Breastfeeding: Support, Challenges, and Benefits | Pediatric Collection
Breastfeeding—Perspectives on an Essential Health Intervention
Why a collection of recently published articles on breastfeeding? Breastfeeding is a health care intervention of profound significance. Optimal breastfeeding practices, defined as exclusive breastfeeding through 6 months of age followed by continued breastfeeding with introduction of solid foods, save lives. Worldwide, in children 0–23 months, careful meta-analysis demonstrates a significantly decreased mortality rate with dose response in both all-cause and infection-related mortality among infants and children who received recommended breastfeeding, compared to those who received partial or no breastfeeding.1 Mothers benefit from optimal breastfeeding practices too, and recent analysis of data from high-, middle-, and low-income countries shows that universal optimal breastfeeding could prevent 20,000 deaths due to breast cancer (breastfeeding has been clearly shown to decrease risk of breast cancer in a dose-related manner).2 Breastfeeding may be the least expensive yet most cost-effective health intervention known. Both in the United States and abroad, the calculated cost of not breastfeeding is extraordinary, estimated to represent economic losses of about $302 billion annually worldwide or 0.49% of world gross national income.3 In the United States alone, the medical cost of suboptimal breastfeeding is estimated at $3 billion, and to bring this all the way home for you, consider that for every 597 women who optimally breastfeed their infant, one death of a child or mother is prevented.4 I’d call this data absolutely staggering.
So, I would argue that this group of breastfeeding-related articles, blogs, news articles, and commentaries is just a beginning, hopefully, in raising awareness about a basic health practice that makes huge differences globally. The editors have carefully curated a broad array of pragmatic articles and research that samples the current literature and focuses on 3 areas: support, challenges, and benefits.
Until Healthy People 2020 goals5 for breastfeeding initiation and exclusive continuation have been met and exceeded, and conversely goal rates of formula supplementation have been met and lowered, it’s relatively easy to agree that additional support for breastfeeding is needed. Dr. Joan Meek, Chairperson of the AAP Section on Breastfeeding, kicks off with a comprehensive, practical, and evidence-based outline explaining how to move your office practice toward “breastfeeding friendly”—a nice riff on the Baby-Friendly Hospital Initiative. Several commentaries respond to concerning findings in an original article by Drs. Lori Feldman-Winter, Richard Schanler, and colleagues: even as pediatricians’ recommendations and practices regarding breastfeeding have improved from 1995 to 2014, their attitudes about the likelihood that mothers will actually achieve breastfeeding success have declined. Section Executive Member Dr. Maya Bunik reaches out a helping hand with “The Pediatrician’s Role in Encouraging Exclusive Breastfeeding,” offering “can-do” pragmatic advice for all of us. The bane of exclusive breastfeeding is formula supplementation, and Dr. Trang Nguyen and colleagues examine the prevalence of formula supplementation among breastfed infants in maternity hospitals in New York state. Using birth certificate–based information, they ask the important question: what factors impact this key hospital practice? Finally, acknowledging increasing awareness of the vital role that fathers/partners play in supporting breastfeeding, a randomized controlled trial by Dr. Jennifer Abbass-Dick and colleagues evaluate the effectiveness of a coparenting intervention on exclusive breastfeeding among primiparous couples: significant improvements in paternal breastfeeding self-efficacy were just one of the study benefits. Support from all directions is imperative if we hope to move the breastfeeding needle forward. What I love about these articles is that a broad range of approaches and angles are brought together here.
The second section of articles focuses on epidemiological and societal challenges to achieving full breastfeeding. Longstanding variations in rates of breastfeeding between groups of individuals with differing social, economic, educational, and racial backgrounds represent not only health disparities or inequalities (read, differences), but rather need to be recognized as health inequities, meaning that those differences are unfair, unethical, and avoidable. Companion articles from Germany by Dr. Chad Logan et al, and from the United States by Dr. Chelsea O. McKinney et al, each focus on this critical phenomenon of breastfeeding inequities. Both identified demographic factors that explained differences in breastfeeding intent, initiation, and duration between groups, and McKinney et al additionally find that early in-hospital formula supplementation played a unique role in perpetuating inequities in breastfeeding duration. Both are must-read articles, and a commentary is included. Finally, a well done oral health study from Brazil yielded provocative results regarding severe caries among children breastfed for more than 2 years—will this result be meaningful for your practice?
