Rapid responses are electronic comments to the editor. They enable our users
to debate issues raised in articles published on bmj.com. A rapid response
is first posted online. If you need the URL (web address) of an individual
response, simply click on the response headline and copy the URL from the
browser window. A proportion of responses will, after editing, be published
online and in the print journal as letters, which are indexed in PubMed.
Rapid responses are not indexed in PubMed and they are not journal articles.
The BMJ reserves the right to remove responses which are being
wilfully misrepresented as published articles or when it is brought to our
attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not
including references and author details. We will no longer post responses
that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
As I parent and clinical psychologist, I read Rammya Mathew’s article with interest. I welcome her call for a holistic, shared-decision making approach to supporting parents making decisions about how to feed their babies. I share her disappointment at the lack clear information and decision-making tools outlining absolute risk reductions for the benefits of breastfeeding. However, I question whether the strong public health imperative to improve breastfeeding initiation, duration and exclusivity rates may be at odds with the shared decision-making approach she envisages.
Clinicians supporting patients making these decisions may find useful data from a recent review article which calculated the numbers needed to prevent for various benefits of breastfeeding1. In addition, this article highlights important risks associated with exclusive breastfeeding including an increased likelihood of requiring hospital admission due to hyperbilirubinemia, dehydration, hypernatremia and weight loss with a number needed to harm (NNH) of 71 for term infants. For weight loss >10% of birthweight the NNH was calculated at 13. Another recent study conducted in the US suggests that exclusive breastfeeding is now the leading risk factor for readmission to hospital in the first month of life2.
Breastfeeding and its promotion as a public health intervention also has potential adverse effects on mothers. Mastitis affects up to 33% of lactating women3. A recent systematic review of the Baby Friendly Initiative in the UK suggests inconsistent advice, dogmatism, reluctance to discuss formula and the framing of breastfeeding being “best” for all babies may contribute to feelings of shame for women who struggle with it, having an adverse effect on their mental health4.
Bodies charged with public health promotion would do well to carefully calculate both the benefits and risks associated with breastfeeding in the UK today and consider whether increasing breastfeeding rates is likely to lead to public health savings taking into account both the proven benefits and potential adverse effects of breastfeeding and its promotion.
I am also concerned about the potential adverse effects of activities carried out to promote and support breastfeeding. It is notable that the most common reasons women give for stopping breastfeeding before they had planned are pain, latching difficulties and low supply5. A recent Cochrane review on treatments for nipple pain in breastfeeding women found insufficient evidence to make recommendations for its treatment6. I could find no such review or established recommendations for latching problems or low supply.
Public health initiatives often focus on changing health behaviours. For example, encouraging fruit and vegetable consumption, taking exercise, attending screening appointments, getting vaccinations or to reduce/stop other behaviours such as smoking. Breastfeeding is a complex set of processes involving both a decision to engage in certain behaviours (e.g. putting the baby to the breast) and a set of physiological processes which may or may not function optimally. It must be initiated soon after birth, a time of physical recovery and tremendous adjustment to having a new baby. Even when breastfeeding is going well it has profound effects on the person breastfeeding and on their family life. As a clinical psychologist, I am sceptical about blanket application of behavioural change strategies (e.g. motivational interviewing7 and financial incentives8 have both been trialled recently in the UK) to this complex process.
A recent systematic review of psychosocial interventions to increase breastfeeding rates highlights that whilst they may have some effect on initiation rates, they did not have an effect on duration and exclusivity of breastfeeding9. Moreover, the review highlighted a lack of theoretical basis for these interventions. I am concerned about the impact on women of attempts to shape their behaviour in the absence of sound theoretical models integrating the bio-psycho-social aspects of infant feeding and a lack of evidence-based solutions to common breastfeeding problems. Whilst the data suggest psychosocial approaches are largely unsuccessful at increasing breastfeeding behaviour, their impact on maternal mental health is under investigated and unknown.
I would like to see infant feeding incorporated as an integral part of postnatal care, conducted in an individualised, collaborative and clinically accountable manner. Parents can be offered clear information about what the evidence currently says as to the benefits and risks of all safe feeding methods and trusted to make the decisions that are most appropriate for their individual families. Health providers would do well to focus on safe management (e.g. having clear evidence-based protocols to prevent babies requiring admission to hospital with feeding related complications and safe bottle preparation of formula/expressed breastmilk). A research focus on developing an evidence base to prevent and resolve common breastfeeding problems may put evidence-based solutions to common breastfeeding problems in the hands of individuals and their health care providers. In so doing, parents can be empowered to attain the most important outcomes for them and their families.
