Applied Evidence

Is the "breast is best" mantra an oversimplification?

J Fam Pract. 2018 June;67(6):E1-E9

From The Journal of Family Practice | 2018;67(6):E1-E9.

References

1. Global Strategy for Infant and Young Child Feeding. Geneva, Switzerland: World Health Organization, and New York, NY: UNICEF; 2003. Available at: www.who.int/maternal_child_adolescent/documents/9241562218/en/. Accessed April 4, 2018.

2. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice; Breastfeeding Expert Work Group. Committee Opinion No. 658: Optimizing support for breastfeeding as part of obstetric practice. Obstet Gynecol. 2016;127:e86-e92.

3. Gartner LM, Morton J, Lawrence RA, et al; American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506.

4. Breastfeeding (policy statement). Leawood, KS: American Academy of Family Physicians; 2007. Available at: https://www.aafp.org/about/policies/all/breastfeeding.html. Accessed April 3, 2018.

5. Office of the Surgeon General (US); Centers for Disease Control and Prevention (US); Office on Women’s Health (US). The Surgeon General’s call to action to support breastfeeding. Rockville, MD: US Department of Health and Human Services; 2011. Available at: www.surgeongeneral.gov/library/calls/breastfeeding/index.html. Updated August 12, 2014. Accessed April 4, 2018.

6. Breastfeeding: data & statistics. Atlanta, GA: Centers for Disease Control and Prevention; December 11, 2017. Available at: http://www.cdc.gov/breastfeeding/data/. Accessed May 17, 2018.

7. Fewtrell M, Wilson DC, Booth I, et al. A. Six months of exclusive breast feeding: how good is the evidence? BMJ. 2010;342:c5955.

8. Colen CG, Ramey DM. Is breast truly best? Estimating the effect of breastfeeding on long-term child wellbeing in the United States using sibling comparisons. Soc Sci Med. 2014;109:55-65.

9. Wolf J. Is Breast Best? Taking on the Breastfeeding Experts and the New High Stakes of Motherhood. New York, NY: NYU Press; 2010.

10. Tuteur A. Push Back: Guilt in the Age of Natural Parenting. New York, NY: HarperCollins Publishers; 2016.

11. Lee E. Health, morality, and infant feeding: British mothers’ experiences of formula milk use in the early weeks. Sociol Health Illn. 2007;29:1075-1090.

12. Williams K, Donaghue N, Kurz T. “Giving guilt the flick”?: an investigation of mothers’ talk about guilt in relation to infant feeding. Psychol Women Q. 2013;37:97-112.

13. Fahlquist JN, Roeser S. Ethical problems with information on infant feeding in developed countries. J Health Polit Policy Law. 2012;37:155-160.

14. U.S. Preventive Services Task Force. Final Recommendation Statement. Breastfeeding: Counseling. Available at: www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breastfeeding-counseling. Accessed April 4, 2018.

15. US Preventive Services Task Force. Primary Care Interventions to Support Breastfeeding: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;316:1688-1693.

16. Zahn CM, Hanley LE. Concerns over USPSTF draft recommendation on breastfeeding interventions [letter]. Washington, DC: The American College of Obstetricians and Gynecologists; May 18, 2016. Available at: https://www.acog.org/-/media/Departments/Breastfeeding/Breast-Feeding-ACOG-USPSTF.pdf?dmc=1&ts=20180518T1850056558. Accessed May 22, 2018.

17. Stuebe A. The risks of not breastfeeding for mothers and infants. Rev Obstet Gynecol. 2009;2:222-231.

18. Bowatte G, Tham R, Allen KJ, et al. Breastfeeding and childhood acute otitis media: a systematic review and meta-analysis. Acta Paediatr. 2015;104:85-95.

19. Chonmaitree T, Trujillo R, Jennings K, et al. Acute otitis media and other complications of viral respiratory infection. Pediatrics. 2016;137:e20153555.

20. Teele DW, Klein JO, Rosner B. Epidemiology of otitis media during the first seven years of life in children in greater Boston: a prospective, cohort study. J Infect Dis. 1989;160:83-94.

21. Grijalva CG, Poehling KA, Nuorti JP, et al. National impact of universal childhood immunization with pneumococcal conjugate vaccine on outpatient medical care visits in the United States. Pediatrics. 2006;118:865-873.

22. Duijts L, Jaddoe VW, Hofman A, et al. Prolonged and exclusive breastfeeding reduces the risk of infectious diseases in infancy. Pediatrics. 2010;126:e18-e25.

23. Allan GM, Arroll B. Prevention and treatment of the common cold: making sense of the evidence. CMAJ. 2014;186:190-199.

24. Kramer MS, Chalmers B, Hodnett ED, et al; PROBIT Study Group (Promotion of Breastfeeding Intervention Trial). Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA. 2001;285:413-420.

25. Dennehy PH. Acute diarrheal disease in children: epidemiology, prevention, and treatment. Infect Dis Clin North Am. 2005;19:585-602.

26. Cortese MM, Tate JE, Simonsen L, et al. Reduction in gastroenteritis in United States children and correlation with early rotavirus vaccine uptake from national medical claims databases. Pediatric Infect Dis J. 2010;29:489-494.

