#77484 Breastfeeding Benefits

[pillowy]

As Maven said in her answer, most websites you're going to look for this information are going to be biased one way or the other (usually very pro-breastfeeding). And it's important to look at the studies themselves - many that show huge benefits to breastfeeding don't fully account for confounding factors such as parental education, class, income, or race (which make huge differences in the benefits they're studying). A recent study published just this month - "Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States using sibling comparisons" did account for these factors by using longitudinal data that compared siblings who were breastfed and formula fed. They found that when they took all the socio-economic factors out of the mix, and just compared between breastfed siblings and formula fed siblings within families, there was no statistically significant difference in BMI, obesity, asthma, hyperactivity, parental attachment, behavioral compliance, math skills, reading recognition, vocabulary, intelligence, or scholastic competence.

In their words,

In Table 3, we present descriptive statistics by breastfeeding status (yes/no) for the eleven outcomes of interest across...different subgroups – the full NLSY-Children’s sample...and the discordant sibling sample...[In the first sample] Mean levels of BMI, hyperactivity, math skills, reading recognition, vocabulary word identification, digit recollection, and scholastic competence as well as the percentage of respondents who are obese all appear to significantly (p < 0.05) differ between children who were breastfed and those who were not and are in the predicted direction, with breastfed children exhibiting better outcomes. When the sample is restricted to discordant siblings, mean scores across all eleven indicators of child health and wellbeing are comparable and differences between breast- and bottle-fed respondents are small enough to be attributable to random chance alone.

They conclude:

Efforts to increase breastfeeding that solely focus on individually based behavior change without addressing the economic and social realities women face and the difficult tradeoffs they are forced to make in the months following the birth of their child risk alienating and stigmatizing the very women they hope to help… A truly comprehensive approach to increasing breastfeeding in the U.S., with a particular focus on reducing racial and SES disparities, will need to work toward increasing and improving parental leave policies, flexible work schedules and health benefits even for low-wage workers, and access to high quality child care that can ease the transition back to work for both mother and child. Hopefully, this multifaceted approach will allow women who want to breastfeed to do so for as long as possible without promoting a cult of “total motherhood” in which women’s identities are solely constructed in terms of providing the best possible opportunities for their children and the risks associated with a failure to breastfeed are drastically overstated (Wolf, 2011).

Basically, every woman who wants to breastfeed should be able to, and every woman who wants to formula feed should be able to do so without feeling like she's hurting her child or her relationship with her child somehow, because she's not. You're just as good of a mom whichever way you feed your baby.

That's not to say there are no benefits to breastfeeding - there do seem to be short-term benefits to babies (less ear infections, a couple less colds), and possibly some long-term benefits to mothers (possibly less breast cancer). The greatest benefits of breastfeeding are absolutely to those in developing countries - solely breastfeeding a child protects that child from water-borne illnesses that could be introduced in unclean water mixed with formula. This is why the WHO recommends exclusive breastfeeding for the first 6 months of life - to protect children in developing countries. But with the clean water we have in the US, the long-term benefits of breastfeeding to the babies themselves seem to be greatly exaggerated.

*edited for spelling*

[Portia]

I wasn't breastfed and I don't seem to be doing too shabbily.

Yet another of the things that puts me off child-rearing. The competitiveness among white UMC women. Don't give a ****.

[pillowy]

What's UMC?

[Portia]

What's UMC?

I used it to mean upper-middle class. I thought of you when I read this article about the natural childbirth fetish.

[pillowy]

Haha, I totally read that article already today. And this one, about the same book.

[Portia]

I read Expecting Better so I know at least some of the research out there about epidurals, pain management, and birth. But I just don't get it! I have some tokophobia, granted, but for crying out loud, it's not climbing K2, I don't see why you wouldn't want to minimize pain. I suppose the recovery is worse, but I have never heard of a causative relationship between pain meds and Cesareans.

I take ibuprofen for headaches; I can pretty much guarantee I'm not going to soldier through with nothing but a tub of water. But I have an extremely low tolerance for pain of any kind.

