27 Mar Dear Doctor
Re-posted from October 2015:
Last week I met a GP who told me two things. Firstly, “many women simply can’t breastfeed” and secondly, “apart from a few infections, the research is clear that there is very little difference between breast milk and formula”.
If you would like to hear my response, please read on.
I’m sure you remember our brief discussion about breastfeeding. I was really interested to hear your view and I would love to have had more of an opportunity to chat with you. As there was no time, I’d like to just share some thoughts with you now, which I hope will be of interest to you. Please don’t stop reading!
I am not in the business of being “militant”, creating misplaced feelings of guilt or throwing about any unsubstantiated facts. I simply feel very strongly, as I know you do too, about providing compassionate and evidence-based care to women, to help them achieve whatever their goals may be.
I firmly believe that all mothers deserve to have the chance to make their own fully-informed decisions about how they feed their babies (since without information it is never truly a ‘choice’) and if they subsequently choose to breastfeed, that the best quality support and advice is readily available to them to help them succeed.
As a little background, prior to being allowed to sit the exam to become a certified Lactation Consultant (IBCLC), I was required to have a minimum of 1000 hours of direct breastfeeding counselling experience, within the previous 5 years and to have undertaken a minimum of 90 hours of academic breastfeeding training by attending conferences, courses etc within those 5 years. I also went one step further and completed a postgraduate MSc in Mother and Child Health, which included a specific 4-week module on Breastfeeding Practice and Policy. I continue to attend regular breastfeeding-related conferences and training days and estimate that I have accrued over 3000 hours of one-to-one breastfeeding counselling, during my career to date. I am only telling you this as I feel it puts me in a reasonable position to discuss this topic.
As you are aware, not everyone can breastfeed and it should never be assumed that they are able to. It is estimated that around 5% of women are truly unable to breastfeed due to anatomic breast variations or medical illness (Neifert 2001, Prevention of breastfeeding tragedies. Pediatric Clin North Am 48 (2): 273-97). These mothers may require specialist support to help them understand why breastfeeding wasn’t possible and/or to enable them to feed via a supplemental device such as an SNS or Lactaid, should they wish.
However, many more women than this are under the impression that they “can’t” breastfeed. In some parts of the world, such as Norway, the breastfeeding initiation rate at birth is 99% and 70% of women are still exclusively breastfeeding at 3 months. This compares to the UK where 81% initiate breastfeeding at birth and yet only 13% are still exclusively breastfeeding at 3 months.
Of course, a proportion of these women have willingly and intentionally stopped or started to mix feed, but it is also known that around 63% of mothers who stop breastfeeding would have liked to have breastfed for longer. The reason why so many women in the UK seemingly “can’t” breastfeed is not because these mothers and/or babies have any specific design fault, it is simply because they have been failed by a system that has not enabled them to fulfill their wishes.
Amongst many others, the three most commonly cited reasons why women stop before they had initially planned to, are perceived milk supply insufficiency, baby “refusing the breast” and pain. Outside of the 5% of women mentioned previously (including mothers with conditions such as hypoplasia) and a very small proportion of babies for whom breastfeeding is intolerable (e.g. galactosemia), it is highly likely that with correct management of breastfeeding (most notably giving attention to the frequency of feeding, skin-to-skin contact and effective latching), plus having information on the expected and normal behaviour of infants, many of these issues can be either prevented or resolved.
However, there are also far wider and more complex institutional, cultural and commercial practices at play, that hinder a woman’s breastfeeding journey from the start. There are too many to discuss in this context, although I would like to briefly mention two of them from a medical perspective.
Firstly, the well known effects of instrumental and medicated birth on breastfeeding (such as the compression of various cranial nerves related to feeding during delivery and/or the sedative effects of medication), are vastly underestimated by many practitioners and these mothers and babies do need to be given extra physical and emotional support to succeed with feeding.
Another significant reason for breastfeeding difficulties are undiagnosed tongue ties (posterior ties can cause as many, and sometimes more, issues than anterior ties). These lead to a vast number of problems from pain, low milk supply and fussy feeding to reflux, colicky symptoms and huge emotional upset for the mother, to name just a few.
You told me that you are known as the GP who says that ‘it is OK to bottle-feed’. I couldn’t agree with you more. Of course it is OK to bottle-feed and I know that by the time mothers see you, some are desperate to be given this “permission”.
