Abstract
Breastfeeding is a core component of population health. All major medical organizations recommend 6 months of exclusive breastfeeding, followed by continued breastfeeding for at least 12 months, and longer as mutually desired by parent and child. Although 84% of birthing parents initiate breastfeeding in the United States, just 26% are able to sustain exclusive breastfeeding for 6 months, and 35% continue for the recommended 12 months. Sixty percent stop breastfeeding earlier than desired. 1
Premature weaning is associated with increased lifetime disease burden, including higher parental rates of breast cancer, ovarian cancer, diabetes, hypertension, and heart disease. For infants, premature weaning is associated with infectious morbidity, obesity, diabetes, and sudden infant death syndrome. A simulation study found that suboptimal breastfeeding in the United States is associated with 2,619 excess parental deaths and 721 excess child deaths. 2
Multiple factors contribute to premature weaning, including policy issues such early return to work due to insufficient paid parental leave, unregulated marketing of infant formula, and routine hospital policies that disrupt breastfeeding.
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There is also a dearth of evidence to inform management of common medical complications. The Academy of Breastfeeding Medicine has published >30 protocols to inform medical management of breastfeeding. Through a rigorous process, these protocols synthesize the extant evidence; however, for many topics, the evidence is scant, and multiple gaps have been identified. For example:
Mastitis affects up to 33% of breastfeeding dyads, but there is insufficient evidence to inform appropriate antibiotic selection and duration of treatment.
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A 36% of birthing people report overfull, engorged milk in the first 2 weeks after birth,
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but a Cochrane review found insufficient evidence to recommend management strategies.
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Among those who wean earlier than desired, 58% reported not having enough milk.
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However, minimal data exist on effective medications, herbal supplements, or milk expression strategies to increase milk production.
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Similarly, among those who wean early, 20% cited sore, cracked, or bleeding nipples, and 15% cited breast pain, as a reason for cessation; however, a Cochrane review found insufficient evidence for treating nipple pain during breastfeeding.
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There is an urgent need for well-designed clinical trials to determine the efficacy and effectiveness of strategies for managing such breastfeeding challenges. This body of work would recognize that the lactation, like every other physiologic process, can malfunction. To repair that malfunction, we need the tools to diagnose the underlying pathophysiology and an evidence base for treatment.
We also need to measure robust patient-centered outcomes. Duration and exclusivity of breastfeeding are commonly measured, but these metrics do not consider the experience of breastfeeding or the impact on health-related quality of life. In my breastfeeding medicine practice, I frequently see patients who have struggled to produce milk and spend most of their waking hours attached to a pump. One mother came to see me with her second baby. She described grieving as she looked back at videos of her first child; for every memory, she could hear the whirring of a breast pump in the background. Her “duration of breastfeeding” was 12 months; however, this measure did not capture the adverse impact of her breastfeeding experience.
Niles Newton described this mismatch in 1955:
More research which considers the whole nature of the breast feeding situation is badly needed. The number of months of breast feeding are probably much less important psychologically than the type of breastfeeding and the type of weaning involved. Was the breastfeeding unsuccessful breastfeeding—with all the tension, fear, and pain that that involves? Or was it successful breastfeeding with its peace of mind and physical pleasure?
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I have been intrigued by a 1994 measure, the Maternal Breastfeeding Evaluation Scale, 10 which assesses the domains of maternal enjoyment and role attainment, infant satisfaction and growth, and lifestyle and maternal body image. The scale includes statements such as “With breastfeeding I felt a sense of inner contentment” as well as “Breastfeeding made me feel like a cow,” in an attempt to explore the peaks and valleys of infant feeding.
To enable successful breastfeeding, we need to invest in clinical research, and we need to quantify comprehensive patient-reported outcomes so that we can provide each dyad with evidence-based care. By enabling birthing people to reach their infant feeding goals, we can improve health and well-being across generations.