2Flaherman V, Schaefer E, Kuzniewicz M et al. Health Care Utilization in the First Month after Birth and Its Relationship to Newborn Weight Loss and Method of Feeding, Academic Pediatrics 2018; 18(6): 677-684.
3Angelopoulou A, Field D, Ryan C, et al. The microbiology and treatment of human mastitis. Med Microbiol Immunol. 2018; 207(2):8 3-94.
4Fallon V, Harrold J &andChisholm, A. The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: A mixed methods systematic review. Maternal & Child Nutrition 2019; e12778. doi:10.1111/mcn.12778 (Accessed 19 June 2019).
6Dennis C, Jackson K and Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD007366. DOI: 10.1002/14651858.CD007366.pub2 (Accessed 19 June 2019).
7Paranjothy S, Copeland L, Merrett L, et al. A novel peer-support intervention using motivational interviewing for breastfeeding maintenance: a UK feasibility study. Health Technol Assess. 2017;21(77): 1–138.
8Relton C, Strong M, Thomas KJ, et al. Effect of Financial Incentives on Breastfeeding: A Cluster Randomized Clinical Trial. JAMA Pediatr. Published online February 01, 2018172(2):e174523. doi:10.1001/jamapediatrics.2017.4523 (Accessed 19 June 2019).
9Davie P, Chilcot J, Chang Y et al. Effectiveness of Social-psychological Interventions at Promoting Breastfeeding Initiation, Duration and Exclusivity: A Systematic Review and Meta-analysis. Health Psychology Review 2019. DOI: 10.1080/17437199.2019.1630293 (Accessed 19 June 2019).
Competing interests:
I am a cofounder of Infant Feeding Alliance, a UK based parent -led movement campaigning for compassion, autonomy and safety in infant feeding. The group and I have no funding from any organisation linked with infant feeding, commercial or otherwise.
Re: Rammya Mathew: Infant feeding, informed choice, and shared decisions
As I parent and clinical psychologist, I read Rammya Mathew’s article with interest. I welcome her call for a holistic, shared-decision making approach to supporting parents making decisions about how to feed their babies. I share her disappointment at the lack clear information and decision-making tools outlining absolute risk reductions for the benefits of breastfeeding. However, I question whether the strong public health imperative to improve breastfeeding initiation, duration and exclusivity rates may be at odds with the shared decision-making approach she envisages.
Clinicians supporting patients making these decisions may find useful data from a recent review article which calculated the numbers needed to prevent for various benefits of breastfeeding1. In addition, this article highlights important risks associated with exclusive breastfeeding including an increased likelihood of requiring hospital admission due to hyperbilirubinemia, dehydration, hypernatremia and weight loss with a number needed to harm (NNH) of 71 for term infants. For weight loss >10% of birthweight the NNH was calculated at 13. Another recent study conducted in the US suggests that exclusive breastfeeding is now the leading risk factor for readmission to hospital in the first month of life2.
Breastfeeding and its promotion as a public health intervention also has potential adverse effects on mothers. Mastitis affects up to 33% of lactating women3. A recent systematic review of the Baby Friendly Initiative in the UK suggests inconsistent advice, dogmatism, reluctance to discuss formula and the framing of breastfeeding being “best” for all babies may contribute to feelings of shame for women who struggle with it, having an adverse effect on their mental health4.
Bodies charged with public health promotion would do well to carefully calculate both the benefits and risks associated with breastfeeding in the UK today and consider whether increasing breastfeeding rates is likely to lead to public health savings taking into account both the proven benefits and potential adverse effects of breastfeeding and its promotion.
I am also concerned about the potential adverse effects of activities carried out to promote and support breastfeeding. It is notable that the most common reasons women give for stopping breastfeeding before they had planned are pain, latching difficulties and low supply5. A recent Cochrane review on treatments for nipple pain in breastfeeding women found insufficient evidence to make recommendations for its treatment6. I could find no such review or established recommendations for latching problems or low supply.
