The AAP doubled down on the long-term benefits of breastfeeding, just as the evidence for those benefits was crumbling underneath their feet.
In their most recent statement on breastfeeding, issued in 2012, the American Academy of Pediatrics (AAP) reaffirmed their earlier guidelines recommending 6 months of exclusive breastfeeding. They justified this recommendation by citing “the health outcomes of exclusively breastfed infants and infants who never or only partially breastfed.”
This statement represents a doubling down by the AAP. They are once again affirming idea breastfeeding confers massive, lifelong benefits to babies—benefits so profound, they say, that the decision to breastfeed should not be considered a “lifestyle” choice but in “investment” in your child’s future—despite recent, large, and better-designed studies have overwhelmingly shown that the benefits of breastfeeding in the developed world are trivial.
To see how just how astonishingly out of step these statements are with the actual evidence, let’s quickly review the last decade of breastfeeding research.
What does the available evidence suggest about breastfeeding?
1) The largest benefits of breastfeeding occur while an infant is being breastfed.
Breastfeeding lowers risk of diarrhea, respiratory infections, and perhaps ear infections.
Breastfeeding also appears reduces the risk of SIDS by 30-50%. This latter benefit sounds substantial, but it’s worth remembering that SIDS is, thankfully, very rare, and that the protective effect of breastfeeding again SIDS is tiny compared to the huge effects of putting your baby to sleep on her back, not overbundling, and avoiding drugs or alcohol while co-sleeping with your baby.
In short, in developed countries like the United States, for full term babies, these short term benefits are nice but not essential. They mostly matter from a public health perspective, lowering the risk of rare yet costly hospitalizations. They matter little from an individual perspective.
2) In preterm babies, especially those born very early or very small, the benefits of breastfeeding are profound.
Breastmilk substantially lowers their chances of two relatively common life-threatening infections that afflict preemies: necrotizing enterocolitis and bronchiolitis, and reduces the risk of vision impairments from another common complication of early birth, retinopathy of prematurity.
3) The supposed long-term benefits of breastfeeding for reducing the risk of obesity, allergies and asthma and for raising IQ are either small (in the case of IQ) or non-existent (in the case of obesity and allergies).
While a reduction in allergies and asthma and obesity show up in studies that simply compare formula-fed with breastfed babies, no such benefits are seen in studies that more fully account for the myriad other advantages of breastfed babies. The sole, large randomized trial of breastfeeding showed no benefit. If anything, children who were breastfed were at a slightly higher risk of allergies. Sibling and cross-cultural comparisons have come to similar conclusions: breastfeeding does not prevent allergies or asthma.
In short, the supposed long-term benefits found in observational research conducted in the 1980s and 1990s almost certainly derived from differences between breastfed and formula fed babies in parenting, home environment, and social and economic status, rather than from breastfeeding per se
(For a more in-depth look at this research, please see my earlier post.)
By contrast, breastfeeding does actually appear to boost IQ and educational performance, but the effect is tiny. A recent review of the research suggested that, once studies account for differences in maternal IQ, breastfeeding boosts IQ by an average of about 2 IQ points ( less than a fifth of a standard deviation)–roughly equivalent to the effect of sneezing while taking an IQ test.
While this boost may be real, in practice, it’s hardly significant. Breastfeeding will not get your baby into Harvard.
It’s also worth noting, for parents who care about their child’s IQ, that the breastfeeding boost seems most pronounced among those living in poverty, and fades to close to zero among the socially and economically advantaged.
Given all this, let’s return to our original question.
Why is the AAP exaggerating breastfeeding’s benefits?
Almost certainly the AAP and others who overzealously promote breastfeeding are acting in good faith, but for bad reasons.
First of all, they want to err on what they perceive as the side of caution.
Since breastfeeding does confer benefits against infections, has a large impact at a public health level, despite doing little at the individual level, and may have unknown beneficial impacts, it seems at first blush safer to encourage women to breastfeed.
Second, public health organizations like the AAP and CDC place little faith in the public’s ability to grasp nuanced messaging–especially when it comes to health advice for women.
(As just one egregious example, recall the tone-deaf recommendation by the CDC that all women of reproductive age avoid alcohol because they might become pregnant.)
If public health officials allowed for nuance, the “breast is best” mantra might morph into a more accurate, nuanced statement like, “All else being equal, it is better to breastfeed. But if breastfeeding causes you severe emotional distress or is physically difficult or financially costly, those costs likely outweigh the small benefits breastfeeding confers for full-term babies.”
