by Marion Nestle
Jan 16 2011

Furor about new breastfeeding study

A recent commentary in the British Medical Journal (BMJ) is causing a furor among breastfeeding advocates in Great Britain.

Titled Six months of exclusive breast feeding: how good is the evidence?, its authors argue that four months is probably just as good and less likely to cause harm.

The current British recommendation is for six months of exclusive breastfeeding—meaning no added solid foods.  This is based on a systematic analysis of research first published as a Cochrane review in 2002 and updated in 2006.  It compared the health of infants breastfed for six months to those breastfed for three-to-four months, and concluded that the science demonstrated significant advantages to the longer breastfeeding period.

That analysis was the basis of breastfeeding recommendations by United Nations agencies, such as the World Health Organization and UNICEF.  In Great Britain, UNICEF UK has issued its own statement defending the six-months recommendation.

Adding to the furor, the British Guardian titled its article about the new commentary, “Six months of breastmilk alone is too long and could harm babies, scientists now say.”  A second account in the Guardian provided a more cautious interpretation of the science.

I can understand why breastfeeding advocates are so upset about the BMJ paper.  They are worried about promotion of infant formulas as substitutes for breast milk, especially in developing countries.  Infant formulas can be adequate, if not perfect, substitutes for breast milk under conditions where they can be properly diluted and refrigerated.  When those conditions are impossible, as is the case in many low-income areas, formulas can become contaminated with harmful bacteria.  Use of infant formulas has a long history of association with infant illness and death (I wrote about this in Food Politics).

Formula companies did and continue to promote their products as convenient—and preferable—substitutes for breast feeding.

As it turns out, several of the authors of the BMJ commentary consult for formula companies.

Those authors vehemently deny that their ties to formula companies influence their opinions.  That may or may not be so, but such ties strongly correlate with research results and opinions favorable to the corporate ally.

In the United States, pediatricians strongly advocate breastfeeding, but flexibly.  In 1997, the American Academy of Pediatrics (AAP)  policy statement said.

Exclusive breastfeeding is sufficient to support optimal growth and development for approximately the first 6 months of life and provides continuing protection against diarrhea and respiratory tract infection….Complementary foods rich in iron should be introduced gradually beginning around 6 months of age.

But the AAP noted,

Unique needs or feeding behaviors of individual infants may indicate a need for introduction of complementary foods as early as 4 months of age, whereas other infants may not be ready to accept other foods until approximately 8 months of age.

As any parent of more than one child can tell you, babies differ.  Some are happy with exclusive breastfeeding.  Others want solid foods the instant they learn how to swallow.

The new commentary isn’t wrong, exactly, although it says nothing new.

It just isn’t helpful.  And that’s reason enough to be upset about it.

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  • Anthro

    I’d be very happy if most of the women I’ve known over forty years would get past three to six WEEKS of breastfeeding. Even those who pass this benchmark are usually supplementing. My own doctor (age 30!), who had a generous maternity leave, only managed two weeks! The constant excuse is, “I just didn’t make enough milk”. No, you just wouldn’t sit still, eat, drink water, and focus of the task at hand; you had to “get in shape”, go shopping, clean the house, etc. This and your constant use of supplements greatly diminishes the amount of milk you produce. I always wonder if these women could manage to make more milk if formula were not available?

    I know that much of your concern is for the poor (here and elsewhere), and so is mine, but I am always sad to see so many young mothers fail so miserably at breastfeeding right here in the US. My view is definitely anecdotal; anyone out there have statistics on what percentage of women breastfeed exclusively for four to six months? Two of mine demanded real food around four months, but also nursed vigorously for many months more. I’m glad to see that the AAP guidelines include some flexibility–often they do not and women end up feeling very confused or guilty.

    As to four months vs. six months–good grief! Two of mine were exclusively breastfed for eight or ten months and they are just as healthy as the other two. You’re right–this info is not helpful!

