How long should mothers breastfeed their babies?
The controversial question has cropped up again after the nation’s leading pediatrics group has issued new recommendations calling for women to breastfeed until their children turn 2, and possibly even longer.
The policy statement, Breastfeeding and the Use of Human Milk, was released on June 27 by the American Academy of Pediatrics (AAP). It calls out stigma, lack of support, and workplace barriers that make continued breastfeeding difficult for many mothers.
But the new policy statement isn’t going down smoothly with the Fed Is Best Foundation, a nonprofit group hoping to “debunk and sort out for the public” many of the proclamations in the AAP’s policies, said Christie del Castillo-Hegyi, MD, co-founder of the group and emergency physician at CHI St. Vincent, Little Rock, Arkansas.
The goal of Fed Is Best is to assist families and healthcare professionals with current research on the safe feeding of infants ― whether with breast milk, formula, or a combination of each.
The AAP’s previous guidelines, issued in 2012, called for infants to be fed breast milk exclusively for their first 6 months. Continued breastfeeding was recommended while introducing complementary foods for a period of 1 year or longer, the policy stated. The updated policy extends the optimum timeline for breastfeeding to up to 2 years, citing the health benefits for babies.
“Tone Deaf and One-Sided”
The AAP policy is “tone deaf and one-sided to the 75% of the US mothers who use formula either by necessity or choice,” del Castillo-Hegyi told Medscape Medical News.
She pointed to a long list of factors that could affect the health outcomes of infants with regard to breastfeeding vs formula-feeding. These include socioeconomic status, baseline maternal health and education, maternal genetics, and the effects of developing feeding complications from exclusive breastfeeding for infants whose mothers can’t produce enough milk. These issues can contribute to negative health outcomes and brain development in infants who go on to be formula fed, she said.
She also objected to the fact that the guidelines make little reference to a mother who needs to supplement breast milk with formula within 4 months ― and even before that ― to meet her infant’s nutritional requirements.
Mothers need to hear “that making sure their infant is adequately fed is the most important goal of any infant feeding recommendation,” del Castillo-Hegyi said. She noted that the AAP’s rigid guidelines may be impossible for many mothers to follow.
“The pressure to meet [the AAP’s] exceedingly high expectations is causing harm to mothers and babies,” she said, referring to earlier guidelines that contained similar suggestions.
If a mother’s milk is insufficient, babies are at risk for low growth rates, jaundice, and dehydration. Mothers also can be affected if they’re made to feel shame because they cannot provide adequate amounts of breastmilk and must supplement their supply with formula.
The blanket nature of the AAPs recommendations is “irresponsible,” given the fact that only about 1 in 4 nursing people can produce sufficient breast milk to feed their baby, del Castillo-Hegyi said.
“Not only is there harm to the infant, who may suffer from developmental problems as a result of the malnutrition they experience, but it harms the mother who believes in the AAP to provide responsible guidelines that help them ensure the best nutrition to their infants,” she said.
Lori Feldman-Winter, MD, chair of the AAP Section on Breastfeeding, defended the updated guidance.
The policy aims “to clarify the evidence that breastfeeding matters and to use the best evidence to equip pediatricians with the ways they can support the mother’s choice,” Feldman-Winter told Medscape. “The bottom line is that most women can exclusively breastfeed according to our recommendation, but a growing number of women have conditions that make it difficult, such as obesity. Pediatricians are essential in recognizing suboptimal intake in the breastfed infant, and the policy delineates how to do this.”
Feldman-Winter added that the criticism of the policy “is not unexpected, given the many barriers in our society for women doing the work of mothering and trying to reach their personal breastfeeding goals. We know over 60% of mothers do not reach their intended goals. These barriers are even more apparent for the populations that are underserved and least likely to breastfeed.”
But del Castillo-Hegyi pushed back on the AAP’s claim that exclusive breastfeeding of infants up to 6 months of age confers significant benefits beyond combination breast feeding and formula feeding. The policy “fails to address the fact that many mothers do not have the biological capacity to meet the recommendation and are simply unable to exclusively breastfeed their infants” for that length of time, she said.
While the differences of opinion might leave lactating mothers in limbo, another expert pointed out that “support” of mothers is critical.
Jessica Madden, MD, a pediatrician and lactation consultant in Cleveland, Ohio, said advocates should work to normalize extended breastfeeding in the general public.
“I think everyone should work to advocate together,” Madden said. “From the professional society standpoint, advocacy for extended breastfeeding should come from the Academy of Breastfeeding Medicine and the APP’s Section on Breastfeeding Medicine.”
She said more emphasis should be focused on the roles that pediatricians and healthcare providers play, along with insurers and employers, to ensure that moms are confident and comfortable with whatever breastfeeding journey they take.
The AAP will be revisiting the recommendations again soon, Feldman-Winter said. The US Preventive Services Task Force (USPSTF) has completed a systematic review but has not set a date to release findings, she said.
Among the issues the USPSTF will address are whether interventions that support breastfeeding improve outcomes for children and mothers; how to improve the initiation, duration, intensity, and exclusivity of breastfeeding; and the identification of any potential harms of interventions that support breastfeeding.
“The research plan illustrates that breastfeeding is now an active area for research, and we will continue to update our recommendations according to the best evidence,” Feldman-Winter said.
Del Castillo-Hegyi, Feldman-Winter, and Madden have disclosed no relevant financial relationships.
Pediatrics. Published online June 27, 2022. Full text
Sharon Donovan is a journalist in New Orleans.