Colicky Baby? Nursing Problems? Consider Cranio-Sacral Therapy

When my first baby was born, she had a rough time. So did we. She spent hours screaming. She couldn't settle down to sleep for long until the middle of the night. She just wasn't a happy baby. I felt so bad for her, and I certainly felt like a bad mother.

She was like this for FOUR MONTHS, four verry longgggg months.

We tried everything we could think of but nothing worked. Going for walks often helps but not for this baby. Going for a drive helps many babies but just seemed to make this one worse. Jiggling and swaying sometimes helped but mostly it didn't. Vacuums and washing machines, no luck.

There were times I got so frustrated that I put her into her playpen, nice and safe, and let her scream while I went into the bathroom around the corner and pounded the walls with my fists and cried too. Better the wall than the baby, I reasoned. Afterwards I could return to her calmer and more able to respond lovingly. Sometimes I called up my husband at work and told him, "Get home NOW!!" because I couldn't stand it any longer. We would tag team parent to keep sane on the really tough days. There's no question, a colicky baby is extremely difficult at times.

My baby cried so much sometimes that even the neighbors heard. A neighbor who lived behind us diagonally suggested Craniosacral therapy. She had a child with cerebral palsy and said it worked wonders for him when he was a fussy newborn.

I was intrigued and tempted. But in the end it sounded way too "woo-woo" for me so I never tried it. I just couldn't trust my baby to it. She was my first baby and I just couldn't bear to try anything out of the ordinary. So we all suffered through together.

My daughter finally did outgrow the colic, but it was a loooooooooooong four months, let me tell you. While she was always a sensitive baby in many ways, after that she got a lot easier to deal with and she was definitely much happier.

My second baby was much more easy-going, thank goodness. As long as he got nursed on time and held plenty, he was a happy guy. He had his own challenges, as all babies do, but nothing like as his sister.

My third baby, though, was a lot like his sister. To this day, they follow each other's patterns in many ways. When he was born and started having troubles with crying and sleeping, I knew I was NOT going to go through Colic Hell again. So I decided to heed my neighbor's suggestion and try Craniosacral therapy.

Stresses from Birth

When a baby is born, there is a lot of twisting and turning to navigate the mother's pelvis. This can be stressful on the baby's head and neck areas. In addition, the baby's head is made of separate bones that can fold in on each other slightly like a vegetable steamer so it can fit through the pelvis more easily.

However, after the birth all the pressure and twisting and turning may not leave these bones moving freely. Craniosacral therapy aims to restore that freedom of movement and ease, as well as a free flow of cerebral spinal fluid.

Craniosacral therapy (CST) is a very light-touch, hands-on therapy. It uses the pressure of the weight of a nickel on the baby's skin to slowly and carefully address any misalignment in the baby's head, neck, sacrum, or soft palate. It aims to restore good nerve function so the baby's systems can operate optimally.

Some births are more stressful on the baby than others. Births that tend to benefit most from CST include:

• Forceps/vacuum births
• A very slow and/or difficult birth
• A traumatic birth
• A birth where the baby was malpositioned or got "stuck" 
• An extremely fast birth
• A cesarean birth

Some people might think that a cesarean would be easiest on the baby, but it's actually just a different kind of stress. Babies born by cesarean are pulled out sideways through a small incision; sometimes that happens easily and sometimes it doesn't. Thus some cesarean babies can also have a difficult time post-birth.

Some of the behaviors that CST might be able to help include:

• Fussy babies who don't soothe easily
• Babies who don't sleep well
• Babies who have digestion or elimination problems
• Babies with lots of spitting up or reflux
• Babies with Colic
• Breastfeeding problems
• Difficult latching for baby; resulting sore nipples for moms
• Babies who favor turning their heads to one side
• Babies who favor one breast or position for nursing
• Babies who seem overly sensitive

CST Controversy

Unfortunately, there is NO gold standard evidence on Craniosacral therapy. Like many alternative medicine fields, the research is mostly based on case studies, which basically amount to someone's story that it works. Anecdotal evidence is not irrelevant, but it is not science.