  • Wouldn’t it be wonderful to live in a world that saw breastfeeding as a benefit to women, rather than a burden? I’m thinking of a world that advocated for breastfeeding as a public health issue, a world that celebrated and supported breastfeeding women, a world that saw the emotional/nutritional/physiological relation between women and infants as a natural support to health and wellness (for mother and baby alike) rather than as a disturbing intrusion into individualistic ideals of work and privacy. What if breastfeeding was viewed as a woman’s right, rather than a (all too easily dismissed) choice?

  • Renee

    In my opinion, if you take any funding from companies that sell Formula, you are disqualified to provide any serious information about breastfeeding.

    I am grateful that Formula exists, for those mothers who honestly can not breastfeed for some medical reason, but it should never replace breast milk unless it is absolutely necessary. If your baby wants real food, great –but Formula is not real food, and should be avoided if at all possible.

  • …babies differ! Probably, very likely, one type of advice is not applicable to every situation, but we don’t yet have much idea of how to select.

    The choice here is not breastfeeding vs. infant formula, it should be made very clear that the evidence suggesting adding solid foods before 6 months do NOT also suggest stopping breastfeeding. Precisely the opposite. The ESPGHAN (European Society for Pediatric Gastroenterology, Hepatology, and Nutrition) issued some precise advice targeted especially at infants with possible celiac disease risk (i.e. a genetic predisposition): For further details see

    “It is prudent to avoid both early (or=7 months) introduction of gluten, and to introduce gluten gradually while the infant is still breast-fed, inasmuch as this may reduce the risk of celiac disease, type 1 diabetes mellitus, and wheat allergy.”

    Using genetics to give targeted advice is in it’s infancy (excuse me!) – but could be useful in this case. If the universal advice were to suggest introducing solid foods between 4-6 months, that could lead to more frequent introduction actually before 4 months, which according to the evidence is even more risky for allergies and autoimmune diseases. So in this perspective the WHO advice could be considered to be wise, but there are exceptions

  • The constant excuse is, “I just didn’t make enough milk”. No, you just wouldn’t sit still, eat, drink water, and focus of the task at hand; you had to “get in shape”, go shopping, clean the house, etc.

    Selfish bloody women! They just live for pleasure. [/sarcasm]

  • One of the problems with the coverage of this comment piece, is the media – and the public – confuse what is being talked about by the authors (the period of exclusive breastfeeding), with breastfeeding itself. The authors have not suggested that breastfeeding should stop when complementary foods are introduced, whether at four months or six months.

    Just to clarify another point, powdered infant formula is not sterile and may be contaminated with harmful bacteria – this is not restricted to developing countries, but is the nature of the product and specific cases of infant death in industrialised countries have been directly attributed to such contamination, prompting product recalls of the batches containing Enterobacter Sakazakii, one of the principal problems (salmonella is another).

    The more significant problem when babies are not breastfed is they are denied the protection breastfeeding affords and are more likely to become sick. In developed countries that can be treated – costing the health service millions of pounds every year according to the UK National Institute of Clinical Excellence – whereas in poor settings babies denied breastmilk are more likely to die from such illness.

    The concern about early introduction of complementary foods is it provides another route for infection at a time when the child is particularly vulnerable without being nutritionally necessary. From the baby food industry’s viewpoint, early introduction means a child is more likely to be fed purees and paps, which parents are less likely to home prepare and so become consumers of processed foods. Baby-led weaning, where children are allowed to play with solid food and start to eat it when they are ready is gaining popularity, and children seem to be ready at about 6 months as various developmental factors come together. It is perhaps unsurprising that this should coincide with what research has identified as the time of nutritional need for additional nutrients.

