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?
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