Critics charge that the idea behind Craniosacral therapy is nonsensical, that there is "no plausible mechanism of action," that studies end up producing conflicting diagnoses from different practitioners instead of consistent results, and that what studies there are mostly come from the inventor of the technique, which could easily bias the results. These are all valid concerns.

When you watch or experience Craniosacral therapy, it certainly appears as very "woo-woo." It certainly fits many stereotypes of alternative medicine quackery, and there really isn't any good proof that it works. All it has going for it are people's testimonials about how helpful it can be in some cases, which could be caused by a placebo effect as much as anything. As one critic writes, "No one can deny that craniosacral therapy is relaxing. But, then again, so is a nap & a nap is cheaper."

So I can't say there's proof that CST works, but there are plenty of stories out there of its helpfulness. Take that as you will.  For some people, these stories are enough to at least give CST a try. For others, it's absolutely not. If you are willing to try it, go for it. If it all sounds far too woo-woo and quackery to you, don't try it. The decision is always yours.

All I can do is share my personal stories in which Craniosacral therapy was helpful to my family. I started out as a total skeptic on it, completely unwilling to buy into it. But I was so desperate to avoid the 4-month Colic Hell I'd experienced with my first that I was willing to suspend my disbelief and give it a try on the desperate hope that it might help. I fully expected it to fail -- but it didn't. I have since used it in enough situations that I think it's worth considering if you find a very skilled and experienced provider that has the specialized training needed.

Colic

The first time our family tried CST, it was on baby #3. He had trouble settling down and going to sleep, had trouble sleeping for more than a few minutes at a time, and was just generally fussy, crying, and unhappy. At 2 weeks old I took him in for some CST. I used a pediatric chiropractor trained in CST. I stood right beside them so I could snatch him away if needed.

When we started, his arms and his legs were tucked up tight against his body and his little hands were held tightly in fists. He was a tense little guy. When the therapist started, she put one hand on his head and one hand underneath his sacrum. He began crying and tensed up even further. As his crying intensified (it didn't last long), I was just about ready to grab him and give up. Just then he gave a loud cry, a HUGE sigh, and relaxed his whole body. His legs fell to his sides, his arms relaxed, and his little fists uncurled. He stopped crying and fell deeply asleep. He napped all through the appointment and then was bright and cheery later on. That night, he slept SO well!

We used CST several times with him as a baby and he seemed to really breathe into it and enjoy it each time. It did seem to help him resolve whatever had been causing his colic.

There is an interesting description of CST for young babies, along with many CST resources, here.

Nursing Issues

We used CST on my 4th baby too. Not because she had colic but just as a precaution and because it had helped my other babies. But then one night when she was several months old, my husband fell asleep while holding her. He inadvertently relaxed his grip on her and she rolled off his lap and fell onto the floor. She cried very loudly but didn't seem hurt at all. However, after that, nursing all of a sudden hurt. It had been fine before that fall, but suddenly nursing seemed to pain her, and I know it pained me. Her latch had changed and I was left very sore. She was fussy too.

So we got her into our same pediatric chiropractor as soon as we could. She had me nurse the baby just before the treatment, then did the treatment, and had me nurse her again just after it. It was like night and day, the difference! It no longer hurt, the baby was satisfied and not fussy after, and I had no pain from her latch afterwards. Obviously, something about the treatment itself had changed things for the baby, even though the treatment looked like nothing was being done. It obviously had some effect.

It makes logical sense to me that CST might be able to help nursing issues. Often the CST therapist will put on a medical glove and have the baby suck on an upside down finger. In this way they are evaluating the baby's suck and latch, and if anything is off, they can adjust the palate with a little light pressure from the inside. Works like a charm and did not seem rough at all.

There is a good article describing what a lactation consultant is looking for when treating a breastfeeding baby, which can be found here.