Third, the World Health Organization has asked the AAP to match their positions on breastfeeding. Unfortunately, this results in painting with too broad a brush.
Unlike the AAP, which focuses on the United States, the World Health Organization makes global recommendations, and therefore must consider the impact of their positions on both the developed and developing world. In many developing countries where mothers and infants lack access to clean water and safe sources of food, the benefits of breastfeeding are frequently lifesaving.
Why does it matter if the AAP exaggerates breastfeeding’s benefits?
There are two major problems with this err on the side of “caution” approach.
1. By focusing on breastfeeding per se, which is what good science does (try to determine the impact of a single factor), we have unwittingly moved other aspects of early parenting and child development to the background.
Outside of a narrow scientific context, what researchers call confounders are actually the main enchilada. Mom’s education, your family’s social and financial well being, and most importantly your loving care for your child are vastly more important for your child’s health and well-being than whether you exclusively breastfeed, exclusively formula feed, or somewhere in between.
As Courtney Jung, a political science professor and author of Lactivism: How Feminists and Fundamentalists, Hippies and Yuppies, Physicians and Politicians Made Breastfeeding Big Business and Bad Policy, explains, familiarity with the research would radically reshape her earlier perspective on breastfeeding were she to have another baby:
“I would have to admit that breastfeeding is not the panacea I brandished so confidently when my children were babies. Even though I might use breastfeeding as a way to feed my baby, I could not longer use it as a talisman to ward off evil.
In fact, if I were to make up a list of things that really matter to the health of our children, breastfeeding wouldn’t even make it to the top ten.
It’s nowhere near as important as loving your child very much and letting her know it. It’s not important as putting your child to sleep on his back, or securely buckling the seatbelt… It’s not as important as talking and listening to your child… And it’s definitely not as important as simply caring, a great deal.”
2. Overstating the benefits takes the breastfeeding decision out of women’s hands, where it belongs.
Sure, for some, breastfeeding is easy. Your milk comes in early, you have no problems with supply, and you are physically, financially, and emotionally able to weather the demands on your time and the interrupted sleep.
But this is not the case for everyone. And so, outside the stodgy world of scientific papers and the ubiquitous idealized images of moms nursing their babies, there are tradeoffs.
Maybe you can either exclusively breastfeed and quit your job or you can supplement with formula and return to work. Maybe you need reasonable amounts of sleep, and your husband being able to feed the baby with formula keeps you from becoming depressed.
Despite these very real challenges, breastfeeding advocacy has been shockingly silent on the complex economic, mental, and emotional tradeoffs mothers and families face when deciding whether to breastfeeding and for how long to breastfeed, acting as if the right answer is always more is better, longer is better.
Advocates have focused much of their efforts to promote breastfeeding onto women themselves, instead of focusing on the complex systemic barriers to breastfeeding, like our pathetically subpar maternity leave policies.
I personally have seen the ill consequences of the overzealous “breast is best” messaging. I have seen competent, successful women brought to their knees, emotionally and physically, by failed efforts to breastfeed. I have been horrified by the stories of newborns starving because their mothers were afraid to give them a single bottle of formula.
And I can’t help but wonder, would these mothers have chosen to breastfeed or to deny their babies a bottle of formula knowing that the main benefit in the developed world is a lower chance of severe diarrhea during the first year of life?
And this, ultimately, is why it matters when the AAP oversells breastfeeding, because women have to make complex calculations about the relative benefits and risks of breastfeeding for themselves and their families. And how can they make good decisions when the benefits have been vastly oversold?
References
Bharwani, S. K., Green, B. F., Pezzullo, J. C., Bharwani, S. S., Bharwani, S. S., & Dhanireddy, R. (2016). Systematic review and meta-analysis of human milk intake and retinopathy of prematurity: a significant update. Journal of Perinatology: Official Journal of the California Perinatal Association, 36(11), 913–920.
Brion, M.-J. A., Lawlor, D. A., Matijasevich, A., Horta, B., Anselmi, L., Araújo, C. L., … Smith, G. D. (2011). What are the causal effects of breastfeeding on IQ, obesity and blood pressure? Evidence from comparing high-income with middle-income cohorts. International Journal of Epidemiology, 40(3), 670–680.
