Is the &quot;breast is best&quot; mantra an oversimplification?

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Applied Evidence

Is the "breast is best" mantra an oversimplification?

J Fam Pract. 2018 June;67(6):E1-E9

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From The Journal of Family Practice | 2018;67(6):E1-E9.

References

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Infectious disease

Acute otitis media. Exclusive breastfeeding for 6 months is associated with a 43% reduction in the risk of acute otitis media (AOM) by 2 years of age (odds ratio [OR]=0.57; 95% confidence interval [CI], 0.44-0.75). Beyond 2 years of age, or when comparing “ever” and “never” breastfeeding, the effect disappears. All studies in this meta-analysis had serious limitations.¹⁸

Nearly half of children will have at least one case of AOM by one year of age; 80%, by 2 years.^19,20 Since the introduction of the heptavalent pneumococcal conjugate vaccine, the rate of AOM at 2 years has fallen by as much as 20%.²¹ Assuming an incidence of 60% to 80% of AOM by 2 years, only 2 or 3 infants need to be exclusively breastfed for 6 months to prevent a single case of AOM.¹⁸ Prevention of AOM through breastfeeding may be related to head position during feeding, antibacterial effects of breast milk, protective oral microbiome in the breastfed infant pharynx, and/or prevention of primary viral upper respiratory infection (URI), which nearly always precedes AOM.^18,19

Upper and lower respiratory tract infections. Infants who are exclusively breastfed for 4 months and partially breastfed after 4 months have a lower risk of URI (OR=0.65; 95% CI, 0.51-0.83) and of lower respiratory tract infection (LRTI; OR=0.50; 95% CI, 0.32-0.72).²²

The effect is stronger for URI among infants exclusively breastfed for at least 6 months (OR=0.37; 95% CI, 0.18-0.74), but is no longer significant by that time for LRTI (OR=0.33; 95% CI, 0.08-1.40). Importantly, AOM was included in the URI group, and, as previously discussed, AOM has independently been shown to have an inverse relationship with breastfeeding duration.

At 7 to 12 months of age, no association was seen between breastfeeding and the incidence of URI. Curiously, an association with LRTI was again detected for infants breastfed exclusively for 4 months and partially thereafter, but was not detected with exclusive breastfeeding for at least 6 months (OR=0.46; 95% CI, 0.31-0.69). In this study, in the first 6 months of life, 40% of infants had a URI and 8% had an LRTI. The findings in this cohort suggest an NNT of 6 or 7 for prevention of URI and an NNT of 25 for prevention of LRTI in the first 6 months of life.²²

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