Breast may be best, but bottles do the job too

Contemporary PEDS Journal, April 2022, Volume 39, Issue 3

Experts still advocate for breast milk, but pediatricians must be able to offer advice on all options for feeding babies

When it comes to infant feeding, national and global health experts acknowledge that breast milk is the ideal source of nutrition for at least the first few months of life. Yet, according to the World Health Organization (WHO), just 2 out of 3 babies are breastfed for the recommended 6 months.1

“If there are no contraindications to breastfeeding or breast milk, then there is no reason to use infant formula, as long as the mother is able to breastfeed and/or provide breast milk,” said Lori Feldman-Winter, MD, MPH, chair of the American Academy of Pediatrics (AAP) Section on Breastfeeding and a professor of pediatrics at Cooper Medical School of Rowan University in Camden, New Jersey. “If for some reason the mother cannot breastfeed or provide her baby breast milk, then infant formula is the recommended feeding source until 1 year of age.”

If mothers choose not to breastfeed even though they are able, infant formula is a viable option, though Feldman-Winter called it “a recognized and significantly substandard method of feeding.”

Both AAP and the WHO recommend exclusive breastfeeding for at least the first 6 months of life. Beyond that, continued breastfeeding is recommended until at least age 1 but in conjunction with the introduction of complementary nutritious solid foods.1,2

Because there is no defined reason to transition from breastfeeding or use of breast milk to formula, Feldman-Winter said, there really is no official recommendation on the best time to make that move. “The only thing that may impact timing is if a mother becomes unable to continue breastfeeding or breast milk feeding for some reason, and at that time, infant formula is recommended,” she said. “The longer the mother breastfeeds or provides her milk for the baby, the better the health outcomes.”

Pediatricians should base guidance on the infant’s overall health and nutrition and counsel parents on the options and best practices for feeding.

There is no clinical evidence that 1 type of infant formula is better than another, according to Feldman-Winter. “If and when infant formula is introduced, it really does not matter which formula is selected, as long as it is commercially available and meets US Department of Agriculture [USDA] standards and is reconstituted according to guidelines developed by the USDA, the Centers for Disease Control and Prevention [CDC], and AAP,” she said.

Giving a bottle should be done with responsive feeding practices, following the baby’s cues to avoid overfeeding, Feldman-Winter said. “Bottle-feeding should follow the AAP guidance on responsive feeding, using bottles until about 6 months, and the infants may transition to staged cup feeding depending on development,” she said. “If feeding formula, the formula should be mixed according to guidelines provided by the manufacturer and not altered. Some babies prefer warm breast milk or formula to mimic the temperature of direct breastfeeding.”

The CDC echoes AAP’s position that breast milk is the healthiest option for both infants and mothers in the first few years of life, but the agency also acknowledges that both mothers and babies may decide to stop breastfeeding at any point.3

According to the CDC, common reasons parents stop breastfeeding early include:

  • difficulty with lactation,
  • latching problems,
  • insufficient infant nutrition or weight gain,
  • concerns about medications the mother is taking,
  • challenges related to work or parental leave policies,
  • lack of family or cultural support, and
  • lack of support from health care providers and/or hospitals.

The timing of weaning, from breast milk to both formula and solid foods, is a personal decision, the CDC states.3 The agency suggests that parents interested in weaning an infant from breast milk to formula substitute 1 formula feeding for a breast milk feeding per day to start, gradually increasing the frequency of substitutions.4

Breastfeeding rates have not risen much in the past few decades, but the push to increase the practice really took hold in the mid-2010s. That is when the Breast Is Best initiative launched a campaign to encourage hospitals to achieve a Baby-Friendly designation and support breastfeeding mothers. By the end of the campaign, overall breastfeeding rates grew by about 4%, and exclusive breastfeeding increased from 39% to 61%.5

However, in the years since the campaign’s launch, some researchers and advocacy groups have questioned the “breast is best” narrative, suggesting that proper nutrition, not how it is provided, is key.6

The Fed Is Best Foundation, a national nonprofit group staffed by volunteer health care professional and parents, suggests that research findings point to a rise in hospitalizations of exclusively breastfed infants due to feeding complications from poor milk production or constitution. In 2018, a paper in the Journal of Human Lactation called the Breast Is Best campaign into question, arguing that anxiety, depression, and mental health complications mothers face in the breastfeeding process should be considered when weighing the risks vs benefits of breastfeeding.

La Leche League International suggests that parents who plan to switch from breastfeeding to bottle-feeding breast milk wait until about the fourth week of breastfeeding.8 If supplementation is needed, several types of manufactured formulas, including cow’s milk, soy based, and hypoallergenic, are available to meet infants’ needs.9

Pediatricians should be sure that formulas offered to infants are USDA approved and warn parents never to use homemade formulas or stray from the manufacturer’s mixing guidelines.9

References

1. World Health Organization. Breastfeeding. Accessed February 15, 2022.
https://www.who.int/health-topics/breastfeeding#tab=tab_1

2. Recommendations and benefits: breastfeeding. Centers for Disease Control and Prevention. Updated July 9, 2021. Accessed February 15, 2022.
https://www.cdc.gov/nutrition/infantandtoddlernutrition/breastfeeding/recommendations-benefits.html

3. Facts: key breastfeeding indicators. Centers for Disease Control and Prevention. Updated August 24, 2021. Accessed February 15, 2022.
https://www.cdc.gov/breastfeeding/data/facts.html

4. Weaning. Centers for Disease Control and Prevention. Updated July 9, 2021. Accessed February 15, 2022.
https://www.cdc.gov/nutrition/infantandtoddlernutrition/breastfeeding/weaning.html

5. Feldman-Winter L, Ustianov J, Anastasio J, et al. Best fed beginnings: a nationwide quality improvement initiative to increase breastfeeding. Pediatrics. 2017;140(1):e20163121. doi:10.1542/peds.2016-3121

6. About/FAQs. Fed Is Best Foundation. Accessed February 15, 2022. https://fedisbest.org/about/

7. McIntyre LM, Griffen AM, BrintzenhofeSzoc K. Breast is best…except when it’s not. J Hum Lact. 2018;34(3):575-580. doi:10.1177/0890334418774011

8. Introducing a bottle to a breastfed baby. La Leche League International. August 2018. Accessed February 15, 2022.
https://www.llli.org/breastfeeding-info/introducing-a-bottle-to-a-breastfed-baby/

9. Nemours KidsHealth. Formula feeding FAQs: getting started. Updated November 2021. Accessed February 2022.
https://kidshealth.org/en/parents/formulafeed-starting.html