Is the "breast is best" mantra an oversimplification?

What issues frame and guide counseling on breastfeeding?

There is that “problem” with the evidence. 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.

The use of pacifiers before last sleep is more protective against SIDS than breastfeeding.

Breastfeeding rates are strongly socially patterned alongside socioeconomic status, race, and education level, all of which are simultaneously strongly tied to short- and long-term health outcomes.⁶ Other factors limiting the strength of the data set include varying definitions of infant feeding practices in different studies, varying definitions of outcomes and diseases, reverse causation, and evidence of publication bias in many meta-analyses. Given these shortcomings, the NNTs in this article probably represent a best-case scenario for breastfeeding outcomes for infants in the United States (TABLE 1^{18,22-24,28,36,39-43,47,48}).

Data need to be put into context. The NNTs for many breastfeeding outcomes (TABLE) compare favorably with other recommended interventions, particularly for other preventive care measures. Two examples: 81 mg/d aspirin for a 50-year-old man has an NNT of 35 to 45 for preventing nonfatal myocardial infarction, and the number needed to invite to screen with mammography to prevent one breast cancer death for a 50-year-old woman is 1339.^59,60

In both of these examples, >95% of patients will not benefit from the intervention, yet these preventive measures are routinely recommended and have a significant impact at the public health level. Notably, these outcomes are more serious than most breastfeeding outcomes; have a longer-lasting effect, better-quality data, and better data for potential harms; are causally linked to the intervention; and require much less effort and commitment of time than breastfeeding.

The question must be reckoned with: Can advocacy be harmful?

In recent years, a growing number of concerns have been raised about:

• the potential harms of breastfeeding advocacy
• exaggeration of the benefits of breastfeeding
• promotion of breastfeeding at the expense of evidence-based medicine.

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.^61,62 The BFHI, promoted by the Centers for Disease Control and Prevention, is increasingly being adopted by hospitals with the expressed goal of increasing the breastfeeding rate from birth to discharge.

Continue to: Some of the "Ten Steps"...