Fibromyalgia

My eldest child went on to develop fibromyalgia as an adult. She's pretty functional most of the time but she does deal with a lot of pain, including headaches. We have found that Craniosacral therapy is the ONLY thing that really dials down her pain levels effectively. Because fibromyalgia is a chronic condition, she seems to do best if she goes for CST treatment about once a month. She has to pay for her own CST but it helps her so much she makes room for it in her limited budget. She's a real believer in it.

There is one small study that supports the use of CST for fibromyalgia. The details can be found here.

Headaches

In my fourth pregnancy I began to experience a lot of headaches. There was a lot of stress in my life at that point as I was a caregiver to a dying parent, but these felt like more than just stress headaches. None of my usual headache fixes were working very well, so when I was a few months' pregnant I decided to try CST.

Some people feel immense emotional releases during CST but I felt a weird physical release during my first session. The therapist was working on my sacrum, an area that has given me lots of trouble. All of a sudden my low back got really really warm. I asked her if she had turned on a heating pad or anything, but she swore she hadn't. The heat kept increasing until finally it peaked and went away suddenly. That was the only time that I have ever experienced anything like that during CST so it's not routine, but it was powerful and it was real. I don't see how it could have been faked. I wasn't expecting anything like that so it wasn't my expectations setting up a physical reaction. It was strange but I have to say the headaches disappeared afterwards.

Some years later, I was in a bad car accident. I was waiting to turn left on a country road when the car behind me struck me at full speed, 55+ MPH. He was on his cell phone and didn't notice that I had stopped. The impact shattered my car windows and totaled my van and changed my life.

I reminded myself it could have been much worse. There was no blood and no bones broken, so I counted myself lucky. I went home to my children that night. However, I didn't realize how much trauma my soft tissues, shoulders, neck, head, back, and knees took until later. It took me a long time to recover from the worst of it and I still have lingering problems from it even now.

One of the more difficult effects I had was headaches -- sudden, blinding headaches that felt like someone was suddenly stabbing me in the eye with an ice pick. This was different than any headache I'd ever had before. I tried chiropractic care and acupuncture; they were very helpful for the rest of my symptoms but didn't begin to touch my headaches, which were very debilitating.

Finally I decided to try Craniosacral therapy. I found someone who did CST for people with traumatic brain injuries, concussions, and veterans returning from war. She worked on me multiple times and slowly the blinding ice-pick headaches went away. It was effective for my headaches when nothing else was.

So that's my experience with Craniosacral Therapy. I've found it useful in several different scenarios, and I know a number of other women who have found it useful for colic, nursing problems, and head injuries.

CST still makes me cringe every time I watch it because it seems so woo-woo and unbelievable.  I would point out again that it's not been proven. It's possible the good results I and others have gotten have simply been due to the healing effect of hands-on touch and a desire to believe that it's helpful, but honestly I don't think a placebo effect is enough to explain it all.

I don't believe every claim that's made for CST, but I know it was helpful for me and my kids. I certainly believe it's worth considering for certain things like colic, nursing problems, headaches, and fibromyalgia.

Summary

Craniosacral therapy is light, hands-on therapy that many people report being helpful. I first got to know it as a treatment for colic and nursing problems but it may be helpful for other indications as well. It is very woo-woo in nature and hard to justify scientifically, yet the favorable anecdotal experiences of many should not be dismissed either.

Currently, there is no good-quality proof that Craniosacral therapy is effective. However, most of the material critical of CST is based on a few limited reviews from 2006 and 2011. It's time for higher quality protocols and less dismissive research.

Until we have that research, it is up to each family whether or not to try Craniosacral therapy. If you do try it, choose a practitioner who is very experienced and has several levels of training in it. Some will be massage therapists with advanced training, while others will be pediatric chiropractors who have additional CST training. If you use it for colic or nursing problems, you want someone trained in newborn issues.

You can find a directory of some Craniosacral therapy practitioners with training in babies and breastfeeding here.