27. Ajetunmobi OM, Whyte B, Chalmers J, et al. Breastfeeding is associated with reduced childhood hospitalization: evidence from a Scottish birth cohort (1997-2009). J Pediatr. 2015;166:620-625.

28. Quigley MA, Kelly YJ, Sacker A. Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom Millennium Cohort Study. Pediatrics. 2007;119:e837-e842.

29. Radtke JV. The paradox of breastfeeding-associated morbidity among late preterm infants. J Obstet Gynecol Neonatal Nurs. 2011;40:9-24.

30. Escobar GJ, Gonzales VM, Armstrong M, et al. Rehospitalization for neonatal dehydration: a nested case-control study. Arch Pediatr Adolesc Med. 2002;156:155-161.

31. Salas AA, Salazar J, Burgoa CV, et al. Significant weight loss in breastfed term infants readmitted for hyperbilirubinemia. BMC Pediatr. 2009;9:82.

32. Tarcan A, Tiker F, Vatandaş NS, et al. Weight loss and hypernatremia in breast-fed babies: frequency in neonates with non-hemolytic jaundice. J Paediatr Child Health. 2005;41:484-487.

33. Flaherman VJ, Aby J, Burgos AE, et al. Effect of early limited formula on duration and exclusivity of breastfeeding in at-risk infants: an RCT. Pediatrics. 2013;131:1059-1065.

34. Straňák Z, Feyereislova S, Černá M, et al. J. Limited amount of formula may facilitate breastfeeding: randomized, controlled trial to compare standard clinical practice versus limited supplemental feeding. Denning PW, ed. PLoS One. 2016;11:e0150053.

35. Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Rockville, MD: Agency for Healthcare Research and Quality (US); 2007. Evidence Reports/Technology Assessments, No. 153. Available at: www.ncbi.nlm.nih.gov/books/NBK38337/. Accessed April 3, 2018.

36. Quigley M, McGuire W. Formula versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. 2014;(4):CD002971.

37. Hauck FR, Thompson JM, Tanabe KO, et al. Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis. Pediatrics. 2011;128:103-110.

38. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. The changing concept of sudden infant death syndrome: diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk. Pediatrics. 2005;116:1245-1255.

39. Moon RY, Fu L. Sudden infant death syndrome: an update. Pediatr Rev. 2012;33:314-320.

40. Lodge CJ, Tan DJ, Lau MX, et al. Breastfeeding and asthma and allergies: a systematic review and meta-analysis. Acta Paediatr. 2015;104:38-53.

41. Brim SN, Rudd RA, Funk RH, et al. Asthma prevalence among US children in underrepresented minority populations: American Indian/Alaska Native, Chinese, Filipino, and Asian Indian. Pediatrics. 2008;122:e217-e222.

42. Shaw TF, Currie GP, Koudelka CW, et al. Eczema prevalence in the United States: data from the 2003 National Survey of Children’s Health. J Invest Dermatol. 2011;131:67-73.

43. Mallol J, Crane J, von Mutius E, et al. The international study of asthma and allergies in childhood (ISAAC) Phase Three: a global synthesis. Allergol Immunopathol (Madr). 2013;41:73-85.

44. Flohr C, Nagel G, Weinmayr G, et al. Lack of evidence for a protective effect of prolonged breastfeeding on childhood eczema: lessons from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two. Br J Dermatol. 2011;165:1280-1289.

45. Tham R, Bowatte G, Dharmage SC, et al. Breastfeeding and the risk of dental caries: a systematic review and meta-analysis. Acta Paediatr. 2015;104:62-84.

46. Peres KG, Cascaes AM, Nascimento GG, et al. Effect of breastfeeding on malocclusions: a systematic review and meta-analysis. Acta Paediatr. 2015;104:54-61.

47. Amitya EL, Keinan-Boker L. Breastfeeding and childhood leukemia incidence: a meta-analysis and systematic review. JAMA Pediatr. 2015;169:e151025.

48. Inaba H, Greaves M, Mullighan CG. Acute lymphoblastic leukaemia. Lancet. 2013;381:1943-1955.

49. Guxens M, Mendez MA, Moltó-Puigmartí C, et al. Breastfeeding, long-chain polyunsaturated fatty acids in colostrum, and infant mental development. Pediatrics. 2011;128:e880-e889.

50. Andres A, Cleves MA, Bellando JB, et al. Developmental status of 1-year-old infants fed breast milk, cow’s milk, formula, or soy formula. Pediatrics. 2012;129:1134-1140.

51. Horta BL, Victora CG. Long-term effects of breastfeeding: a systematic review. Geneva, Switzerland: World Health Organization; 2013. Available at: http://apps.who.int/iris/bitstream/10665/79198/1/9789241505307_eng.pdf. Accessed August 16, 2016.

52. Horta BL, Loret de Mola C, Victora CG. Breastfeeding and intelligence: a systematic review and meta-analysis. Acta Paediatr. 2015;104:14-19.

