By Pamela Heggie, MD, FAAP, IBCLC, Fairview Children’s Clinic, Minneapolis and Robert M. Jacobson, MD, FAAP, Mayo Clinic, Rochester and MNAAP President
A recent article published in the journal Social Science and Medicine made headlines and was widely quoted in blogs, email list-serves and Facebook: “Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons” (Colen, 2014). This article raised questions about the long-term benefits of breastfeeding on health outcomes for children.
The investigators reviewed infant feeding histories within families and compared the long-term health outcomes of siblings within the same family. In particular they focused on families with siblings who had discordant feeding types where one sibling was breastfed and the other bottle-fed. The investigators compared the outcomes of these siblings over time, looking at 11 variables, including body mass index, asthma, obesity, and additional behavioral and academic outcomes. The study found that overall the breastfed children scored better than the bottle-fed children in 10 out of 11 health outcomes when all children were combined.
Yet when the investigators compared siblings in the same family–one breastfed and the other not, they found no statistically significant differences. They suggest that it is familial factors such as home environment, socio-economic status, race, and work status of mother that influence health outcome more than infant feeding type. The investigators conclude that breastfeeding has no long-term benefits.
However, the study is deeply flawed. When looking at the methods and the way the study was conducted, we note that the investigators fail to consider the duration of breastfeeding. The investigators included children in the breastfed group who may have received any amount of breastfeeding. Even breastfeeding prior to discharge from the hospital following delivery would have sufficed. The AAP recommends breastfeeding over formula feeding when possible and exclusive breastfeeding for six months before the introduction of solids. The study did not compare infants fed exclusively with breastmilk for six months with infants fed exclusively with formula for six months. The reader is left wondering how many of the discordant siblings were both basically formula-fed the entirety of their infancy.
This shortcoming of the study ignores the robust body of literature demonstrating a dose response relationship between breastmilk and health outcome. Multiple studies reported by the Agency for Healthcare Research and Quality (AHRQ) and noted in the 2011 Surgeon General’s Call to Action to Support Breastfeeding show that exclusive breastfeeding and a longer duration of breastfeeding improve health in a number of areas, including reduced risk for obesity, diabetes, infection, sudden infant death syndrome, necrotizing enterocolitis, and other health outcomes.
In addition, the investigators do not define “bottle-feeding.” The investigators appear to assume that a bottle-fed infant was given formula, but many mothers who choose not to nurse give breastmilk to their baby by bottle. By including babies who received breastmilk in the bottle-fed group, differences due to breastmilk versus formula would be lost.
Another limitation of this study is that it only addresses long-term effects (4 -14 years) when looking at potential benefits of breastfeeding versus bottle feeding. It ignores the early short-term benefits of breastfeeding so important in preventing illness in a baby’s first year of life, including reduction in sudden infant death syndrome, necrotizing enterocolitis, pneumonia, otitis media, and diarrhea.
Finally, the investigators disregard the benefits of breastfeeding on maternal health. Women who breastfeed have much lower rates of obesity, heart disease, and cancer and these effects last a lifetime for the mother. In addition, breastfeeding mothers often note the cost and time savings of breastfeeding.
The authors claim their results show that the benefits of breastfeeding are “overstated.” We disagree, given the many limitations of this study. Often the headlines from controversial studies like this one are confusing for families in our practices. So what shall we tell parents about breastfeeding?
The AAP 2012 Statement on Breastfeeding and the Use of Human Milk gives clear guidance to us and to the families we provide care for: Pediatricians should recommend exclusive breastfeeding for about 6 months, followed by continued breastfeeding to at least 1 year as complementary foods are introduced. The AAP statement goes on to say that “Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice.”
Minnesota Hospitals Act to Support Breastfeeding
Many hospitals throughout Minnesota are focusing on ways to improve breastfeeding rates and support infant feeding choice so that all families can reach their infant feeding goals. Some hospitals have chosen to pursue the Baby-Friendly Hospital Initiative as a way to help families get off to the right start with breastfeeding. The Baby-Friendly Hospital Initiative not only helps to increase overall rates of breastfeeding, it also reduces racial and ethnic disparity in breastfeeding rates.
The Baby-Friendly Hospital Initiative is a program developed in 1991 by the World Health Organization and UNICEF in an effort to reduce worldwide child mortality and improve health outcomes for mothers and babies. The initiative focuses on ten evidence-based hospital and birthing center practices that have been shown to increase the rates of breastfeeding regardless of race, ethnicity, income, language, or family constellation. The “10 Steps to Successful Breastfeeding” describe these evidence-based practices in detail. Hospitals pursuing Baby-Friendly designation must undergo a rigorous certification process including an on-site visit from the certifying agency.
The ten steps of the Baby-Friendly Hospital Initiative were endorsed by the AAP in 2009. Baby-Friendly hospitals provide care that emphasizes best practice in infant feeding, while helping ALL families reach their infant feeding goals. Hospitals provide breastfeeding support for mothers who plan to breastfeed and instruction about safe formula feeding for mothers who choose to formula feed their babies. No mother is ever “forced” to breastfeed.
There are currently 20,000 Baby-Friendly hospitals and birthing centers worldwide in 150 countries, but as of 2013, only 6.9% of US birth hospitals were certified Baby-Friendly. In Minnesota, two hospitals are Baby-Friendly: the University of Minnesota Amplatz Children’s Hospital and Austin Medical Center (Mayo Clinic Health System). Regions Hospital in St. Paul and Hennepin County Medical Center (HCMC) in Minneapolis are participating in a grant program from the Centers for Disease Control and Prevention called Best Fed Beginnings, which is designed to increase the number of Baby-Friendly hospitals in the country. Regions and HCMC joined 88 other hospitals throughout the country on a fast track Baby-Friendly journey as part of this grant program.
As of January 2014, 16 out of 97 Minnesota maternity care hospitals have declared intention to work on becoming Baby-Friendly hospitals. Despite this progress, 73.5 percent of women giving birth in Minnesota start out breastfeeding but less than half are still breastfeeding at 6 months and only 23.5 percent are exclusively breastfeeding (CDC, 2013), falling short of the AAP’s recommendation to exclusively breastfeed for 6 months. Also, according to recent data from the Minnesota Women, Infant and Children’s nutrition program (WIC), significant racial and ethnic disparities persist in breastfeeding rates throughout Minnesota (WIC, 2012).
The Baby-Friendly Hospital Initiative helps to create health equity in infant feeding, emphasizing cultural competence and equal access to best practice maternity care and lactation support regardless of race, ethnicity, income, family structure or language.
Be on the look-out for more Baby-Friendly hospitals in Minnesota! Maybe you can take the lead at your hospital to improve health equity in Minnesota for mothers and babies!
The 10 Steps to Successful Breastfeeding
1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within 1 hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming-in—allow mothers and infants to remain together—24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial nipples or pacifiers to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