Resources

Neonatal Netw. 2016;35(2):105-7. doi: 10.1891/0730-0832.35.2.105. Feeding in the NICU: A  Perspective from a Craniosacral Therapist. Quraishy K. PMID: 27052985

Completing full feedings is a requirement for discharge for babies in the NICU. interaction between the nerves and the muscles of the jaw, tongue, and the soft palate is required for functional sucking and swallowing. Jaw misalignment, compressed nerves, and misshapen heads can interfere with these interactions and create feeding difficulties. craniosacral therapy (CST) is a noninvasive manual therapy that is perfect for the fragile population in the NICU. CST can be used as a treatment modality to release fascial restrictions that are affecting the structures involved in feeding, thereby improving feeding outcomes.

• "CST for Infants & Children," by Carol Gray
• "The Benefits of Craniosacral Therapy for Newborns" by Venetia Moore, Greenchild Magazine, January 12, 2018. 
• "CranioSacral Work and Other Gentle Body work for Helping Breastfeeding Problems," www.kellymom.com breastfeeding resource
• http://www.carolgray.com/about-craniosacral-therapy/craniosacral-therapy-for-infants-and-chidren/
• "Breastfeeding and CranioSacral Therapy: When It Can Help" by Dee. Kassing, IBCLC 
• http://www.carolgraycenterforcststudies.com/member-directory/
• https://www.ncbi.nlm.nih.gov/pubmed/26891636 - CST for PTSD and traumatic brain injury

Breastfeeding Reduces Long-Term Risk for Diabetes

Here is yet another study showing that breastfeeding long-term decreases the risk for developing diabetes.

In this latest study, breastfeeding for a total of 12 months or more cut the risk for diabetes by about HALF.

That's a pretty significant decrease. It's not an absolute guarantee against diabetes, of course, but there is excellent evidence that breastfeeding strongly reduces the risk for diabetes or delays its presentation. This has obvious benefits for heart health.

This latest study just adds to the accumulating evidence of the importance of breastfeeding for a woman's long-term health. Pregnancy alters the metabolism significantly, increasing insulin resistance and blood sugar in order to divert more energy to the developing baby. This is good in the short term, but bad for the mother long term.

Biologically speaking, lactation was meant to "re-set" the mother's metabolism back to normal after pregnancy. When this doesn't happen, the mother's metabolism remains altered to some extent and more prone to health issues like diabetes and heart problems.

Sometimes breastfeeding doesn't work out, and that's okay. But new mothers should know that biologically, their bodies were meant to lactate, and the longer the better. Moms who do nurse should be encouraged to nurse as long as possible, and given every support to do so. Moms who don't nurse or who stop within a few weeks or months should be alerted to be even more proactive about avoiding/watching for diabetes.


References

JAMA Intern Med. 2018 Jan 16. doi: 10.1001/jamainternmed.2017.7978. [Epub ahead of print] Lactation Duration and Progression to Diabetes in Women Across the Childbearing Years: The 30-Year CARDIA Study. Gunderson EP, Lewis CE, Lin Y, Sorel M, Gross M, Sidney S, Jacobs DR Jr, Shikany JM, Quesenberry CP Jr. PMID: 29340577

...OBJECTIVE: To evaluate the association between lactation and progression to diabetes using biochemical testing both before and after pregnancy and accounting for prepregnancy cardiometabolic measures, gestational diabetes (GD), and lifestyle behaviors. DESIGN, SETTING, AND PARTICIPANTS: For this US multicenter, community-based 30-year prospective cohort study, there were 1238 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study of young black and white women ages 18 to 30 years without diabetes at baseline (1985-1986) who had 1 or more live births after baseline, reported lactation duration, and were screened for diabetes up to 7 times during 30 years after baseline (1986-2016)...RESULTS: Overall 1238 women were included in this analysis (mean [SD] age, 24.2 [3.7] years; 615 black women). There were 182 incident diabetes cases during 27 598 person-years for an overall incidence rate of 6.6 cases per 1000 person-years (95% CI, 5.6-7.6); and rates for women with GD and without GD were 18.0 (95% CI, 13.3-22.8) and 5.1 (95% CI, 4.2-6.0), respectively (P for difference < .001). Lactation duration showed a strong, graded inverse association with diabetes incidence: adjusted RH [relative hazard] for more than 0 to 6 months, 0.75 (95% CI, 0.51-1.09); more than 6 months to less than 12 months, 0.52 (95% CI, 0.31-0.87), and 12 months or more 0.53 (0.29-0.98) vs none (0 days) (P for trend = .01). There was no evidence of effect modification by race, GD, or parity. CONCLUSIONS AND RELEVANCE: This study provides longitudinal biochemical evidence that lactation duration is independently associated with lower incidence of diabetes....

