On the surface, it may seem surprising that breastfeeding should be the contentious issue it often is. It benefits infants' health in so many ways. But for the new mothers who decide they cannot manage it or who are unsuccessful in their efforts, breastfeeding can be a source of feelings of failure and frustration.

Two recent studies, taken together, offer a more balanced picture of an area of motherhood that too-often resembles a battleground. The American Academy of Pediatrics has just issued an updated statement on the value of breastfeeding and the use of human milk.

The evidence for the health benefits of breastfeeding to infant and mother is abundant and compelling.

At almost the same time, a British study provides a clear-eyed look at the reasons why women decide not to breastfeed and finds it is time for breastfeeding recommendations to acknowledge the realities that may lead mothers to decide against the practice.

Strong Evidence for the Benefits of Breastfeeding

Citing numerous short and long-term health benefits to children and mothers, the American Academy of Pediatrics (AAP) urges that breastfeeding be viewed as “ a public health issue and not only a life style choice” and recommend “exclusive breastfeeding for about six months followed by continued breastfeeding as complementary foods are introduced a with continuation of breastfeeding for one year or longer as mutually desired by mother and infant.”

The AAP has have taken such a strong position because the evidence for the health benefits of breastfeeding to infant and mother is abundant and compelling. Citing data from the Agency for Health Care Research and Quality, the Academy offers a long list of the ways breast milk can improve or safeguard infants' health:

  • The risk of being hospitalized for a lower respiratory track infection (pneumonia, bronchitis) is reduced by 72% in infants who are breastfed exclusively for more than four months.
  • The risk of ear infections is decreased by 50% in infants who breastfeed for more than three months, and by 63% in infants who breastfed exclusively for six months.
  • Breastfeeding reduced the incidence of gastrointestinal infections by 64 %, with the protection lasting for two months after breastfeeding is discontinued.
  • Breastfeeding confers a 38% reduction in the risk of sudden infant death syndrome (SIDS) that is independent of the sleeping position of the infant.
  • When infants are breastfed exclusively for 3-4 months, they have a 27% decrease in the development of asthma, atopic dermatitis and eczema. This protection increases to 42% decrease in infants with a positive family history for these allergic conditions.
  • If infants are being breastfed at the time of their first exposure to gluten, there is a 52% reduction in the risk of developing celiac disease.
  • There is a 31% reduction in the development of inflammatory bowel disease in breastfed children.
  • When breastfeeding of any duration had occurred, there was a 15-30% decrease in adolescent and adult obesity, the longer the breastfeeding, the more the reduction in overweight.
  • Infants who were exclusively breastfed for at least three months with no exposure to cows milk protein had up to a 30% decrease in type one diabetes and a reduction of 40% in the incidence of type 2 diabetes.
  • A reduction of 20 % in the risk of acute lymphocytic leukemia and 15% in the risk of acute myeloid leukemia has been seen in infants breastfed for six months or longer.

Breastfeeding has also been shown to improve neurodevelopmental outcomes and IQ scores, Higher IQ scores and higher teacher ratings are seen in infants who were exclusively breastfed for three months or longer.

Especially Good for Preemies
The Academy maintains that, “The potent benefits of human milk are such that all preterm infants should receive human milk.” Although premature infants often cannot breastfeed directly, they can be fed their own mother’s or pasteurized donor milk.

The AAP policy statement outlines safe practices for storage and use of human milk in the Neonatal ICU. Preterm infants fed breast milk have lower incidences of necrotizing enterocolitis, a serious inflammation of the gastrointestinal tract, and sepsis, widespread infection. IQ tests and brain imaging studies support the positive neurodevelopmental impact of breast milk on the developing premature central nervous system.

Benefits to Mothers
The immediate benefits to breastfeeding mothers include shorter postpartum bleeding time, more rapid involution of the uterus, and increased child spacing since exclusive breastfeeding prevents ovulation.

Higher IQ scores and higher teacher ratings are seen in infants who were exclusively breastfed for three months or longer.

Longer-term benefits include a decreased risk of type two diabetes, rheumatoid arthritis, adult cardiovascular disease, and breast and ovarian cancer. Generally, longer duration of breastfeeding confers more protection. For example, breastfeeding longer than 12 months is associated with a 28% decreased risk in breast cancer and each additional year of breastfeeding results in an additional 4.3 % reduction.

There are relatively few medical reasons not to breastfeed, and the Academy’s statement contains recommendations for the management of specific medical conditions that may require short-term changes in breastfeeding routines. Similarly, there are some maternal medications that do not preclude breastfeeding completely although they may require special management.

Obstacles and Opportunities to Increase Breastfeeding

Because breastfeeding rates in the US fall far short of the Academy’s goals, the policy statement reviews the barriers to breastfeeding and describes the policies that have been developed for U.S. hospitals to address them.

The AAP especially recommends that hospitals develop policies and programs to encourage breastfeeding. Five early breastfeeding practices have proven to increase breastfeeding success and duration:

  1. Newborns should be breastfed in the first hour after birth.
  2. Newborns should be breastfed exclusively.
  3. Hospitals should promote rooming in to make breastfeeding easier.
  4. Pacifiers should be avoided.
  5. New mothers should be given a telephone number to call for breastfeeding help and support after discharge from the hospital.

The goal of the AAP's updated statement is to make new parents and parents-to-be aware of the compelling evidence for the extensive and diverse health benefits of breastfeeding to children and mothers. They would like the public and the medical community to view giving new mothers breastfeeding support as a critical public health issue that can decrease the individual and societal burden of acute and chronic illness.

Breastfeeding Doesn't Work for All

In light of the benefits of breastfeeding, it is also valuable to know why people decide not to do it, both to provide assistance that might make it possible and to offer more support to those women who opt not to breastfeed.

Not everyone is willing to commit to six months of exclusive breastfeeding. There are maternal, family, social, economic, and environmental factors that may all make breastfeeding more difficult.  

There is a striking contrast between the idealism of the breastfeeding... and the realities of the demands of infant feeding within family systems and complex lives. 

British researchers conducted 220 interviews with women and their partners or other caregivers every month during their infants’ first six months of life.

The researchers were interested in the challenges the women and their families faced and what influenced their decision not to breastfeed or to give it up. They found a striking contrast between the idealism of breastfeeding recommendations, which are based on the desire to optimize the health of women and infants, and the realities of the demands of infant feeding within family systems and complex lives. 

Women and their partners reported a need to factor in the immediate well-being of their families before the "theoretical longer term health benefits.”  Mothers who need to tend to other young children, for example, may find it easier to hand their infants over to fathers or family to feed, making formula feeding more attractive.

The authors of the study are supportive of breastfeeding and emphasize that breastfeeding need not be an all-or-nothing proposition. In addition to setting incremental goals for breastfeeding and introducing it in the context of a family-centered approach to feeding, they urge that efforts to promote breastfeeding take into account the "... diverse values, meanings and emotions around infant feeding within families.”