Written by Fed is Best Co-Founder, Christie del Castillo-Hegyi, M.D.

In the latest issue of The Journal of the American Medical Assocation (JAMA), pediatricians and public health investigators Dr. Valerie Flaherman, M.D., M.P.H. and Dr. Isabelle Von Kohorn, M.D., Ph.D. co-wrote an editorial on the United States Preventative Services Task Force (USPSTF)’s updated recommendations for primary care interventions that support breastfeeding.

Among the highlights of the the USPSTF’s recommendations include urging clinicians to “support” breastfeeding instead of  current dictates that “promote” it, citing that their stance and language remains unchanged as the recommendation is meant to “ensure that the autonomy of women is respected.”

Specifically, they wrote that, “Although there is moderate certainty that breastfeeding is of moderate net benefit to women and their infants and children, not all women choose to or are able to breastfeed. Clinicians should, as with any preventive service, respect the autonomy of women and their families to make decisions that fit their specific situation, values, and preferences.”

They also emphasized that their recommendations do not apply to “circumstances in which there are contraindications to breastfeeding (e.g. certain maternal medical condition or infant metabolic disorders),” and do not cover breastfeeding-related interventions directed toward preterm infants.

While we are disappointed that they did not discuss the risks of newborn dehydration, hypoglycemia and hyperbilirubinemia (severe jaundice)  and their long-term risks to the newborn brain in their “Potential Harms of Interventions” section, we absolutely applaud their discussion regarding respecting the autonomy of mothers when it comes to decisions of whether or not to breastfeed, depending on their life circumstances.  We also appreciate their recognition of the fact that not all women choose to or are able to breastfeed.

In the same issue of JAMA, Dr. Flaherman and Dr. Von Kohorn discussed the evidence reviewed by the USPSTF citing that “there was no consistent association between system-level interventions and any beneficial outcomes” with regard to breastfeeding outcomes.  Specifically, they noted that “certification by [the Baby-Friendly Hospital Initiative] in 2 studies^4,5 with concurrent control groups from 5 US states…was not associated with increased breastfeeding duration.”  They also noted a study from Australia,⁶ which was not included in the USPSTF document, which reported similar results.

They also mentioned one study that provided “good-quality evidence that BFHI certification may be beneficial for mothers of low educational attainment, although it was ineffective for mothers overall,⁵ ” concluding that, “using clinical judgment individualized for each mother and infant may result in better outcomes than following a rigid system of practices.”

We could not agree more.

They went on to say that, “Any intervention, no matter how well-intentioned, carries a risk of adverse events.”  They went on to call for additional research on adverse events caused by breastfeeding promotion on mothers and infants, as there is limited data looking at adverse effects of breastfeeding promotion on mothers, and even more limited data on its effects on infants.

Two areas of controversy in breastfeeding promotion were also discussed, namely counseling mothers to avoid pacifiers and current commentary that suggests families avoid feedings other than breast milk.

With regard to pacifier use, they cited evidence showing that pacifier use reduced the risk of
sudden infant death syndrome. They also cited evidence that avoiding pacifier had no effect on breastfeeding outcomes. Therefore, counseling mothers to avoid pacifiers may be “unethical,” potentially harmful while yielding no benefit.

But the most ground-breaking part of the article was the second point – regarding their honest assessment of the current recommendation to avoid feedings other than breast milk:

“Counseling mothers to avoid giving infants any food or drink other than breast milk during the newborn period is step 6 of the BFHI and one of the primary care interventions most commonly used to support breastfeeding. Three randomized trials have specifically examined the effectiveness of counseling to avoid giving newborns any food or drink other than breast milk; none showed a beneficial effect of such counseling on breastfeeding duration. Studies examining counseling to avoid giving newborns any food or drink other than breast milk were not included in the evidence review. The authors did include several studies examining the effectiveness of multiple-component interventions that incorporated such counseling. These studies also did not show a beneficial effect on breastfeeding outcomes.”

In other words, encouraging mother to avoid supplementation did not show a beneficial effect on breastfeeding duration according to multiple studies.

“Lack of proven efficacy for exclusive breastfeeding during the newborn period to improve breastfeeding duration is important, because exclusivity during the newborn period may not be free of potential harm. For example, the onset of copious breast milk production varies. For women who have scant colostrum and no copious milk production for 4 to 7 days, exclusive breastfeeding in the first few days after birth is associated with increased risk of hyperbilirubinemia, dehydration, and readmission. Although these conditions are generally mild and often resolve rapidly, their frequency is high; 1% to 2% of all US newborns require readmission in the first week after birth, and the risk is approximately doubled for those exclusively breastfed. If counseling to avoid food and drink other than breast milk is not an effective method to support breastfeeding, the frequent low morbidity and rare high morbidity outcomes could potentially be avoided without reducing breastfeeding duration.”

This means that making supplementation of newborns more acceptable to mothers may not only prevent the more common mild-to-moderate complications, and less common severe brain-threatening complications from exclusive breastfeeding of newborns, but doing so does not hinder a mother’s ability to breastfeed long-term. 

They even called into question the 6-month exclusive breastfeeding rule as new evidence and recommendations have shown that introducing allergenic foods by age 4 to 6 months actually reduces risk of developing food allergies.

They close the article by stating that, “To improve breastfeeding rates in the United States, further implementation of system-level interventions such as the BFHI for the general population should be reconsidered until good-quality evidence emerges that these interventions are safe and effective. Implementation of ineffective strategies, potentially those not based on evidence, may divert resources from effective interventions at the individual level and risk causing unnecessary harm.

Thank you, Dr. Flaherman and Dr. Von Kohorn for your excellent review of the literature and for protecting moms and babies with your work.

Fed is Best!