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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.
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FOR THE RECORD:
Breast-feeding: An article in Monday's Health section said a mother had consulted a pediatric orthopedist about her difficulties breast-feeding. She consulted a pediatric occupational therapist.
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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 U.S., 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 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.
Temporary benefits?
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.
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.
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 TV spots comparing 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 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 may 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. And 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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