However, what I don’t feel is satisfactory, is for a mother who initially wanted to breastfeed, to be left with only this message and not actually provided with the sufficient support and information, to enable her to overcome the presenting issues, should she wish to do so. This isn’t personal to you but as a general enquiry, I am interested to know why a doctor might refer a patient with a heart or skin condition requiring specialist support to a cardiologist or a dermatologist and yet a mother with a breastfeeding problem, is all too often left both un-referred to anybody but also has her efforts to breastfeed minimized by being told “don’t worry, it’s OK to bottlefeed”; even possibly followed up with “it isn’t that different anyway”. (again, please don’t stop reading just yet ).
This leads me on to my last point I wanted to raise with you, since you told us before X (deleted for anonymity), that apart from a few infections, research has shown that there isn’t really much difference between breastmilk and formula.
To reiterate, I am not about creating misplaced feelings of guilt and failure, or being anti-formula feeding parents. I work with and support all mothers, regardless of their choices and/or personal circumstance. Formula milk, after all, is a necessity for the health and development of babies under 1 year, who are not breastfed. This letter is simply about sharing accurate, evidence-based information which we have available to us.
Firstly, one only has to look at the living and dynamic constituents of our species-specific and bio-available breast milk, compared to the inert, heavily manufactured and modified constituents of formula milk, to realise how profound the difference is. Please do have a look at this comparison list – it’s fascinating.
In the last 15 years there has been an explosion of interest in the unique properties of breast milk and their potential for health. I find this incredibly exciting. To name just two of the numerous, unique and irreplicable components:
- HAMLET (Human alpha-lactalbumin made lethal to tumour cells):
The study demonstrates that HAMLET acts as an antimicrobial adjuvant that can increase the activity of a broad spectrum of antibiotics (methicillin, vancomycin, gentamicin and erythromycin) against multi-drug resistant Staphylococcus aureus, to a degree where they become sensitive to those same antibiotics, both in antimicrobial assays against planktonic and biofilm bacteria and in an in vivo model of nasopharyngeal colonization.
This research studies the mechanism for the tumoricidal effects of HAMLET (which has been shown to cause cell suicide in over 40 types of cancer)
- STEM CELLS
Of course, it is important to say that breast milk is not a magical potion that is able to prevent 100% of individual cases of anything it may be associated with. I don’t think anyone with any knowledge on the topic would try to claim otherwise. It reduces risk but doesn’t eliminate it. There will always be individual breastfed children who are frequently ill and formula fed children who have never seen the GP in their lives.
However, this doesn’t mean that the differences in feeding methods aren’t significant across populations.
Unfortunately, there are several methodological issues in breastfeeding research, which I believe only serve to underestimate the true significance of the biological norm. For a start, it is very difficult (if not impossible!) to do randomized controlled trials and therefore we rely mainly on analysing large cohort studies and case-control studies.
One of the biggest issues with some of these studies is that the definition of breastfeeding can be heavily diluted. ‘Breastfeeding’ case groups, may well include any babies who have ever been breastfed – that is they are classified as having been breastfed, even if they only ever had one or two breastfeeds. Clearly this is a major limitation of any conclusions that are drawn and this was perfectly demonstrated in the well-publicised Sibling Study in 2014 which, together with its many other flaws and vastly overblown conclusions by the media, has had such a negative impact on women’s approach to infant feeding.
Media reporting like this is one cultural factor that is serving to undermine the awareness and acceptance of the wealth of excellent quality information that continues to be uncovered about breastfeeding.
I thought that you may be interested to see just a small example of some recent studies below. Please do view the links for specific details:
– Childhood Leukemia:
Study Type: Meta-analysis
Year Published: 2015
Compared with no or shorter breastfeeding, any breastfeeding for 6 months or longer was associated with a 19% lower risk for childhood leukemia (odds ratio, 0.81; 95% CI, 0.73-0.89).
– Bone Health in adolescence:
Study Type: Cohort Study
Year published: 2011
The researchers found that the duration of exclusive breastfeeding was positively correlated with the sex-adjusted lumbar spine (LS) bone mineral content (BMC), LS bone area (BA), and LS bone mineral density (BMD) (all P<0.03) and with size-adjusted LS-BMC (P=0.075) at 17 years of age. Serum osteocalcin at 6 months of age was positively correlated with sex-adjusted LS-BMC and LS-BMD (both P<0.04) and with size-adjusted LS-BMC (P=0.047) at 17 years of age. The authors conclude the duration of exclusive breastfeeding and the markers of bone turnover at 6 months seem to be positively related to LS bone mass at age 17 years.