Finally, the third section of articles describes new benefits (and non-benefits) of breastfeeding. Dr. Lisa-Christine Girard and colleagues examined the impact of breastfeeding on cognitive and behavioral outcomes at ages 3–5 years, and to the surprise of many, could not find an enduring benefit of breastfeeding after careful statistical correction for underlying breastfed versus not breastfed differences in the studied children. We can learn a lot from negative studies, and a commentary and blog highlight this. Two other articles and accompanying comments identify meaningful new benefits of breastfeeding: Dr. Fern Hauck et al used individual participant data meta-analysis to examine the specific role of breastfeeding duration in SIDS, and Dr. Takashi Yorifuji et al found a remarkable protective effect of breastfeeding against Kawasaki syndrome in Japan, the country in which the disease is most common. A unique article from Dr. Stacey A. Carling and colleagues studied the role of breastfeeding in obesity prevention by scrutinizing early weight for length increases among infants at high-risk for obesity due to multiple maternal factors: those infants at highest risk benefitted significantly from just 4+ months of breastfeeding, a highly instructive result.
In summary, enjoy the depth and breadth of these articles related to breastfeeding. Each one will give you a boost in your understanding of one of the most meaningful and important health practices we know.
Lydia Furman, MD, FAAP, Associate Editor, Pediatrics
1. Sankar MJ, Sinha B, Chowdhury R, et al. Optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. Acta Paediatr. 2015;104(467):3-13
2. Victora CG, Bahl R, Barros AJ, et al; Lancet Breastfeeding Series Group. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-90
3. Rollins NC, Bhandari N, Hajeebhoy N, et al; Lancet Breastfeeding Series Group. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387(10017):491-504
4. Bartick MC, Schwarz EB, Green BD, et al. Suboptimal breastfeeding in the United States: maternal and pediatric health outcomes and costs. Matern Child Nutr. 2017;13(1)
5. HealthyPeople.gov. 2020 Topics and Objectives. US Department of Health and Human Services. https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives. Accessed 7-3-2018
A print version of this collection will be available on shopAAP in August.
How to Establish a Breastfeeding-Friendly Pediatric Office
AAP News Original Publication April 17, 2017
The Breastfeeding-Friendly Pediatric Office Practice
From the American Academy of Pediatrics Original Publication May 1, 2017
Get Comfortable With Giving Breastfeeding Support
Journals Blog Original Publication August 24, 2017
The Pediatrician’s Role in Encouraging Exclusive Breastfeeding
Article Original Publication August 1, 2017
Study Looks at Trends in Breastfeeding Attitudes, Counseling Practices
AAP News Original Publication November 6, 2017
When It Comes to Having a Positive Attitude About Breastfeeding Success, Pediatricians Have Some Work to Do
Journals Blog Original Publication October 2, 2017
Pediatrician Competency in Breastfeeding Support Has Room for Improvement
Commentary Original Publication October 1, 2017
National Trends in Pediatricians’ Practices and Attitudes About Breastfeeding: 1995 to 2014
Article Original Publication October 1, 2017
Measuring Breastfeeding Success
Journals Blog Original Publication June 26, 2017
Variation in Formula Supplementation of Breastfed Newborn Infants in New York Hospitals
Article Original Publication July 1, 2017
Fathers, Coparenting, and Breastfeeding
Article Original Publication May 1, 2015
Coparenting Breastfeeding Support and Exclusive Breastfeeding: A Randomized Controlled Trial
Article Original Publication January 1, 2015
New Ways of Understanding Disparities in Rates of Breastfeeding
Journals Blog Original Publication July 28, 2016
Racial and Ethnic Differences in Breastfeeding
Article Original Publication July 1, 2016
Changing Societal and Lifestyle Factors and Breastfeeding Patterns Over Time
Article Original Publication May 1, 2016
Impact of Prolonged Breastfeeding on Dental Caries: A Population-Based Birth Cohort Study
Article Original Publication July 1, 2017
Breastfeeding and Improved Cognitive/Noncognitive Development: Does the Effect Last Post Infancy and Toddlerhood?
Journals Blog Original Publication March 27, 2017
Breastfeeding: What Do We Know, and Where Do We Go From Here?
Commentary Original Publication April 1, 2017
Breastfeeding, Cognitive and Noncognitive Development in Early Childhood: A Population Study
Article Original Publication April 1, 2017
Study: Breastfeeding for at Least 2 months Decreases Risk of SIDS
AAP News Original Publication October 30, 2017
Duration of Breastfeeding and Risk of SIDS: An Individual Participant Data Meta-analysis
Review Article Original Publication November 1, 2017
Another Great Reason to Breastfeed: Decreased Risk of Kawasaki Disease
Journals Blog Original Publication May 25, 2016
Breastfeeding and Risk of Kawasaki Disease: A Nationwide Longitudinal Survey in Japan
Article Original Publication May 1, 2016