For Amy Forstadt, the first six weeks of breast-feeding were a nightmare.
"I have pretty sensitive skin, and my baby was just a chomper," said Forstadt, a 37-year-old writer from Beachwood Canyon. Lactation consultants and a pediatric orthopedist were unable to detect a problem with Benjamin's "latch," so she wound up pumping milk to feed him from a bottle for the first month and half -- a cumbersome but, for her, less painful approach. That solution collapsed one night when the family dog devoured part of her breast pump, forcing her to nurse while her tears of agony splashed on Benjie's face.
Forstadt stuck with the nursing -- with the help of a different lactation consultant -- in large part so that her son could get the health benefits of breast milk. He's now 6 months old, and Forstadt loves breast-feeding him.
But the truth about the health benefits of breast-feeding is more complicated than most people realize.
This spring, the federal Agency for Healthcare Quality and Research (AHRQ) published a report that evaluated the research on breast-feeding and children's health. Assembling the data involved a year and a half of combing through more than 9,000 studies and reviews, selecting those that met strict quality criteria.
Dr. Ruth Lawrence, who chairs the breast-feeding task force of the American Academy of Pediatrics (AAP), said the result is the "most comprehensive, all-inclusive" document on breast-feeding in developed countries. "It's an excellent report," she said.
The report didn't address the role of breast-feeding in developing countries, where infant formula mixed with tainted water is often deadly. It focused instead on countries such as the United States, where the effects are less dramatic -- and more difficult to measure.
The researchers found that breast-fed babies had fewer ear, gastrointestinal tract, and severe lower respiratory tract infections than formula-fed ones and were less prone to sudden infant death syndrome (SIDS), obesity, Type 1 and Type 2 diabetes, childhood leukemia, early-childhood asthma and atopic dermatitis (a skin disorder that causes eczema).
Though the reductions were as large as 72% (for severe lower respiratory tract infections), the report states that none of its findings imply causality.
This inability to prove cause and effect is a problem that plagues virtually all breast-feeding research. The problem is that women who breast-feed, as a whole, are very different from their bottle-feeding counterparts: wealthier, older and more educated, for starters. Although researchers are able to adjust their results for such factors, there's no way to adjust for every difference. Women who breast-feed are probably more health-conscious in numerous ways, which could explain why breast-fed children tend to be healthier.
The evidence is more suggestive in some areas than in others. "It's well proven that breast-feeding is effective at reducing infections in the newborn period, as long as children continue to be breast-fed," said Dr. Lawrence Gartner, past chairman of the AAP's breast-feeding group. The reason is that breast milk contains antibodies and other agents that prevent bacteria, toxins and viruses the baby has swallowed from attaching to the lining of the throat and gut.
He said that the research was "not nearly as good" for the other claims. One reason is that fewer studies have been done; another is that how breast milk might offer protection is less clear.
For example, scientists know that breast-fed babies are less likely to die of SIDS. Although much of this difference is explained by the fact that women who breast-feed tend to be more affluent and less likely to smoke cigarettes, not all of it is.
"I'm convinced about the benefits of breast-feeding against SIDS," said Dr. Michael Kramer, a professor of pediatrics and of epidemiology and biostatistics at McGill University in Montreal. One explanation, he said, is that breast milk might offer some protection by warding off respiratory illness.
But scientists aren't sure what causes SIDS. A leading hypothesis is that some babies are born with a brain stem abnormality that affects their ability to respond when they're not getting enough oxygen. The AHRQ researchers point out that babies who are prone to SIDS may also have difficulty with breast-feeding -- which could explain the difference in SIDS rates between breast-fed and bottle-fed babies.
In some cases, health differences may be related to the bottle itself. For example breast-fed babies may be less likely to be obese later in life because overzealous bottle-feeding -- "working the baby" until a bottle is empty -- interferes with babies' ability to stop eating when they're full, said Dr. Laurence Grummer-Strawn, chief of maternal and child nutrition for the Centers for Disease Control and Prevention.
Another example is ear infections. "There's discussion that the way the baby is positioned during feeding may be different," Grummer-Strawn said. Some parents bottle-feed their baby in a lying-down position, which may allow fluid to pool in the middle ear and contribute to ear infections.
If bottles are the culprit in obesity and ear infections, then babies who drink breast milk from a bottle might miss out on certain benefits. On the other hand, bottle-fed babies might benefit from improved feeding methods.
