Is extended breastfeeding really best?
I never dreamed that my beautiful baby girl and I would still be on our breastfeeding journey. We thankfully had no major feeding issues that would have halted it, such as tongue tie or low supply, for example. Yes, it was painful – excruciating – for the first few weeks. And the sheer relentlessness of it took my breath away; one feed finished, only for another to begin immediately. Trapped on the couch for the best part of 12 hours, we would finally go to bed, where my husband would have to latch her on as I fell helplessly asleep.
I will be 90 years old and the phrase ‘cluster-feeding’ will still have the power to make me shudder. Here we are seven months later, still going strong. What I didn’t know in those godawful early days was that it would become easier – too easy in fact. The sheer convenience of it means I don’t want to give up. Yet I am a self-employed writer, and the pump that gave me the freedom to go back to work – or go to the supermarket – has now become a frenemy, the drone of it penetrating my dreams. Carting it around as I attend meetings or social events is not that convenient, I will admit. Family and friends ask me when I intend to finish up. I don’t know, is the honest answer.
In Ireland, just two per cent of mothers are still exclusively breastfeeding at six months. But when is the right time to stop? At a recent meet-up with some local mums, one (breastfeeding) mother knowingly said to me: “Up to six months it’s for them – after six months, it’s for you.”
Why don’t I want to stop breastfeeding my baby? Am I just high on oxytocin? Or does the evidence support me? Indeed, the release of oxytocin in both mother and baby is one of the main psychological benefits of breastfeeding, says Dr Malie Coyne, clinical psychologist.
“Close skin-to-skin body contact, post-natally and beyond, significantly improves the physical and mental health and wellbeing for both mother and baby. Oxytocin acts like a fertiliser for their growing brain, helping them to be happier and more confident as they grow older.”
It also naturally helps to build the attachment bond and ensures plenty of mother and baby time, she adds.
In terms of supposed health benefits, I decided to take a look at what is the hard evidence and what is dogma when it comes to breastfeeding vs bottle feeding. The list of apparent advantages is as long as it is varied: children who are breastfed go onto have higher IQs, are less likely to be obese, less likely to have allergies and have superior immune systems.
But like with many things, when you dig a little deeper, the evidence is conflicting. For every study you find that lauds the benefits of breast versus bottle, another is inconclusive.
The other confounding factor is that observational studies of breastfeeding are subject to selection bias – mothers who breastfeed tend to be more educated and more advantaged than those who choose to formula feed, so it stands to reason their children may score higher in IQ tests and be less likely to be obese.
To do away with these biases, one study compared siblings who were fed differently during infancy; they found that breast-feeding might be no more beneficial than bottle-feeding for 10 of 11 long-term health and well-being outcomes such as body mass index (BMI), obesity, asthma, hyperactivity, and verbal and maths skills.
Cochrane Reviews are up-to-date summaries of reliable evidence of the benefits and risks of health care, and are the gospel for most doctors. A 2012 Cochrane Review of the evidence for optimal duration of exclusive breastfeeding found that exclusive breastfeeding for six months (versus three to four months, with continued mixed breastfeeding thereafter) “reduced gastrointestinal infection and helps the mother lose weight and prevent pregnancy but has no long-term impact on allergic disease, growth, obesity, cognitive ability, or behaviour”.
In poorer countries with limited access to clean water and inadequate health systems, the reduced risk of infection is critical.
A recent breastfeeding special report in leading medical journal The Lancet, however, saw its experts admit that its importance in richer countries is somewhat nebulous. “Less consensus exists about its importance in high-income countries,” they wrote.
Their meta-analyses – reviews of all the available evidence – did find evidence for protection against child infections, increases in intelligence, and probable reductions in overweight and diabetes. But there was no obvious associations with allergic disorders such as asthma or with blood pressure or cholesterol, and they also noted an increase in tooth decay with longer periods of breastfeeding.
The maternal benefits are not insignificant: breastfeeding delivers protection against breast cancer. It also improved birth spacing (particularly important in the developing world), and there was some evidence to suggest it may protect against ovarian cancer and type 2 diabetes.
The World Health Organisation (WHO) recommends to breastfeed exclusively for six months and up to two years and beyond, and this advice has been adopted by the health authorities in most countries, including Ireland. Yet this is a blanket recommendation, and surely six months is an entirely arbitrary timeframe?
It is, according to consultant neonatologist Dr Roy Philip. “Nothing happens physiologically in terms of development on the day of six months, it is just when baby is starting to take solid food – the WHO should have said, up until the baby is on solids the baby should be on human breast milk.”
Dr Philip is based in the neonatal unit at University Hospital Limerick. His work with extreme pre-term infants – less than 1,000 grams at birth – has shown first-hand the importance of exposure to breast milk.
“There is clear evidence that mother’s own breast milk preferably, but also donor breast milk, could improve or significantly reduce necrotising enterocolitis, or NEC, which is one of the biggest risks for these babies.”
The first milk a mother produces, colostrum, is lauded as ‘liquid gold’, packed full of protein, minerals, antioxidants and antibodies. Its main benefit is to prevent infection to the newborn. Many women may choose to breastfeed while in hospital, in order to give their baby this superfood produced in the first days after birth.
Dr Philip says the evidence to back this up is growing. “Colostrum is the original vaccine and the latest studies say that it is full of stem cells too.”
For the Irish population, reducing obesity could be one of the biggest impacts of increased breastfeeding, says Dr Philip. “This is a way of reducing it without introducing any medication or other intervention.”
I put it to him about the role of selection bias in these studies and he is quick to refute this.
“The best evidence in terms of its impact on obesity is coming from Scandinavian countries, where they have some of the highest breastfeeding rates in the world, across the entire socio-economic spectrum. It is an independent value of breastfeeding,” he explains.
As explained above, the evidence on breastfeeding playing a role in preventing allergies is inconclusive, yet Dr Philip says that for families with a high risk of allergic tendencies, breast milk has been shown to reduce the frequency and severity of allergic reactions.
Similarly, he says the biggest study on breastfeeding and cognitive skills published in the last five years applied logistical regression to exclude the contribution of societal variability as the reason for the better IQ seen in children who were breastfed.
“Of course, there is a contribution of the better educational and financial background but even allowing for that there is a significant improvement in cognitive skills and neurodevelopment in the exclusively breastfed population for the prolonged period,” he notes.
But even if you think you have a child genius on your hands, give it time. Long-term, the research shows that the apparent cognitive benefits tend to balance out between breastfed and bottle-fed children; studies have noted that, as they approach adulthood, the differences just weren’t as pronounced as in the early years. Dr Philip agrees that this is the case.
“Yes the cognitive benefits are reducing because as the years go by the environment becomes the biggest factor in how we perform in life, and when you get to about 17 or 18 those differences become negligible.”
In Dr Philip’s opinion, the WHO advice should be “breast milk as early as possible for as long as possible” but is conscious this isn’t applicable to everyone.
“People think it is very easy – it is not at all easy. This is not an easy path, it is tough, it is boring, it is constant, but despite all of that, the benefits are undisputed of continuing it beyond weaning, as much as a mother’s environment and personal situation allows.”
Dr Coyne cautions: “Whether you breastfeed or not, the most important thing is to show yourself kindness and compassion as a parent, as this will most enable you to be emotionally available to you and towards your baby.
“At the end of the day, it is your decision and yours only to make.”
For now, I am continuing to breastfeed. I see it as an easy and convenient way of feeding my daughter, and it undoubtedly has benefits for both of us. Or maybe I’m just not ready to give up the damn oxytocin.
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