Other Breastfeeding and Diabetes Research

Am J Physiol Endocrinol Metab. 2017 Mar 1;312(3):E215-E223. doi: 10.1152/ajpendo.00403.2016. Epub 2016 Dec 13. Prior lactation reduces future diabetic risk through sustained postweaning effects on insulin sensitivity. Bajaj H, Ye C, Hanley AJ, Connelly PW, Sermer M, Zinman B, Retnakaran R. PMID: 27965206

...in this study, we evaluated the relationships between duration of lactation [≤3 mo (n = 70), 3-12 mo (n = 140), and ≥12 mo (n = 120)] and trajectories of insulin sensitivity/resistance, β-cell function, and glycemia over the first 3 yr postpartum in a cohort of 330 women comprising the full spectrum of glucose tolerance in pregnancy, who underwent serial metabolic characterization, including oral glucose tolerance tests, at 3 mo, 1 yr, and 3 yr postpartum. The prevalence of dysglycemia (pre-diabetes/diabetes) at 3 yr postpartum was lower in women who breastfed for ≥12 mo (12.5%) than in those who breastfed for ≤3 mo (21.4%) or for 3-12 mo (25.7%)(overall P = 0.028). On logistic regression analysis, lactation for ≥12 mo independently predicted a lower likelihood of prediabetes/diabetes at 3 yr postpartum (OR = 0.37, 95% CI 0.18-0.78, P = 0.009). Notably, lactation for ≥12 mo predicted lesser worsening of insulin sensitivity/resistance (P < 0.0001), fasting glucose (P < 0.0001), and 2-h glucose (P = 0.011) over 3 yr compared with lactation ≤3 mo but no differences in β-cell function (P ≥ 0.37)....

Diabetes Care. 2010 Jun;33(6):1239-41. doi: 10.2337/dc10-0347. Epub 2010 Mar 23.Parity, breastfeeding, and the subsequent risk of maternal type 2 diabetes. Liu B, Jorm L, Banks E. PMID: 20332359

...Using information on parity, breastfeeding, and diabetes collected from 52,731 women recruited into a cohort study, we estimated the risk of type 2 diabetes using multivariate logistic regression... Among parous women, there was a 14% (95% CI 10-18%, P < 0.001) reduced likelihood of diabetes per year of breastfeeding... CONCLUSIONS: Compared with nulliparous women, childbearing women who do not breastfeed have about a 50% increased risk of type 2 diabetes in later life. Breastfeeding substantially reduces this excess risk.

JAMA. 2005 Nov 23;294(20):2601-10. Duration of lactation and incidence of type 2 diabetes. Stuebe AM, Rich-Edwards JW, Willett WC, Manson JE, Michels KB. PMID: 16304074

...Prospective observational cohort study of 83,585 parous women in the Nurses' Health Study (NHS) and retrospective observational cohort study of 73,418 parous women in the Nurses' Health Study II (NHS II)...RESULTS: ...Among parous women, increasing duration of lactation was associated with a reduced risk of type 2 diabetes. For each additional year of lactation, women with a birth in the prior 15 years had a decrease in the risk of diabetes of 15% (95% confidence interval, 1%-27%) among NHS participants and of 14% (95% confidence interval, 7%-21%) among NHS II participants, controlling for current body mass index and other relevant risk factors for type 2 diabetes. CONCLUSIONS: Longer duration of breastfeeding was associated with reduced incidence of type 2 diabetes in 2 large US cohorts of women....