Colen, C. G., & Ramey, D. M. (2014). Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States using sibling comparisons. Social Science & Medicine, 109, 55–65.
Cristofalo, E. A., Schanler, R. J., Blanco, C. L., Sullivan, S., Trawoeger, R., Kiechl-Kohlendorfer, U., … Abrams, S. (2013). Randomized trial of exclusive human milk versus preterm formula diets in extremely premature infants. The Journal of Pediatrics, 163(6), 1592–1595.e1.
Jung, C. (2015, October 16). Overselling Breast-Feeding. The New York Times. Retrieved from https://www.nytimes.com/2015/10/18/opinion/sunday/overselling-breast-feeding.html
Metzger, M. W., & McDade, T. W. (2010). Breastfeeding as obesity prevention in the United States: a sibling difference model. American Journal of Human Biology: The Official Journal of the Human Biology Council, 22(3), 291–296.
Section on Breastfeeding. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827–e841.
Smithers, L. G., Kramer, M. S., & Lynch, J. W. (2015). Effects of Breastfeeding on Obesity and Intelligence: Causal Insights From Different Study Designs. JAMA Pediatrics, 169(8), 707–708.
Victora, C. G., Horta, B. L., Loret de Mola, C., Quevedo, L., Pinheiro, R. T., Gigante, D. P., … Barros, F. C. (2015). Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. The Lancet. Global Health, 3(4), e199–e205.
Villamor-Martínez, E., Pierro, M., Cavallaro, G., Mosca, F., Kramer, B. W., & Villamor, E. (2018). Donor Human Milk Protects against Bronchopulmonary Dysplasia: A Systematic Review and Meta-Analysis. Nutrients, 10(2). https://doi.org/10.3390/nu10020238
love. this. site.
On Wed, Mar 21, 2018 at 11:54 AM, Expecting Science wrote:
> Amy Kiefer posted: “AAP has doubled-down on the long-term benefits of > breastfeeding, just as the evidence for those benefits crumbled underneath > their feet. In their most recent statement on breastfeeding, issued in > 2012, the American Academy of Pediatrics (AAP) reaffirmed t” >
All. Of. This.
I am a longtime reader who enjoys your blog. You suggest that public health proscriptions have infringed on a woman’s right to choose how she feeds her baby. But you pick only one public policy to acknowledge in your analysis, while suggesting that it provides a complete picture.
If you truly believe, after assessing the scientific literature, that breastfeeding in the United States provides no longterm health benefits, does it follow that women deserve no workplace accommodations, health insurance coverage or other support if they choose to “indulge” in breastfeeding? That appears to be the logical conclusion of your piece when you suggest that breastfeeding can be viewed as “lifestyle choice” and argue that it is inaccurate to refer to it as an “investment” in a child’s health. You briefly mention preemies and SIDS but suggest those factors are of limited and relatively trivial overall importance when weighed against the body of evidence.
It is clear that many women feel unsupported and criticized when they choose to not breastfeed. It is also clear that many women have inadequate support when they do breastfeed. You describe the great practical challenges of breastfeeding (its impact on work, sleep, and other aspects of a mother’s life) in the context of wanting to affirm the choice to NOT breastfeed. Yet when I struggled mightily with breastfeeding, I did not feel affirmed in my choice TO breastfeed. I found it systematically blocked in many ways. One recommendation from the AAP was much less influential on my reality than the daily grind of when, where and how to feed.
To provide women with a true personal choice to breastfeed, we as a community would need to remove systematic barriers to breastfeeding at the same time we provided accurate and honest information about its benefits.
Do women have real, accessible, health insurance coverage for lactation help and for breast pumps, supplies and training? Are there workplace laws and compliance enforcement that allow them to pump or feed during the workday without great personal stress? What about paid maternity leave for the first 6 months or at least the first 3 months to allow for breastfeeding at home?
You analyze whether breastfeeding is a medically unnecessary choice but in weighing the costs and benefits, you provide the impression that public policy pushes in only one direction (pro breastfeeding) rather than in multiple directions (for and against). The suggestion that there is a systematic governmental collusion to guilt-trip women who don’t breastfeed seems like a very narrow assessment of reality. And if you characterize breastfeeding as a luxury that only some women could or should indulge in, you are also suggesting that it should not qualify as a medical right. Addressing unnecessary guilt-tripping can be done without undermining our community’s already ambivalent and limited willingness to tolerate breastfeeding.
