Is the "breast is best" mantra an oversimplification?
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.
Some of the “Ten Steps,” such as the call for skin-to-skin care and 24-hour rooming-in, have well-established benefit yet, when performed without supervision, can have the rare but serious unintended consequences of sudden unexpected postnatal collapse (the incidence of which may be higher than that of SIDS) and unsafe sleeping practices.62,63
Furthermore, despite evidence that early formula supplementation, when medically necessary, does not adversely impact the breastfeeding rate, the “Ten Steps” program advises that giving formula before breast milk comes in might “lead to failure to breastfeed.”33,34,61,63
Similarly, the ban on pacifiers is contrary to available evidence. The use of pacifiers before last sleep is more protective against SIDS than breastfeeding (NNT=2733), and there is evidence at one hospital that BFHI-inspired pacifier restriction is associated with a decrease in the rate of breastfeeding.64,65
Other harms of advocacy are even more poorly studied. Most of the evidence for harm comes from the psychology and social science literature—not the medical literature, perhaps because the prevailing opinion in the medical community is that breastfeeding has overwhelming evidence for benefit. In fact, in the USPSTF’s 2008 recommendation, the evidence review of breastfeeding promotion practices in primary care did not identify a single study that measured harm; in the 2016 update of that recommendation, only 2 such studies were identified.15,66
The literature that does investigate harm consistently finds that women who have difficulty breastfeeding or choose formula feeding report feelings of inadequacy, guilt, loss of agency, anxiety, and physical pain during breastfeeding that interferes with 1) their ability to bond or otherwise care for their infant and 2) competing work obligations.11-13,67-69 Given the lack of attention paid to these variables in the medical literature, it is the individual mother who is best positioned to weigh these factors against the benefits of breastfeeding.
Continue to: Shared decision-making is best—for mother and baby