Molgaard C, Larnkjaer A, Budek A et al (2011). Are early growth and nutrition related to bone health in adolescence? The Copenhagen Cohort Study of infant nutrition and growth. Am J Clin Nutr. published 17 August 2011, 10.3945/ajcn.110.001214
– Necrotizing Enterocolitis:
Study Type: Retrospective study
Year published: 2014
Primary outcomes were rates of necrotizing enterocolitis (NEC) and NEC plus significant gastrointestinal bleeding (GIB) in very low birth weight babies admitted to NICU between 2007-2011. Exclusive human milk lowered the incidence of NEC compared with formula. Using exclusive human milk feeds in VLBW infants at higher risk of NEC appears to be cost-effective.
Huston, P.K., Markell, A.M., McCulley, E.A., et al (2014) Decreasing Necrotizing Enterocolitis and Gastrointestinal Bleeding in the Neonatal Intensive Care Unit: The Role of Donor Human Milk and Exclusive Human Milk Diets in Infants <=1500 g Birth Weight; ICAN: Infant, Child, & Adolescent Nutrition; 6(2): p. 86-93.
– Sudden Infant Death Syndrome:
Study Type: Case-Control
Year published: 2009
Breastfeeding reduced the risk of SIDS by around 50% at all ages throughout infancy and for as long as the infant is breastfed. They highlight that the implication of their findings is that breastfeeding should be continued until the infant is six months of age as the risks of SIDS are low by that stage. They therefore recommend including the advice to breastfeed through six months of age in sudden infant death syndrome risk-reduction messages.
M M Vennemann, T Bajanowski, B Brinkmann, G Jorch, K Yücesan, C Sauerland, E A Mitchell and the GeSID Study Group (2009) Does Breastfeeding Reduce the Risk of Sudden Infant Death Syndrome? PEDIATRICS Vol. 123 No. 3 March 2009, pp. e406-e410
– Autistic Spectrum Disorder
Study Type: Case-Control
Year published: 2014
The results of this study are consistent with previous research showing a relationship between fatty acid metabolism, breastfeeding and ASD such that early infant feeding practices and the influence this has on the fatty acid metabolism of the child may be a risk factor for ASD
– Childhood Asthma:
Study type: Systematic review and meta-analysis of 117 studies
Year Published: 2014
A positive association of breastfeeding with reduced asthma/wheezing is supported by the combined evidence of existing studies.
– Rheumatoid arthritis:
Study type: meta-analysis
Year published: 2015
Conclusion: This meta-analysis suggests that breastfeeding is associated with a lower risk of RA, whether breastfeeding duration is longer or shorter than 12 months.
– Cardiovascular and Metabolic Disease Risk:
Study type: Large cohort study (n= 6951)
Year published: 2014
Results of the study suggest that low birth weight (<2.8kg), not breastfeeding and shorter duration of breastfeeding (<3 months), were significantly associated with higher CRP measurements in young adulthood and thus greater disease risk. In sibling comparison models, higher birth weight was associated with lower CRP for birth weights above 2.5 kg, and breastfeeding greater than or equal to three months was significantly associated with lower CRP. The longer the duration of breastfeeding (>12 months) the greater the protection against future long term cardiovascular and metabolic disease risk (heart disease and type 1 diabetes). The authors conclude that efforts to promote the duration of breastfeeding and improve birth outcomes may have clinically relevant effects on reducing chronic inflammation and lowering risk for cardiovascular and metabolic diseases in adulthood.
– Type 2 diabetes:
Study type: Systematic review
Year Published: 2006
The authors conclude that breastfeeding is associated with a reduced risk of type 2 diabetes, with lower blood glucose and serum insulin concentrations in infancy and marginally lower insulin concentrations in later life.
Owen CG, Martin RM, Whincup PH, Davey Smith G, Cook DG. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. American Journal of Clinical Nutrition. 2006; 84: 1043-1054.
– Type 1 diabetes:
Study Type: Case-control study
Year Published: 2004
This study aimed to determine whether early nutrition is an independent risk factor for diabetes despite other life events. Data from 517 children (268 boys and 249 girls) in south-east of Sweden and 286 children (133 boys and 153 girls) in Lithuania in the age group of 0 to 15 years with newly diagnosed type 1 diabetes mellitus were included into analysis. Three age- and sex-matched healthy controls were randomly selected. Response rate in control families in Sweden was 72.9% and in Lithuania 94.8%.
Exclusive breastfeeding longer than five months (odds ratio 0.54, 95% confidence interval 0.36-0.81) and total breastfeeding longer than 7 (0.56, 0.38-0.84) or 9 months (0.61, 0.38-0.84), breastfeeding substitution that started later than the third month (0.57, 0.33-0.98) among Swedish children 5 to 9 years old and later than the seventh month (0.24, 0.07-0.84) among all Swedish children is protective against diabetes when adjusted for all other above-listed risk factors. In Lithuania, exclusive breastfeeding longer than two months in the age group of 5 to 9 years is protective (0.58, 0.34-0.99) when adjusted for other factors.
