Applied Evidence

Is the "breast is best" mantra an oversimplification?

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Recommendations about breastfeeding—absent critical analysis and removed from context—may overvalue its benefit. Here's a look at the evidence.

PRACTICE RECOMMENDATIONS

› Encourage breastfeeding for its potential to reduce the risk of acute otitis media, upper- and lower-respiratory infections, gastrointestinal infection, and dental malocclusion. A

› Promote breastfeeding for its potential to make a small difference in intelligence quotient and the incidence of overweight and obesity—but not for any other significant impact on long-term health. B

› Consider the needs and preferences of the individual when advocating breastfeeding so as to avoid potentially engendering maternal feelings of guilt and inadequacy. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series


 

From The Journal of Family Practice | 2018;67(6):E1-E9.

References

The benefits of breastfeeding for infants have long been touted as numerous and supported by overwhelming evidence. The World Health Organization (WHO), American College of Obstetricians and Gynecologists, American Academy of Pediatrics (AAP), and American Academy of Family Physicians all strongly recommend exclusive breastfeeding for the first 6 months of life, citing numerous health benefits for child and mother. These groups recommend that some breastfeeding be continued through the first 12 months of life, or longer, as desired (the WHO extends the recommendation to 2 years).1-4 In 2000, the Surgeon General of the United States released a strategic plan to increase rates of breastfeeding,5 setting goals (by 2010) of:

  • 75% of mothers leaving the hospital breastfeeding
  • 50% of babies breastfeeding at 6 months
  • 25% of babies breastfeeding at 1 year.

Massive public health campaigns citing data for the many benefits of breastfeeding have been launched with the goal of increasing the breastfeeding rate. In 2014, statistics offered a testament to the success of these campaigns6:

  • 82.5% of infants had been breastfed “ever”
  • 55.3% were breastfed “some”
  • 24.9% were breastfed exclusively through 6 months of age
  • 33.7% were breastfed “some” at 12 months.

Breastfeeding advocacy has become clouded

In recent years, an increasing number of researchers, physicians, and authors have begun to question whether, in the United States, the benefits of breastfeeding children are exaggerated and the emphasis on breastfeeding might be leading to feelings of inadequacy, guilt, and anxiety among mothers.7-13 In 2016, the US Preventive Services Task Force (USPSTF) amended its recommendation to “promote and support breastfeeding” to simply “support breastfeeding”—a change that created substantial debate and prompted the Task Force to clarify its stance in changing the language: In its response to public comment, the USPSTF said that its position regarding promotion had not changed, but the language in the original statement had been revised to “ensure that the autonomy of women is respected.” 2,14-16

In contrast, others suggest counseling women on the risks of formula feeding rather than on the benefits of breastfeeding, citing substantial health outcome distinctions.17 Indeed, wide-ranging conclusions have been drawn from the same data on the topic, potentially creating uncertainty for physicians on how best to counsel women on their choice of how to feed their infant.

An increasing number of researchers and physicians have begun to question whether the benefits of breastfeeding are exaggerated.

In this article, we address this uncertainty by utilizing the most recent and comprehensive data to examine infant health outcomes. When possible, the number needed to treat (NNT) for a given outcome has been calculated or approximated, allowing the reader to estimate the likelihood of benefit for an individual mother–infant dyad. Exercise caution when interpreting the NNT, however: The numbers suggest causality that cannot be definitively established using the observational data on which those numbers are based.

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