Public health initiatives often focus on changing health behaviours. For example, encouraging fruit and vegetable consumption, taking exercise, attending screening appointments, getting vaccinations or to reduce/stop other behaviours such as smoking. Breastfeeding is a complex set of processes involving both a decision to engage in certain behaviours (e.g. putting the baby to the breast) and a set of physiological processes which may or may not function optimally. It must be initiated soon after birth, a time of physical recovery and tremendous adjustment to having a new baby. Even when breastfeeding is going well it has profound effects on the person breastfeeding and on their family life. As a clinical psychologist, I am sceptical about blanket application of behavioural change strategies (e.g. motivational interviewing7 and financial incentives8 have both been trialled recently in the UK) to this complex process.
A recent systematic review of psychosocial interventions to increase breastfeeding rates highlights that whilst they may have some effect on initiation rates, they did not have an effect on duration and exclusivity of breastfeeding9. Moreover, the review highlighted a lack of theoretical basis for these interventions. I am concerned about the impact on women of attempts to shape their behaviour in the absence of sound theoretical models integrating the bio-psycho-social aspects of infant feeding and a lack of evidence-based solutions to common breastfeeding problems. Whilst the data suggest psychosocial approaches are largely unsuccessful at increasing breastfeeding behaviour, their impact on maternal mental health is under investigated and unknown.
I would like to see infant feeding incorporated as an integral part of postnatal care, conducted in an individualised, collaborative and clinically accountable manner. Parents can be offered clear information about what the evidence currently says as to the benefits and risks of all safe feeding methods and trusted to make the decisions that are most appropriate for their individual families. Health providers would do well to focus on safe management (e.g. having clear evidence-based protocols to prevent babies requiring admission to hospital with feeding related complications and safe bottle preparation of formula/expressed breastmilk). A research focus on developing an evidence base to prevent and resolve common breastfeeding problems may put evidence-based solutions to common breastfeeding problems in the hands of individuals and their health care providers. In so doing, parents can be empowered to attain the most important outcomes for them and their families.
1 Wilson J, Wilson B. Is the “breast is best mantra” an over-simplification? Journal of Family Practice 2018;67(6):E1-E9 https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/D... (Accessed 19 June 2019).
2Flaherman V, Schaefer E, Kuzniewicz M et al. Health Care Utilization in the First Month after Birth and Its Relationship to Newborn Weight Loss and Method of Feeding, Academic Pediatrics 2018; 18(6): 677-684.
3Angelopoulou A, Field D, Ryan C, et al. The microbiology and treatment of human mastitis. Med Microbiol Immunol. 2018; 207(2):8 3-94.
4Fallon V, Harrold J &andChisholm, A. The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: A mixed methods systematic review. Maternal & Child Nutrition 2019; e12778. doi:10.1111/mcn.12778 (Accessed 19 June 2019).
5McAndrew F, Thompson J, Fellows L, et al. Infant Feeding Survey 2010. https://sp.ukdataservice.ac.uk/doc/7281/mrdoc/pdf/7281_ifs-uk-2010_repor... (Accessed 19 June 2019).
6Dennis C, Jackson K and Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews 2014, Issue 12. Art. No.: CD007366. DOI: 10.1002/14651858.CD007366.pub2 (Accessed 19 June 2019).
7Paranjothy S, Copeland L, Merrett L, et al. A novel peer-support intervention using motivational interviewing for breastfeeding maintenance: a UK feasibility study. Health Technol Assess. 2017;21(77): 1–138.
8Relton C, Strong M, Thomas KJ, et al. Effect of Financial Incentives on Breastfeeding: A Cluster Randomized Clinical Trial. JAMA Pediatr. Published online February 01, 2018172(2):e174523. doi:10.1001/jamapediatrics.2017.4523 (Accessed 19 June 2019).
9Davie P, Chilcot J, Chang Y et al. Effectiveness of Social-psychological Interventions at Promoting Breastfeeding Initiation, Duration and Exclusivity: A Systematic Review and Meta-analysis. Health Psychology Review 2019. DOI: 10.1080/17437199.2019.1630293 (Accessed 19 June 2019).
Competing interests: I am a cofounder of Infant Feeding Alliance, a UK based parent -led movement campaigning for compassion, autonomy and safety in infant feeding. The group and I have no funding from any organisation linked with infant feeding, commercial or otherwise.