Thank you for this clearly heartfelt commentary. My goal was *not* to say that there should not be public and systemic support for breastfeeding. Absolutely, we need lactation consultants, hospital staff, and nurses to help support women who choose to breastfeed. Absolutely, we need policies, like longer family leave, that make it easier for women who choose to breastfeed to do so. I have no objections to any of that. Nor am I trying to argue that from a public health or health care cost perspective, breastfeeding does not matter. What I am saying is that for individual women, who are weighing whether, how (exclusively or partially), and for how long to breastfeed, we do them a disservice by misrepresenting the best available evidence. Ultimately, this also does a disservice so public health groups like the AAP, who undermine public trust in their messaging by clinging to discredited evidence.
I hope you will keep reading — and I appreciate your feedback.
-Amy
I would like to comment on the Colen and Ramey (2014) article that you have included in your references.
It IS interesting to consider how researchers find and follow families in which one child was breastfed and one was not. This is a way to assess benefits of breastfeeding that would not be related to the social determinants of health that lead women to breastfeed (or not) in the first place, since both siblings would be raised in a similar environment. For instance, it is known that women who exclusively breastfeed tend to be more educated, have better support systems, and have more ‘tools’ to make healthier lifestyle decisions. And so, it would make sense that their children might do better academically and also be healthier compared to children whose mothers do not have the same advantages.
By doing a study comparing siblings who were fed differently but raised by the same mother, the authors had some interesting findings. I have included an excerpt from the abstract:
“Results from standard multiple regression models suggest that children aged 4 to 14 who were breast- as opposed to bottle-fed did significantly better on 10 of the 11 outcomes studied. Once we restrict analyses to siblings and incorporate within-family fixed effects, estimates of the association between breastfeeding and all but one indicator of child health and wellbeing dramatically decrease and fail to maintain statistical significance. Our results suggest that much of the beneficial long-term effects typically attributed to breastfeeding, per se, may primarily be due to selection pressures into infant feeding practices along key demographic characteristics such as race and socioeconomic status.”
I cannot speak to all the statistical analyses that were done but one flaw that I can see in this study is that the authors looked at two independent variables when considering infant feeding. These were breastfeeding status and duration of breastfeeding. When coding, breastfeeding status was 0 if there was no breastfeeding and 1 if there was ANY breastfeeding. So a woman who only breastfed once in the hospital would be coded the same way as a woman who exclusively breastfed for the recommended duration. This study looked at infants born between 1986 and 2010. Only 25% of infants were exclusively breastfeeding at 6 months in the States in 2015 (https://www.cdc.gov/breastfeeding/data/reportcard.htm ), so the rate would have been lower during the years included in this study, and probably considerably lower in 1986.
I suspect that findings in this study that minimized the benefits of breastfeeding would have been related to this, at least in part. It would be interesting to see a similar study that factored in how much breastfeeding actually occurred. It would be great to replicate this study with a more accurate portrayal of exclusive breastfeeding to see the results.
It seems both authors are sociologists and so they may not appreciate the difference between exclusive breastfeeding and ‘any’ breastfeeding in terms of health benefits.
respectfully,
Although I concur with you, in the sense that if the mother is depressed or sick, taking care of herself and the baby are priorities. I have to say that there is no doubt that “breast is best”. It may not fit into this society, where women have to work and have other priorities. But just by comparing breast milk with formula, the answer is quite simple. As of today one of the best selling formulas in the US ingredients’ are corn syrup solids, vegetable oil, partially hydrolyzed nonfat milk, and a list of synthetic vitamins. Which the body doesn’t absorb as well as breast milk. Therefore babies need more formula to achieve the “same” benefits than with breast milk. Which is one of the reason why formula babies tend to be more overweight than exclusively breastfed babies. On the other hand breast milk has white blood cells, stem cells, more than 1,000 proteins, hormones, antibodies, over 1,400 microRNAs, and the list goes on. So if we actually compare apples to apples breast is best. Have we been able to study the effects or functions of many of this cells in our bodies, nope. Is very complex and difficult to test a long term study. In addition, breastfeeding for a month, three months, a year, mixing breastfeeding with formula feeding (many people that breastfeed also use formula so that other people can feed the baby or at daycare), all these different variables also have different effects in the body. So trying to assess its effectiveness as a whole in comparison with formula feeding will not be accurate. Unless we are testing one year of exclusively breastfeeding with one year of formula, keeping all other variables the same.