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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Children younger than 2 years are estimated to have approximately 6 bouts of the common cold a year, and essentially 100% have at least one bout—perhaps lowering the NNT for URI if applied widely. However, these data are not divided into 6-month intervals, making accurate extrapolation difficult.²³

Gastrointestinal infection. The rate of diarrheal illness in the first year of life is lower in infants who are exclusively breastfed for at least 4 months and partially breastfed after.

Both the Promotion of Breastfeeding Intervention Trial (PROBIT; a clinical trial in which infants were randomized to a breastfeeding education intervention or standard care) and a 2010 prospective cohort study in the Netherlands of more than 3400 infants found a reduction in the risk of one or more gastrointestinal (GI) infections at a similar rate.^22,24

In PROBIT, 9.1% of infants in the intervention group, compared to 13.2% in the standard care group (OR=0.60; 95% CI, 0.40-0.91), had one or more GI infections at 12 months of age.²⁴
In the 2010 Netherlands cohort, 8% of infants had a GI infection by 6 months of age. Infants breastfed exclusively for at least 4 or 6 months had a decreased risk for GI infection (respectively: adjusted OR=0.41; 95% CI, 0.26-0.64 and adjusted OR=0.46; 95% CI, 0.14-1.59). No such association was found for any feeding group 7 to 12 months of age.²²

These studies are notable for the low incidence of GI infection, which is frequently cited as 1.3 to 2.3 episodes per child per year in children younger than 3 years in the United States.²⁵ However, that high incidence has likely declined significantly since the introduction of rotavirus vaccine in 2006. In the years following the introduction of the vaccine, infant visits for gastroenteritis decreased by >90% in all care settings in the South, Northeast, and Midwest regions of the United States and by 53% to 63% in the West region.²⁶ Recent accurate epidemiologic information, in an era of significantly higher vaccination rates, is lacking.

Assuming the low incidence of GI infection reported in PROBIT and the Netherlands trials, about 25 to 30 infants need to be exclusively breastfed for 4 to 6 months to prevent a single GI infection during the first 6 to 12 months of life.^22,24 Assuming a 60% incidence by age 12 months before introduction of the rotavirus vaccine, the NNT would be approximately 4.²⁴ The true number is likely somewhere between those 2 NNTs.

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