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.

Infectious disease

Acute otitis media. Exclusive breastfeeding for 6 months is associated with a 43% reduction in the risk of acute otitis media (AOM) by 2 years of age (odds ratio [OR]=0.57; 95% confidence interval [CI], 0.44-0.75). Beyond 2 years of age, or when comparing “ever” and “never” breastfeeding, the effect disappears. All studies in this meta-analysis had serious limitations.¹⁸

Nearly half of children will have at least one case of AOM by one year of age; 80%, by 2 years.^19,20 Since the introduction of the heptavalent pneumococcal conjugate vaccine, the rate of AOM at 2 years has fallen by as much as 20%.²¹ Assuming an incidence of 60% to 80% of AOM by 2 years, only 2 or 3 infants need to be exclusively breastfed for 6 months to prevent a single case of AOM.¹⁸ Prevention of AOM through breastfeeding may be related to head position during feeding, antibacterial effects of breast milk, protective oral microbiome in the breastfed infant pharynx, and/or prevention of primary viral upper respiratory infection (URI), which nearly always precedes AOM.^18,19

Upper and lower respiratory tract infections. Infants who are exclusively breastfed for 4 months and partially breastfed after 4 months have a lower risk of URI (OR=0.65; 95% CI, 0.51-0.83) and of lower respiratory tract infection (LRTI; OR=0.50; 95% CI, 0.32-0.72).²²

The effect is stronger for URI among infants exclusively breastfed for at least 6 months (OR=0.37; 95% CI, 0.18-0.74), but is no longer significant by that time for LRTI (OR=0.33; 95% CI, 0.08-1.40). Importantly, AOM was included in the URI group, and, as previously discussed, AOM has independently been shown to have an inverse relationship with breastfeeding duration.

At 7 to 12 months of age, no association was seen between breastfeeding and the incidence of URI. Curiously, an association with LRTI was again detected for infants breastfed exclusively for 4 months and partially thereafter, but was not detected with exclusive breastfeeding for at least 6 months (OR=0.46; 95% CI, 0.31-0.69). In this study, in the first 6 months of life, 40% of infants had a URI and 8% had an LRTI. The findings in this cohort suggest an NNT of 6 or 7 for prevention of URI and an NNT of 25 for prevention of LRTI in the first 6 months of life.²²

Continue to: Children younger than 2 years are...