Even if breast-feeding has long-term effects on health, this doesn't mean that these benefits are permanent.
Kramer said that the evidence is very good that breast-feeding protects against atopic dermatitis in early childhood, but the effect might wear off as children get older.
This wearing-off effect may also apply to asthma. The AHRQ researchers found that young children were less likely to be wheezy if they had been breast-fed. Several studies that followed children until their teens or beyond, however, found that those who had been breast-fed were no less likely -- or even more likely -- to have asthma than those who had been fed formula.
The report dismissed the idea that breast-feeding could raise a child's IQ, because that association disappeared in studies that adjusted for the mother's intelligence. But Lawrence said that, for her, the studies on IQ were "pretty persuasive." Kramer agreed, although he said it wasn't clear whether the difference might be because of something in breast milk or the increased attention and physical contact that breast-fed babies tend to get.
Dr. Wendy Slusser, a pediatrician and director of the UCLA Breastfeeding Resource Program, said she didn't understand the need for a 400-page report on breast-feeding and health. "Breast-feeding is better than formula . . . isn't that enough?" she asked. She questioned whether it really mattered that breast-feeding "does prevent this or doesn't prevent that."
But efforts to promote breast-feeding often rely on making specific health claims and, as a result, suggest to women that formula feeding will put their babies at great risk.
When the federal Office of Women's Health commissioned an ad campaign to boost the nation's breast-feeding rate, the Ad Council came up with ads highlighting breast-feeding's potential to reduce respiratory illness, ear infections and obesity. The campaign, which ran from 2004 to 2006, included two controversial television spots that compared formula use with riding a mechanical bull and log-rolling while pregnant.
About 42% of mothers are breast-feeding at 6 months, according to the 2004 National Immunization Survey. This falls short of the 50% goal set forth by a federal initiative called Healthy People 2010. The AAP recommends that women breast-feed exclusively for six months, with supplemental breast-feeding for a baby's first year or longer.
Helping, not 'browbeating'
Not all doctors agree that fear should be used to promote breast-feeding.
Dr. Darshak Sanghavi, an assistant professor of pediatrics at the University of Massachusetts Medical School, said that the focus should be on helping women who want to breast-feed, rather than "browbeating" those who don't. He added that doctors should treat women like "mature adults" by admitting that the breast-feeding research is often inconsistent and poor in quality. Even if certain conclusions do prove true, Sanghavi said, they could resonate differently for different women. For example, learning that breast-feeding could reduce the number of ear infections by one or two a year might be a compelling reason for some women to breast-feed. "But if you're a mom who has a lot of issues with breast-feeding . . . is that really worth it to you?" he asked. "It's a very personal decision."
Breast-feeding advocates say that even when the benefit to the individual is small, the benefit to society can be enormous -- including large overall reductions in doctors' visits and healthcare costs. "Healthcare is cheaper for a breast-fed baby," Lawrence said. What's more, health benefits that seem tiny for one person can add up across the population.
But the decision to breast-feed usually is about more than ear infections and IQ points. Jennifer Pickett, 32, a part-time teacher from West Los Angeles, said that one of her reasons for breast-feeding was that it sounded like a "wonderful way to bond" with her son, Jack.
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Risk reduction, by the numbers
The reduction in risk may seem great for breast-fed infants, but some of the conditions listed below are more prevalent than others.
Gastrointestinal infections are quite common, for example, with the average child experiencing about one a year before age 5, so breast-feeding could protect legions of babies from a nasty bout of diarrhea. By contrast, childhood leukemia is rare. The risk of developing acute lymphocytic leukemia -- the most common form of cancer in children -- before age 20 is 0.063%, according to statisticians at the National Cancer Institute. If breast-feeding could reduce that risk by 19%, the absolute risk reduction would be 0.012%.
With that in mind, the report found that breast-fed babies were:
* 64% less likely to develop gastrointestinal infections
* 72% less likely to be hospitalized for lower respiratory tract disease
* 23% to 50% less likely to develop ear infections
* 4% to 82% less likely to develop necrotizing enterocolitis if premature.
* 36% less likely to die of sudden infant death syndrome
* 42% less likely to develop atopic dermatitis
* 27% to 40% less likely to develop early-childhood asthma
* 15% to 19% less likely to develop childhood leukemia
* 19% to 27% less likely to develop Type 1 diabetes
* 7% to 24% less likely to be obese
* 39% less likely to develop Type 2 diabetes
-- Devon Schuyler