[Portia]

Speaking of it not being a summit, another trend that freaks me out is photographing the whole process. That is something that our parents' generation would not comprehend. It sounds incredibly stressful ... who needs stage fright? I also feel like there's a lot of competitiveness with "baby bump" photos. I don't like the skin-tight maternity clothing look, personally. Then again I'm not a size 2 prior to getting pregnant so I am not the body type they had in mind for their "cute" pregnant ladies.

[Portia]

Do you have kids, pillowy? Or are you an OB-GYN or something?

[pillowy]

Yeah, I don't get it either. And I actually think I have a pretty high pain tolerance; I have a chronic condition that occasionally causes an allergic reaction that feels identical to descriptions of heart attacks. And those last for hours, and I endure through them. There's nothing I can take to make the severe pain go away, I just have to wait until it ends. So...what? Do I deserve a medal? No. Enduring pain isn't a competition, it's a necessity. And I see childbirth as the same way. I don't see the point in pain for pain's sake.

[pillowy]

Yeah, I have two girls. (They're adorable, by the way.) One born with an epidural, one medication-free. One breastfed, one formula-fed. And if anyone had to guess which was which, there's no way they'd be able to tell, because there's just no difference.

I'm not an OB, although I'm flattered you'd think that was possible. I did get a bachelor's degree in biology, so I have that background, but where I get most of this information from is an OB's website that I've been reading for over a year. Her articles and analyses of studies are always really interesting, and the comment section is great. There are literally hundreds of comments on almost every post, and many of the commenters are OBs (and other doctors), nurses, and other medical professionals. I've learned a ton from the studies the OB posts and the comments from people in the medical field.

[The Moo]

It's sort of like the poster today who was upset because she can't get any straight answers. Part of the reason is there are no authoritative straight answers. Each mom is different and each pregnancy is different. I have four kids. 2 C-section and 2 VBAC. My first was a C-section. When the 2nd was born, OB's were promoting VBAC whenever possible. When the third was born, I had to talk my doctor into the VBAC, and I succeeded mostly because I'd already had one successfully and because he'd been around the block a few times. Out of those four pregnancies, labor lasted from about 2 hours to over 40 hours. Three were induced. I had epidurals with all four, although one was only because I elected to have a C-section when I found out in the delivery room that the baby was breach. One was a forceps delivery with a horrendous episiotomy. One had no stitches whatsoever. And the length of time I breastfed ranged from 4 weeks to over a year. Each one is different. You can find a story, somewhere, to support any point of view you are fond of.

[NerdGirl]

After having seen a lot of births now, I'm not sure that I personally would have an epidural. It takes away the pain of contractions, but you have to keep the fetal monitors on once you have it in, which is annoying, and from what I've seen a standard epidural doesn't make much of a difference one you get to the actual pushing stage. I'm not saying no one should have an epidural, but it would not be my personal preference for pain relief in labor. I think I would probably go for nitrous oxide during active labor and morphine in early labor. Of course, this is all very hypothetical anyway because the medication that keeps my body from destroying itself is incredibly unsafe during pregnancy, and unless my autoimmune disease suddenly goes into remission, I will likely not ever be able to have a baby.

[Whistler]

huh. At the hospital I'll be delivering in, you have to have fetal monitors on all the time regardless.

[NerdGirl]

In Canada we tend to not do continuous monitoring unless there's a really good reason to (which an epidural is) or unless the mom asks to have continuous monitoring. Some moms do specifically request it, especially moms who have had a stillbirth in the past. But in general we do intermittent monitoring whenever possible, especially in early labor - that way moms can walk and change positions and go on the birth ball or take a shower. I did my med school labor and delivery rotation in a very high risk OB setting (at the hospital that is the referral center for all of the highest risk pregnancies in our half of the province), and I even worked with some OBs who were comfortable not using continuous monitoring for some VBACs (at least in early labor). That's a bit more controversial, but some of the OBs who do really high risk stuff all the time have done hundreds of VBACs and feel like they have enough clinical judgment to know which VBACs should have continuous monitoring and which are low enough risk that intermittent monitoring is ok.

