Sure breast is best, but is it worth it?

As a pediatrician, I always promoted breast-feeding to my patients, just as the American Academy of Pediatrics recommended. But when my wife, Elizabeth, unsuccessfully tried to breast-feed, I saw the lengths to which many mothers go, and wondered whether it was worth the struggle.

Elizabeth dutifully tried breast-feeding right after childbirth. But our son wouldn't latch on, and Elizabeth felt guilty. After all, she'd had an epidural to relieve the pain, despite seeing a polemical birthing video about its stupor-inducing effects on newborns. A 2001 study in the journal Birth also encouraged mother to forgo epidurals. The authors alleged that the practice reduced newborns' "massage-like hand movements" that thus "interfered [with] spontaneous breast-feeding."

Most mothers seemed to breast-feed their newborns easily. Modern public health campaigns have increased the breast-feeding rate from 22 percent in 1975 to 60 percent today. According to the American Academy of Pediatrics, breast-feeding can reduce a baby's risk of diarrhea, ear infections, botulism, diabetes, allergies, and even cancer. It could even make the baby smarter, and doesn't cost anything. And what, after all, could be more natural and intuitive than breast-feeding?

Determined, Elizabeth called in a lactation consultant. But nothing worked, and at every feeding she felt like a failure. Giving formula seemed like the ultimate defeat. The admonishing tones of many books didn't help; they treated formula like some addictive drug. The "Complete Book of Breastfeeding" warned: "Do not offer your baby formula. A few ounces soon turn into a full bottle, which soon turns into several." La Leche League's manual states: "Just one bottle is enough to confuse some babies, especially in the early weeks. [You'll] want to be wary."

Many mothers like Elizabeth wonder: How far should I go to breast-feed? How important is exclusive breast-feeding to my baby's health? The facts aren't as clear-cut

as I used to think. One of breast-feeding's most-touted benefits is better immunity. Here are the actual statistics: In a Canadian study, for example, the risk of diarrhea, colds, and other infections per week of early infancy was 3 percent in formula-fed infants, and 2 percent in those breast-fed. An Arizona study found that exclusive breast-feeding for the first four months -- that is, no other liquids or solids whatsoever -- reduced the cumulative risk of ear infection from 65 percent to 55 percent by 1 year of age.

So, breast-feeding may help, but regardless of feeding type, a baby will likely get an ear or other minor infection before his or her first birthday. Several studies published in reputable journals haven't found any added protection from breast-feeding.

The benefits in preventing allergies are even hazier. In 1995, the Lancet reported that breast-fed infants had lower rates of asthma and allergies as teenagers. Ominously, the study indicated that "introduction of a cows' milk-based formula [may] have served as a triggering mechanism" for allergies. An astounding 54 percent of formula-fed teenagers had "substantial" allergies, compared to 8 percent of those who were breast-fed. But two months later, the same journal printed a contrary report finding no such link. And more confusing, the Lancet and New England Journal of Medicine published recent reports that "breast-feeding does not protect children against [allergies] and asthma and may even increase the risk," perhaps as much as 80 percent.

Studies suggest that breast-feeding might prevent diabetes, lymphoma, and sudden infant death syndrome. While plausible, the actual protective effect is probably small. For mothers with insufficient breast milk (due to, say, breast reduction, older age, or other reasons), the risks posed to the child by exclusive breast-feeding may outweigh the benefits of preventing uncommon diseases.

In 1999, for example, a mother -- whose doctors overlooked her breast reduction -- failed to nourish her breast-fed son, who got severely dehydrated. He died and his mother was convicted of homicide in a publicized New York case that "Law and Order" and "Chicago Hope" dramatized on TV. Urging clemency, hundreds of other mothers sent letters to the judge describing their own newborns' serious dehydration during exclusive breast-feeding.

By far, the most intriguing argument for breast-feeding is its possible impact on a child's intelligence. In 2002, the Journal of the American Medical Association reported that breast-feeding for several months conferred 2 to 6 bonus IQ points (the average IQ is 100). This neat sound bite hides great complexity. The investigators themselves wrote: "Mothers who spend more time breast-feeding during the first year of life also spend more time later interacting with the child," which partly may explain the difference.

The same year in Pediatrics, two scientists reviewed 40 studies relating breast-feeding to intelligence. Of them, only 2 met standards of high-quality data, and those reached opposing conclusions. Another Lancet article summarized the current state of knowledge: "Intelligent, loving, and caring mothers are likely to have intelligent children, irrespective of how they choose to feed their babies."

(Later this month the Institute of Medicine, a prestigious health advisory organization, will decide whether the additives ARA and DHA in infant formulas like Enfamil Lipil can also raise IQ. To date, the most convincing data is that 4-month-old premature infants fed ARA- and DHA-supplemented formula can see dots on a piece of paper better. Although impressive, it's not clear whether that added intelligence will stick through adulthood.)

In today's competitive world, we think that if our infants aren't fed with the best method, they'll be sick all the time, they'll get strange diseases, and they won't get into the best schools: They'll fall off the path to a prestigious career and satisfying life before they're even potty-trained. It's easy to scare parents into thinking that decisions during infancy, particularly regarding feeding, are more important than they really are.

I'm suspicious when people are overly dogmatic about breast- or bottle-feeding. Today, the proud father of a healthy son who was often fed formula, I certainly continue to encourage and support exclusive breast-feeding, particularly to enhance bonding -- but I no longer present it as a panacea. Families shouldn't feel guilty for passing up exclusive breast-feeding if it's highly stressful or alienates them from their babies. There are plenty of other positive ways to nurture children.

Dr. Darshak Sanghavi is a clinical fellow at Children's Hospital and Harvard Medical School. His e-mail address is

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