The authors concluded that longer exclusive and total breastfeeding appears as an independent protective factor against type 1 diabetes.
– Infectious Disease:
Study type: Cohort Study (n = 4,164)
Year published: 2010
The study analysed breastfeeding rates in the first six months and URTI, LRTI, and GI infections. The researchers conclude that exclusive breastfeeding until the age of 4 months, and partially thereafter, was associated with a significant reduction of respiratory and gastrointestinal morbidity in infants and state that these findings support health policy strategies to promote exclusive breastfeeding for at least 4 months, but preferably 6 months, in industrialized countries.
Study Type: Meta-analysis
Year published: 2003
A meta-analysis of studies from industrialised countries has concluded that the risk of severe respiratory tract illness resulting in hospitalisation is more than tripled among infants who are not breastfed, compared with those who are exclusively breastfed for 4 months (relative risk = 0.28; 95% CI 0.14 – 0.54).
– Dental Malocclusion:
Study type: Birth cohort study (n=1303)
Year published: 2015
A lower prevalence of open bite was found among children exposed to exclusive breastfeeding from 3 to 5.9 months (33%) and up to 6 months (44%) of age. Those who were exclusively breastfed from 3 to 5.9 months and up to 6 months of age exhibited 41% and 72% lower prevalence of moderate/severe malocclusion, respectively, than those who were never breastfed. The authors conclude that promoting exclusive breastfeeding up to 6 months of age to prevent childhood diseases and disorders, should be an effective population strategy to prevent malocclusion.
– Maternal Breast Cancer:
Study Type: Systematic Review (47 studies)
Year published: 2002
The relative risk of breast cancer decreased by 4·3% (95% CI 2·9-5·8; p<0·0001) for every 12 months of breastfeeding. The relative risk remained after controlling for developed versus developing country location, women’s age, menopausal status, ethnic origin, parity, her age when her first child was born, or any of nine other personal characteristics examined.
The study group estimate that the cumulative incidence of breast cancer in developed countries would be reduced by more than half (from 6·3 to 2·7 per 100 women by age 70) if women had the average number of births and lifetime duration of breastfeeding that had been prevalent in developing countries until recently. Breastfeeding could account for almost two-thirds of this estimated reduction in breast cancer incidence.
Collaborative Group on Hormonal Factors in Breast Cancer (2002). Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease. Lancet 360: 187-95.
Study Type: Prospective cohort study (n=60,075)
Year published: 2009
Women who had ever breastfed were less likely to suffer premenopausal breast cancer compared with women who had never breastfed and this association was modified by family history of breast cancer. The authors conclude that a history of having breastfed was inversely associated with incidence of breast cancer among women with a family history of breast cancer.
– Maternal Ovarian Cancer:
Study Type: Case-control study (1092 cases & 1288 controls)
Year published: 2009
The researchers found a strong association between total duration of breastfeeding (all episodes) and reduced ovarian cancer occurrence, with protection increasing per month of breastfeeding. They conclude that a long total duration of breastfeeding appears to be associated with a substantial reduction in the overall risk of ovarian cancer but that this may vary according to histological subtype.
– Maternal Diabetes:
Study type: prospective cohort study (n= 522)
Year published: 2011
The authors conclude that higher intensity of lactation (eg exclusive or mostly breastfeeding) of women with a history of gestational diabetes, was associated with improved fasting glucose and lower insulin levels at 6–9 weeks’ postpartum and argue that lactation may have favourable effects on glucose metabolism and insulin sensitivity that may reduce diabetes risk after GDM pregnancy.
Gunderson EP, Hedderson MM, Chiang V et al (2011) Lactation Intensity and Postpartum Maternal Glucose Tolerance and Insulin Resistance in Women With Recent GDM: The SWIFT cohort. Diabetes Care. Published 19 October 2011, 10.2337/dc11-1409
Finally, putting any research or debates to the side, many women simply have an instinctive mothering desire to want to give breastfeeding a go and I steadfastly believe that we should all be doing everything we can to help them.
I do hope that this has been of interest to you and I would love to hear your feedback. Please do not hesitate to contact me if you wish to discuss anything further.
Wishing you all the very best.
Vanessa Christie (MSc, MN, IBCLC, RHV, RNC, CIMI) is one of the UK’s leading Lactation Consultants and Early Parenting Experts. She is a speaker for The Baby Show and regularly writes for parenting magazines and blogs. To book an online consultation with Vanessa please visit her website.