to be equally negligible when compared with the impact very easy availability of junk food makes.

      • KeeperOfTheBooks

        Exactly.
        As a sample size of one, for me personally, the family ate a lot more healthily once I stopped breastfeeding Baby Books 3. Why? Because evening time is limited–yes, even for we SAHMs–and if the baby is screaming for food, I’ll feed the baby before dealing with dinner, but then the toddlers start yelling for food, and It Ain’t Pretty, fast.
        When I stopped, I could hand DH a hungry baby and a bottle, and get some fruits and veggies on the table in addition to the mac and cheese. :p Sure, prepping fruits or veggies takes only a few minutes, but that’s a few minutes you simply don’t have when you have 45 minutes’ worth of stuff to do in 30.
        As for play places, don’t get me started. I would far, far, FAR rather have my kids get a broken bone swinging off the monkey bars at some point than have them develop lifestyle-related diabetes at ten, but that’s not how our world views risk anymore. Instead, it’s “let’s take all the fun stuff off the playgrounds lest we get sued over a sprained ankle, never mind that now Junior’s gonna be dealing with blood sugar testing, impaired nerve function, and the possibility of blindness.” GRRRR!
        I am…not keen…on megachurches, but I do need to give a shoutout to a couple near us who have as a sort of ministry MASSIVE indoor play places which are free and open to the public all week. The best of them even has a coffee shop at the base, though you’re also welcome to bring food in yourself. The kids have a safe, air-conditioned place to play, they can’t run out without going past their parents, and the churches engage in no proselytizing whatsoever associated with this beyond having their service times posted.

  • Christine O’Hare

    From my side of things, breastfeeding had an overall much higher “consumption” rate than formula feeding.
    Formula equaled bottles, a pkg of formula, water to mix and water/soap to clean bottles.
    Breastfeeding was a pump, monthly pump replacement parts, bottles for pump, cooler & ice packs for pumped milk, electricity & batteries for pump, bags for pumped milk, fridge/freezer electricity for storing milk, bottles for feeding, water/soap to clean bottles and parts, nipple cream, nursing pads, nursing bras day/night, nursing friendly shirts, increased food intake, increased water intake. Increased water & electricity for additional laundry. And of course the packaging all those things came in.
    Note most of the pumping related things were shipped to me (extra packaging) vs. the formula I could pickup from Target on my way home from work or on my lunch break.
    Is it any wonder I’m going to be much quicker to switch to formula with my second child?!

    • Anna

      No, thats where you went wrong. Youre supposed to quit your job and stay home pandering to your childs every need like Jesus intended! When one weans you have another!

      • Christine O’Hare

        Ah, that’s what I forgot. Jesus.

  • rational thinker

    Having breastfeeding “goals” can be more harmful than helpful because if it is a goal you will be coached to reach your goals without regard to your own physical limitations. Most often to the point of hospital readmission.

  • Mel

    *chokes a bit*

    In what universe is necrotizing enterocolitis a common childhood illness?

    Like….even in a NICU populated by micro preemies being fed only formula, the vast majority of those babies will never develop NEC. Current feeding guidelines involving breast milk from the mother of a preemie or donor milk has cut that rate by half in babies born before 34 weeks – but best practices allow the introduction on non-human milk fortifiers and formula at 34 weeks gestation when the total NEC risk has dropped to “possible, but really, really rare”.

    Lumping NEC in with “stomach flu, colds, and ear infections” makes the original author – and whoever published the paper – seem strangely ignorant of basic pediatric medicine.

    • mabelcruet

      Basic pediatric medicine is way above their heads, flying up over the clouds somewhere. I read multiple blogs and posts advising mothers to avoid delivering in large tertiary level regional hospitals because the neonatal death rate in those hospitals is far higher than the smaller district general hospitals. There is absolutely no understanding that the big regional hospitals generally cater for the high risk births-babies with anomalies, micropremies, mothers with complex pregnancies, growth restricted baby etc. Obviously, this means that they will inevitably have more deaths because they’ve got far more vulnerable babies. But the lactivist belief is that if you’re in hospital you shouldn’t die, so if there are deaths someone must be to blame.

      • Mattie

        Also more people means that even if the ‘rate’ of death is the same you will see a higher number of deaths…because that’s how maths works.

        If a death rate is 1 in 1000 and your hospital delivers 1000 babies in a year, you’d expect 1 death in a year. If your hospital delivers 1000 babies a month you’d expect to see 12 deaths a year. The rate is still the same. Not even taking into account that many more of those births would start off with a higher risk of death anyway because they are higher risk births

        (Those numbers are entirely made up)

      • Mel

        I was incredibly grateful that I was giving birth to my micro preemie at a Level 4 NICU; Spawn was considered a pretty easy baby since he was a 26 weeker – not like those tricksy 23 or 24 weekers. And my cousin whose daughter was born with a complex cardiac issue was grateful she lived in a major city with a top-ranked peds cardiac unit.

        The flip side of the ‘higher death rate’ is a higher survival rate for really complicated kiddos.

        Since Spawn was in the NICU for 4 months and I’m a chatterbox, I talked with various nurses who were on the air-transport team who would fly to various small regional hospitals in Michigan to transport babies born at Level 1 +2+3 NICUs to our Level 4 NICU. I’d forgotten how much of a NICU mom I’d become and asked “Are the parents of the baby relieved when the aircrew arrives?” The nurse thought about it and said, “Not really. They’re pretty shell shocked – but the hospital staff looks like we’re Santa Claus because caring for a baby who needs more advanced care than you have access to is terrifying.”

  • FormerPhysicist

    I’ve ranted before. Goals made in ignorance *should* be subject to change when facts on the ground change. Wanting to breastfeed for a year is grand. If you find you don’t like it, or have difficulty, then changing your goals makes sense.
    Sticking to a goal because you once thought it would be nice makes as much sense as having an ultra-marathon for a goal and not changing your goal if you break a leg.