53. Der G, Batty GD, Deary IJ. Effect of breast feeding on intelligence in children: prospective study, sibling pairs analysis, and meta-analysis. BMJ. 2006;333:945.

54. Sajjad A, Tharner A, Kiefte-de Jong JC, et al. Breastfeeding duration and non-verbal IQ in children. J Epidemiol Community Health 2015;69:775-781.

55. Yan J, Liu L, Zhu Y, et al. The association between breastfeeding and childhood obesity: a meta-analysis. BMC Public Health. 2014;14:1267.

56. Martin RM, Patel R, Kramer MS, et al. Effects of promoting longer-term and exclusive breastfeeding on adiposity and insulin-like growth factor-I at age 11.5 years: a randomized trial. JAMA. 2013;309:1005-1013.

57. Horta BL, Loret de Mola C, Victora CG. Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure, and type 2 diabetes: systematic review and meta-analysis. Acta Paediatr. 2015;104:30-37.

58. Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database of Syst Rev. 2012;15:CD003517.

59. U.S. Preventive Services Task Force. Final recommendation statement: aspirin use to prevent cardiovascular disease and colorectal cancer: preventive medication. Available at: www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/aspirin-to-prevent-cardiovascular-disease-and-cancer. Published September 2017. Accessed April 3, 2018.

60. U.S. Preventive Services Task Force. Screening for breast cancer. Available at: www.uspreventiveservicestaskforce.org/Page/SupportingDoc/breast-cancer-screening/final-evidence-summary9. Published November 2009. Accessed April 2, 2018.

61. Bass JL, Gartley T, Kleinman R. Unintended consequences of current breastfeeding initiatives. JAMA Pediatr. 2016;170:923-924.

62. Feldman-Winter L, Goldsmith JP; Committee on Fetus and Newborn; Task Force on Sudden Infant Death Syndrome. Safe sleep and skin-to-skin care in the neonatal period for healthy term newborns. Pediatrics. 2016;138:e20161889.

63. The Mother and Child Health and Education Trust. Ten steps to successful breastfeeding. Available at: www.tensteps.org. Published November 8, 2017. Accessed April 3, 2018.

64. Hauck FR, Omojokun OO, Siadaty MS. Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics. 2005;116:e716-e723.

65. Kair LR, Kenron D, Etheredge K, et al. Pacifier restriction and exclusive breastfeeding. Pediatrics. 2013;131:e1101-e1107.

66. Chung M, Raman G, Trikalinos T, et al. Interventions in primary care to promote breastfeeding: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008;149:565-582.

67. Wolf JB. Is breast really best? Risk and total motherhood in the National Breastfeeding Awareness Campaign. J Health Polit Policy Law. 2007;32:595-636.

68. Marshall JL, Godfrey M, Renfrew MJ. Being a ‘good mother’: managing breastfeeding and merging identities. Soc Sci Med. 2007;65:2147-2159.

69. Kelleher CM. The physical challenges of early breastfeeding. Soc Sci Med. 2006;63:2727-2738.

Hospitalization

Risk of infection is decreased. A large cohort study in Scotland, involving more than 500,000 children, found an association between exclusive breastfeeding for 6 to 8 weeks and decreased risk of hospitalization within the first 6 months of life. Formula-fed and mixed-fed infants had an increased hazard ratio (HR) for hospitalization for common childhood illness (HR=1.40; 95% CI, 1.35-1.45 for formula-fed infants and HR=1.18; 95% CI, 1.11-1.25 for mixed-fed infants).²⁷ The study also found increased rates of hospitalization for conditions for which other meta-analyses have failed to show a protective effect from breastfeeding—leading to suspicion of residual confounding in the study. Another United Kingdom cohort demonstrated lower rates of hospitalization for GI infection (NNT=171) and LRTI (NNT=115) among exclusively breastfed infants by 8 months of age.²⁸

Risk of neonatal readmission is increased. Late preterm infants who are exclusively breastfed are nearly twice as likely to be hospitalized as breastfed term or non-breastfed preterm infants, primarily due to dehydration, failure to thrive, weight loss, and hyperbilirubinemia. In fact, exclusive breastfeeding at discharge from the hospital is likely the single greatest risk factor for hospital readmission in newborns.^29,30 Term infants who are exclusively breastfed are more likely to be hospitalized compared to formula-fed or mixed-fed infants, due to hyperbilirubinemia, dehydration, hypernatremia, and weight loss (number needed to harm (NNH)=71).^30-32 For weight loss >10% of birth weight with or without hospitalization, the NNH for breastfed infants is 13.³²

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 infant rehospitalization.^33,34

Necrotizing enterocolitis

Exclusive breastfeeding for 6 months is associated with a 43% reduction in the risk of acute otitis media by 2 years of age.

In preterm infants, breastfeeding has been associated with a lower rate of necrotizing enterocolitis. In the 2007 Agency for Healthcare Research and Quality report, the association was found to be only marginally statistically significant, 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.³⁵ A 2012 Cochrane review included newer studies in its analysis but reached the same conclusion on the quality and heterogeneity of available evidence, with a NNT of 25.³⁶

Continue to: Sudden infant death syndrome