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Is Breast Really Best? Are the benefits of breastfeeding exaggerated?

I am not against breastfeeding, nor do I support child abuse, and I am not being paid by the formula industry. I have been accused of all three, most recently in reader comments on an interview I did for MacLean’s magazine. Ironically, it was precisely this kind of vitriol that first inspired me to write Is Breast Best?. I wanted to understand how breastfeeding has come to be perceived as the holy grail of health and formula-feeding as the equivalent of giving a baby nicotine. I wanted to have a better sense of why parents have come to believe that how they feed their baby might be the most important decision they’ll ever make and why our public conversations about baby feeding have become so toxic.

What I discovered is that our certainty that “breast is best” far exceeds what the evidence tells us. This misguided confidence in breastfeeding stems from our poor understanding of science. It also comes from the (often unconscious) belief that mothers are all-powerful and that if they try hard enough, they can eliminate risk and produce completely healthy children. We’d like to believe both that the research tells us more than it does and that mothers have a lot more control – and deserve a lot more blame – than they actually do.

In short, writing my book made clear to me that debates about baby feeding are so hostile because they are about so much more than what’s best for babies. And the result of these debates is a culture in which mothers who do not breastfeed are portrayed as harming their children.

I don’t claim that there are no differences between children who have been breast- or bottle-fed. Thousands of studies find that the average breastfed baby is healthier than the average formula-fed baby. What they haven’t found is compelling evidence that breastfeeding causes better health. As the old saying goes, correlation does not equal causation. The better health of breastfed babies could well be due, in part or completely, to other things that breastfeeding moms are doing, not to the breast milk itself.

For example, if you make sure everyone who touches your baby washes their hands first, if you keep your baby away from the grocery store at 5:00, if you can afford to have someone care for your baby in your home, you’re probably doing a lot to reduce your baby’s chances of getting an infection. If you encourage your child to eat healthy foods and to exercise, you’re contributing to healthy body weight. If you read to and have meaningful conversations with your child, you’re stimulating cognitive development.

In fact, if you do the research, you’ll find that it’s not uncommon for scientists to stress the benefits of breastfeeding and at the same time acknowledge that it’s not clear whether some babies are better off because they are or were breast-fed or because they have caretakers who are willing and able to promote good health in other ways. [See, for example, Matthew W. Gilman et. al., "Risk of Overweight among Adolescents Who Were Breastfed," Journal of the American Medical Association, 2001; Erik Lykke Mortensen et. al., "The Association Between Duration of Breastfeeding and Adult Intelligence," Journal of the American Medical Association, 2002.]

Breastfeeding advocates, meanwhile, argue that the sheer number of studies connecting breastfeeding with healthier babies makes the benefits of breastfeeding irrefutable. What they don’t mention is that lots of studies, including many published in top research journals, find that breastfeeding has little or no medical benefit. [See, among others, Catharine Gale et. al., "Breastfeeding, the Use of Docosahexaenoic Acid-Fortified Formulas in Infancy and Neuropsychological Function in Childhood," Archives of Disease in Childhood, 2009; and Michael S. Kramer et. al., "Effect of Prolonged and Exclusive Breastfeeding on Risk of Allergy and Asthma: Cluster Randomized Trial," British Medical Journal, 2007.] They also fail to point out that you can’t fix errors or gaps in the research with quantity; if you have one study that is seriously flawed or that can’t account for an alternative explanation, having 10 or 100 similar studies doesn’t make the problem go away.

There is pretty strong evidence that breastfeeding helps reduce gastrointestinal (GI) infections, but even here we need to be careful not to overstate its benefits. One of the most widely respected studies on breastfeeding [Michael Kramer et. al., "Promotion of Breastfeeding Intervention Trial (PROBIT): A Randomized Trial in the Republic of Belarus," Journal of the American Medical Association, 2001] indicated that for every twenty-five breastfed babies there would be one fewer GI infection in the first year. That’s a benefit, but it’s fairly minimal, and parents need to decide whether the benefit is worth the cost.

And breastfeeding has real costs. The blogosphere is full of testimonials from women who suffered horrible emotional distress and depression from breastfeeding [See, for example, reader responses to the New York Times article, "Breastfeed or Else," June 20, 2006]. Just because you don’t pay cash for it doesn’t mean breastfeeding is free.

Another way some advocates push the superiority of breastfeeding is by promoting the idea that breastfeeding is “natural” and therefore must be superior to “artificial” formula. Yet humans do all sorts of things that other mammals don’t, and many of them are “unnatural,” if by that you mean that they manipulate or circumvent nature. Birth control is unnatural, but so are refrigeration, pasteurization, automobiles, and air conditioning. “Unnatural” does not necessarily mean “unhealthy.”

Most people – mothers included – endorse breastfeeding at least in part because they have a poor understanding and consuming fear of risk. Formula can be contaminated in production, the thinking goes, so why take the risk? Better safe than sorry. But, in addition to the short and long-term risks of breastfeeding for mothers, “natural” breastfeeding poses risks for babies, too. You’d probably be unhappy if you knew exactly what was in your breast milk; in fact, milk is such a good conduit for toxins like lead and DDT that toxicologists often use it to assess environmental contamination. [See, for example, Betsy Lozoff et. al., "Higher Infant Blood Levels with Longer Duration of Breastfeeding," Journal of Pediatrics, 2009; Philip Landrigan et. al., "Chemical Contaminants in Breast Milk and Their Impacts on Children's Health," Environmental Health Perspectives, 2002.] This doesn’t mean you shouldn’t breastfeed; what it means is that science simply has been unable to determine if there are long-term effects of these pollutants. Unfortunately, we just don’t know.

As parents, we make myriad risky decisions every day. Car brakes can malfunction; does that keep you from putting your baby in the car? The truth is that our culture pays more attention to some baby health risks than others, and these tend to be the ones that mothers are expected to alleviate. What’s optimal for a baby gets defined in terms of what mothers can do to optimize.

Certainly mothers (and fathers) should be expected to make sacrifices for their children. What bothers me is that mothers (and not fathers) are expected to prevent virtually any risk to their babies, regardless of how unlikely or poorly understood that risk is or what it will cost them in the process.

I would argue that how you feed your baby (in a developed country with reliable access to clean water) is largely a lifestyle choice and that in the overwhelming majority of cases, either breastfeeding or formula-feeding is a healthy option. These, today, are fighting words, and they lead almost invariably to a conversation in which, by defending formula, I am cast as being against breastfeeding.

But what I’m against, really, is misinformation and the use of breastfeeding – or not breastfeeding – to make mothers feel bad about themselves.

Some women find breastfeeding deeply rewarding, and for them, breastfeeding is the right choice. Others find that formula-feeding works much better, and for them, breastfeeding is the wrong choice. We all know terrific mothers who formula-feed, and plenty of formula-fed babies are as healthy as those who are breastfed. Science has not demonstrated that breastfeeding has serious health advantages, and we need to stop making claims that breastfeeding is the only choice for mothers who care about their children.

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