  • Anthro

    I think I may be guilty of having missed the main thesis of the piece. I may be confusing introduction of solids with breastfeeding in general. But I maintain my point that too many never even get to the point of four months which makes the whole thing moot.
    Nor did I mean to imply that women have no right to assume their previous lives once they have a baby, but I still think that their babies would benefit if they focused more on the baby and less on their personal desire for a less tethered-to-the-baby lifestyle. This is, in the end, a decision for each woman to make for herself. I just remember the day that my daughter-in-law, who had successfully breast fed her three children from birth to the cup–no bottles, ever, told me that her success was attributable to my very early advice that if she was to succeed she would have to do more than “try”; she would have to be absolutely determined that this was the best thing for her children and not waver from that principle. I had shocked her at the time, but she says now that she internalized that message and it got her through the early days when it just seemed too hard and too much of a sacrifice–she started her family late and had had a glamorous single life for some years before marriage and children, so devoting herself to exclusive breastfeeding was a radical lifestyle change for her. I checked with her and she did not introduce solids until around six months, for the record.

    I try to stay away from anecdotes when posting, but I did want to explain my comments about women’s priorities as my words (a bit out of context) made me wince.

  • Rhiana
  • @Anthro, I think this page has the statistics you want:

    I’ve heard that our rates are improving, but not very quickly.

    I’ve got no beef with the original paper, as long as the authors disclosed their connection with the formula makers. As someone with a history of allergies in her family, I’m grateful people are doing research to try to understand if there is anything we can do as parents to minimize the risk of our kids having food allergies and similar problems.

    But I think the mainstream press coverage of this has been shameful, but I guess that doesn’t surprise me. Did the UK press learn nothing from the Wakefield/vaccine saga? Or do they just not care, as long as they sell papers?

    I always tell new moms who are starting out on breastfeeding that it is highly likely that they’ll want to quit in the first few weeks, when neither the mom nor the baby knows what they’re doing and frankly, it often hurts. BUT- if you can hold out until 6 weeks, chances are you’ll keep going. The first 6 weeks of breastfeeding my first child were really hard. But then, it got easier and I was so glad I hadn’t quit. I ended up breastfeeding her for 23 months. We introduced solids sometime around 5 months, because I was going on a business trip and we were hoping she’d get some of her calories from solids. She didn’t really, but somehow I managed to pump enough to leave for that trip, and we made it through, and by that time there was no way I was quitting, because I loved breastfeeding my baby.

    I’m now breastfeeding my second baby, who is 15 months old. The first 6 weeks with her were much easier, but still hard- but this time I knew how much better it would get. I plan to breastfeed her until she’s about two, or until she wants to quit, whichever comes first. I introduced solids at about 5 months again, this time because she seemed interested.

    Anyway, breastfeeding my babies has been one of my favorite things about motherhood. It is so peaceful to sit and watch my baby eat, and I love the bonding time it ensures. I hope the sensationalist coverage of this research paper doesn’t lead many women to forgo breastfeeding.

  • Pete

    “Breastfeeding Burns 1000 Calories a Day!”

    There’s your ad campaign to promote breastfeeding. I can’t think of a woman I know that wouldn’t rather sit and pump than pump some iron.

  • FG_2009

    Besides the advantage of breastfeeding (good for the baby etc) other advantages on my case were:

    No bottles to wash/sterilize (I had no dishwasher at home, so if I had anything less to wash the better it is)

    Convenience – I am besides your diaper bag, no need to pack formula/bottle/water – very handy when traveling too

    I managed to do for a year – at the end I was not making enough milk (seriously I used the pump and nothing came out) so it was a natural transition – by then she was eating other stuff

    As another reader said it’s very esy togive up – I was in pain for a month – but then I was lucky to get the gist and it worked for me.

    I have sympathy for the moms who really can’t do it – but I suspect that quite a few out there just don’t even try – but anyways no mom should feel guilty if you can’t do it – but I hope that you really really really tried before giving up.

  • Rachel

    Just to put this info out there, alot of women are judging how much milk they make by how much they are able to pump. I have exclusively breastfed three babies and I could never get a pump to pump out much of anything. I did not “let down” with the pump. Women should be informed and not assume that this means you have no milk. I never gave a bottle to any of my kids, but I had plenty of milk.