[Whistler]

yeah, I really like the idea of intermittent monitoring, since being hooked up to cords seems kind of limiting. Luckily it's just for a day so I hope the experience doesn't make me hate fetal monitors .

[pillowy]

...from what I've seen a standard epidural doesn't make much of a difference one you get to the actual pushing stage.

I've had two labors - one with an epidural, one without - and in my experience, the epidural made a world of a difference once I got to the pushing stage. It's pretty impossible to describe the difference in pain levels at the pushing stage with an epidural vs. without one. I guess I could say, on a scale of 1 to 10, pain at pushing stage with epidural - 2. Without epidural - 10.

Also, I didn't mind the monitors at all. Plus continuous electronic fetal monitoring has been shown to cut the early neonatal mortality (death from birth to 7 days) in half. So to me it's worth it.

[NerdGirl]

^I don't know how convinced I am based on that article that Dr. Amy referenced in that blog post. First, I think it's just referring to electronic fetal monitoring, not continuous electronic fetal monitoring. We do put women on the monitors here any time they come in to labor and delivery triage, but after doing a 20-30 minute observation on the monitor, we don't necessarily keep them on if there is nothing concerning and there is no medical need for it. So even using intermittent auscultation still involves using EFM, just not continuously. And we often do intermittent monitoring with EFM and just leave the bands on, but unhook them so that the mom can walk around, go on the birth ball, etc. Not all intermittent monitoring is just IA. Plus some of the non-EFM births in the study might have been births done without a skilled provider, so that complicates things.

Second, that is based on studies done only in the US, and prenatal and intrapartum care is so different enough in the US and other places (I'm Canadian, so I am both practicing medicine and hypothetically but probably not giving birth outside of the US) that there may be other factors that account for that difference that would make that study not generalizable to pregnancies outside of the US. And conversely, although the Canadian guidelines (http://sogc.org/guidelines/joint-policy ... statement/ and http://sogc.org/guidelines/fetal-health ... guideline/) don't recommend continuous EFM for everyone, that is not necessarily generalizable to the US. I'm not trying to tell anyone what they should or shouldn't do in labor, I just think it's interesting that there are so many differences in the way birth happens in the US vs Canada. Also, that study is based on retrospective cohort studies, which are not as high-quality evidence as a randomized controlled trial. What would be really useful would be a large, international, multi-center randomized controlled trial comparing outcomes using continuous EFM, intermittent EFM, and intermittent auscultation in-hospital with equally-skilled providers. The trouble with obstetrics in general is that there aren't a lot of randomized controlled trials done, because it's hard to them ethically when babies are involved, and so there just isn't a lot of high-quality evidence for a lot of what we do. And because of the ethics involved, that is not likely to change.

I am all for fetal heart rate monitoring, and I am convinced that it saves lives, I'm just not convinced that continuous EFM is the best way to do it in every case. And there are logistical issues involved with it, too, that sometimes force you to just do IA anyway. Sometimes depending on the mother's size or shape or where the baby is, you just can't get the electronic monitor to stay on the baby's heart rate and it just doesn't work and you need another option. And the other options are IA or a fetal scalp electrode, but the fetal scalp electrodes pick up the closest heartbeat, which means that if the baby's heart has actually stopped, it picks up the mom's heartbeat and if mom's heartbeat is fast because she's in labor and in pain, you might mistake it for the baby's and think everything is fine. And the baby has to be pretty far down for you to actually attach a fetal scalp electrode, so that's not an option in early labor.

And I'm all for epidurals if someone wants one, but just based on what I've seen, nitrous oxide seems to work almost as well, and that is what I would probably personally try first because it's so much easier. But again, that is probably something that varies based on what country you live in. I'm not even sure how common it is to use nitrous oxide in labor in the US.

