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Controversies around breastfeeding surged once again last month with Social Science and Medicine‘s pre-release of Cynthia Colen and David Ramey’s article, “Is Breast Truly Best?  Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling Comparisons.”*  That’s not a very snappy title, so the news sources that picked it up went with the pithier “Breastfeeding Benefits Overstated” (CNN Health) and “Is Breastfeeding Really Better” (New York Times) or with other much shorter versions of the article title.  The article looks at sibling pairs in which one child was breastfed and the other was not.  Statistical comparisons of the children at ages 4-14 on a host of factors showed that the breastfed sibling did not appear to have health, learning, or attachment advantages over the sibling who was never breastfed.

One of the problems with making any assessment of breastfeeding is that it has become a battlefield for Mommy Wars.  One side claims that breastfeeding will guarantee a gifted child who is never ill, and who will always remember to call his mother after graduating from an Ivy League school–plus it will give you an alternative to gas for your car!

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The other side retorts that most adults were formula fed and came out just fine, so there can’t possibly be any benefit to breastfeeding, plus it ties women down, shuts fathers out of parenting, and is kind of icky anyway.

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The more each side trumpets its point of view, the more entrenched each side becomes. Thus, while many news outlets represented the study’s findings as absolute truth, reporting “breastfeeding [is] no better than bottle feeding,”  Melissa Bartick, MD, who spearheaded the Ban the Bags campaign, referred to the Colen and Ramey study as “sensationalism.”

No one is helped when the main breastfeeding support organization in the U.S. states that a tenet of their philosophy is that “Mothering through breastfeeding is the most natural and effective way of understanding and satisfying the needs of the baby,” implying that mothers who don’t breastfeed can never be as attached to their babies and can never satisfy a baby’s needs the way breastfeeding mothers do.  And no one is helped when the United States is among the only countries in the world that has not implemented a single aspect of the World Health Organization’s International Code of Marketing of Breast-Milk Substitutes because no one wants to stand up to the lobbying of a multi-billion dollar formula industry.  (Just so you know, there’s not much of an industry around breast milk production).

Groups like the American Academy of Pediatrics, the World Health Organization, and health arms of the U.S. government promote the benefits of breastfeeding without much consideration of what benefits there might be in not breastfeeding.  The one-note message of these health groups tends to over-inflate breastfeeding’s benefits and to imply that mothers who breastfeed love their children more or are better mothers than those who do not.

The promotion of breastfeeding to individual mothers without equal or greater promotion of breastfeeding in the culture and structure of society is a recipe for guilt.  Colen and Ramey say,

The line between providing information about the health benefits of breastfeeding and stigmatizing mothers facing structured, valid, and often difficult trade-offs in the care and financial support of their children or in fulfilling their own human potential must be drawn sensitively.

This is a very important point.  In the United Arab Emirates, the belief in breastfeeding’s benefits is mirroring some of the U.S. body politic around pregnant women: legislation was introduced that would compel women to breastfeed.  To force one person to use her body for the benefit of another against her will is a human rights violation.  To pit mothers against their children in the name of “child rights” is unconscionable.  (Seriously, click on the link–it’s mind boggling).

This is the climate in which Colen and Ramey conducted their research.  It is perhaps not surprising that as sociologists, who generally abhor structural inequalities, they conclude that structural changes should take precedence over individual-level breastfeeding promotion:

[A] multifaceted approach will allow women who want to breastfeed to do so for as long as possible without promoting a cult of ‘total motherhood’ in which women’s identities are solely constructed in terms of providing the best possible opportunities for their children and the risks  associated with a failure to breastfeed are vastly overstated.

While I agree with the sentiment of their conclusion, I do think we need to further examine the research process that led to a finding that breastfeeding has no benefit that extends through middle childhood.

Here is a summary of their methods:

  • They used the data set from the National Longitudinal Survey of Youth 1979 (NLSY79)
  • To determine if a child had been breastfed, they used two questions, both reported by the woman. One asked if the mother had ever breastfed the child (status); the other asked her to estimate how old the child was in weeks when she stopped breastfeeding (duration).
  • The full sample included 8,237 children.  The “discordant” sample (siblings groups with one child who had been breastfed and one who had not) included 1,773 children.
  • They measured the following outcomes: body mass index, obesity, asthma, hyperactivity, parental attachment, behavioral compliance, and 5 tests of intelligence or academic achievement.
  • Outcomes were only investigated for the children from age 4-14.

Let me say emphatically that all studies have flaws and that no one study can address all research concerns.  This is why we have a body of scientific literature, and no one study should absolutely convince us of anything, especially if it is not a large, well-constructed randomized control trial.  Colen and Ramey have made an important contribution to the literature, but it is also important that they and their promotors do not overstate their case.

Current health recommendations are that all children breastfeed exclusively for 6 months.  In the U.S., it is generally advised that children continue to breastfeed in addition to eating food for at least a year.  The World Health Organization recommends at least two years.

The Colen and Ramey study

  • had no measure of exclusive breastfeeding at all;
  • had no measure of “intensity”–those who reported breastfeeding could have been breastfeeding only once a day while their child consumed primarily formula;
  • found no significance for breastfeeding duration in weeks, but did not discuss longer periods of time that would mirror recommendations (for instance, children who breast fed for 6 months and for a year);
  • did not discuss the sample sizes for each week of duration (I am guessing that the sample size for each week decreased dramatically as the weeks wore on; it is difficult to find statistically significant differences when the sample size is small);
  • did not appear to control for a number of factors that could have been important, such as the financial status of the family at each child’s birth or the child’s place in the birth order.

Colen and Ramey also are not able to examine other crucial health measures, such as the impact on the woman herself (breastfeeding is thought to have heath benefits such as reducing the incidence of diabetes and some cancers) or the impact on the children past age 14 (breastfeeding is thought to have a protective effect against some diseases that emerge in adulthood, such as Crohn’s disease).

Perhaps most importantly, they did not look at what happened to children who never consumed any formula at all, but who were fed according to standard health guidelines for infant feeding.

Ultimately, Colen and Ramey measured what the breastfeeding literature typically calls “any breastfeeding,” meaning the child was fed any breastmilk at all even once.  It is of concern that they conclude (and the reporters report) that the benefits of breastfeeding do not extend into middle childhood, rather than that the benefits of any breastfeeding do not extend into middle childhood.  Though Colen and Ramey concede that there are benefits to breastfeeding for infants, I am not certain that there are any measurable benefits to having been fed a few drops of breastmilk on one occasion.

I agree with the conclusions of an Agency for Healthcare Research and Quality (AHRQ) review,

A history of breastfeeding is associated with a reduced risk of many diseases in infants and mothers from developed countries. Because almost all the data…were gathered from observational studies, one should not infer causality based on…findings. Also, there is a wide range of quality of the body of evidence across different health outcomes.  For future studies, clear subject selection criteria and definition of “exclusive breastfeeding,” reliable collection of feeding data, controlling for important confounders including child-specific factors, and blinded assessment of the outcome measures will help. Sibling analysis provides a method to control for hereditary and household factors that are important in certain outcomes. In addition, cluster randomized controlled studies on the effectiveness of various breastfeeding promotion interventions will provide further opportunity to investigate any disparity in health outcomes as a result of the intervention.

Colen and Ramey meet only the sibling analysis recommendation.  Ultimately, their article may have done nothing more than to fan the flames of the breastfeeding battles, sending each side further into their own trenches while doing nothing to promote structural changes that might support women’s desire to breastfeed.

*You need a subscription or access to an academic library to get a copy of the full article.

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