Sorry to write a book here - I just finished my obstetrics rotation in med school a few months ago and I find this stuff really interesting and could talk about it for weeks. I find it much more interesting to talk about than to actually do it, though. I am actually not planning to deliver babies after I finish residency. I'm going to be a family doctor, so I will do more labor and delivery in residency, and lots of family doctors deliver babies in Canada. But they tend to to just deliver babies, and I have too many other interests in family medicine (chronic pain, mental health, care of the elderly, etc).

[pillowy]

To respond to all your points in turn:

2. Your second point first, since it effects the rest of the answer - Yes, the Canadian and US systems are very different and results and techniques in one country can't be extrapolated to apply to the other country. I should have said that in my post.

1. So, going back to the first point - Usually when talking about it in the US, referencing "intermittent auscultation" means listening to the heart with a doppler, not with EFM. Intermittent auscultation with EFM is not common. Usually it's either continuous EFM (at hospital births) or intermittent auscultation with a doppler (at out of hospital births). Since that's how it is (in the great majority of cases) in the US, I assumed that the births in the analysis of studies done in the US would nearly all fall into these two categories. There will be exceptions, like those births you mentioned where continuous monitoring just doesn't work for one reason or another, but in almost all US hospital births it's continuous EFM that's used. As you said, it'd be better if the info came from randomized controlled trials, but those are just so hard to do in obstetrics due to ethical reasons.

It'd be nice if nitrous oxide was more available here in the US. It's really not commonly an option here at all, and I think that's a shame. I've heard about its common use in other countries and don't understand why it's not more widely available here. Women should have all the pain relief options they can. If I had the chance to choose between the two, I personally would prefer an epidural over nitrous oxide just because I wouldn't want my cognitive function impaired; however, in my last birth there was no time for an epidural and I definitely would have preferred nitrous oxide (which I believe, and correct me if I'm wrong, can be administered rather quickly) over nothing at all.

No worries about the length of the post! I always write huge posts too, and then kind of regret it, but then don't want to delete anything because I wanted to say what I said. Which is a really long way (speak of the devil) of saying I understand, haha.

[Amity]

And I'm all for epidurals if someone wants one, but just based on what I've seen, nitrous oxide seems to work almost as well, and that is what I would probably personally try first because it's so much easier. But again, that is probably something that varies based on what country you live in. I'm not even sure how common it is to use nitrous oxide in labor in the US.

My tendency to read too many random things on the internet can help! I read this a few months ago: http://www.slate.com/articles/double_x/ ... rican.html. Sounds like nitrous oxide is very uncommon in the U.S., but a few places are beginning to offer it.

[NerdGirl]

Yeah, that makes sense actually that they would implicitly mean continuous EFM and I'm surprised I didn't realize that since what we were just talking about was how US hospitals tend to use continuous EFM. And that was an interesting article, Amity.

I can totally see picking an epidural over nitrous oxide if you don't want your cognitive function impaired. I am pretty ok with my cognitive function being impaired, though. Actually I would be ok with just being hooked up to a fentanyl drip and enjoying a bit of an opiate high, but that's not so great for the baby's breathing and stuff. And also, I have developed this huge fear of going to the dentist ever since I got my wisdom teeth out and it was a bit of a disaster, but seeing how well nitrous works for women in labor has made me think that maybe I could handle going to a dentist who offers it.

And you are right that nitrous oxide is very quick. Pretty much instant and it doesn't stay in your system very long, so if you don't like how it makes you feel, you can just stop breathing it and the effects wear off in less than a minute. And there's no set up time involved either and no waiting for the anesthesiologist. They have it all the rooms in the hospital I was at, and nurse or midwife just turns it on and hands you the mask if you want it. It's very much ideal if someone wants pain relief and they are having a super fast labor. They've even got in the triage area, so women can use it if they want to while they are waiting to be assessed and get into a labor room. And even if someone wants an epidural, if they anesthesiologist is stuck in the OR for a complicated c-section or something, they can use nitrous while they are waiting, which is nice.