Breastfeeding and Cardiovascular Health/Mortality

Annu Rev Nutr. 2016 Jul 17;36:627-45. doi: 10.1146/annurev-nutr-071715-051213. Epub 2016 May 4. Lactation and Maternal Cardio-Metabolic Health. Perrine CG, Nelson JM, Corbelli J, Scanlon KS. PMID: 27146017

Researchers hypothesize that pregnancy and lactation are part of a continuum, with lactation meant to "reset" the adverse metabolic profile that develops as a part of normal pregnancy, and that when lactation does not occur, women maintain an elevated risk of cardio-metabolic diseases. Several large prospective and retrospective studies, mostly from the United States and other industrialized countries, have examined the associations between lactation and cardio-metabolic outcomes. Less evidence exists regarding an association of lactation with maternal postpartum weight status and dyslipidemia, whereas more evidence exists for an association with diabetes, hypertension, and subclinical and clinical cardiovascular disease.

Am J Obstet Gynecol. 2009 Feb;200(2):138.e1-8. doi: 10.1016/j.ajog.2008.10.001. Epub 2008 Dec 25. Duration of lactation and incidence of myocardial infarction in middle to late adulthood. Stuebe AM, Michels KB, Willett WC, Manson JE, Rexrode K, Rich-Edwards JW. PMID: 19110223

We assessed the relation between duration of lactation and maternal incident myocardial infarction. STUDY DESIGN: This was a prospective cohort study of 89,326 parous women in the Nurses' Health Study. RESULTS:... Compared with parous women who had never breastfed, women who had breastfed for a lifetime total of 2 years or longer had 37% lower risk of coronary heart disease (95% confidence interval, 23-49%; P for trend < .001), adjusting for age, parity, and stillbirth history. With additional adjustment for early-adult adiposity, parental history, and lifestyle factors, women who had breastfed for a lifetime total of 2 years or longer had a 23% lower risk of coronary heart disease (95% confidence interval, 6-38%; P for trend = .02) than women who had never breastfed. CONCLUSION: In a large, prospective cohort, long duration of lactation was associated with a reduced risk of coronary heart disease.

BMC Public Health. 2013 Nov 13;13:1070. doi: 10.1186/1471-2458-13-1070. A prospective population-based cohort study of lactation and cardiovascular disease mortality: the HUNT study. Natland Fagerhaug T, Forsmo S, Jacobsen GW, Midthjell K, Andersen LF, Ivar Lund Nilsen T. PMID: 24219620

...In a Norwegian population-based prospective cohort study, we studied the association of lifetime duration of lactation with cardiovascular mortality in 21,889 women aged 30 to 85 years who attended the second Nord-Trøndelag Health Survey (HUNT2) in 1995-1997. The cohort was followed for mortality through 2010 by a linkage with the Cause of Death Registry...RESULTS:...Parous women younger than 65 years who had never lactated had a higher cardiovascular mortality than the reference group of women who had lactated 24 months or more (HR 2.77, 95% confidence interval [CI]: 1.28, 5.99)...CONCLUSIONS: Excess cardiovascular mortality rates were observed among parous women younger than 65 years who had never lactated. These findings support the hypothesis that lactation may have long-term influences on maternal cardiovascular health.

Breastfeeding Lowers the Risk for High Blood Pressure and Other Problems in Mid-Life

Photo credit: La Leche League

A new study indicates that breastfeeding can lower the risk for hypertension in middle-aged African-American women.

Interestingly, the study did not find much protection against EVER getting high blood pressure, but it did find a modest protective effect of breastfeeding on getting high blood pressure in your 40s. In other words, it had a temporary but important protective effect as women approached menopause, when high blood pressure often develops. In addition, the longer the duration of breastfeeding, the more protection there was.

This seems to echo other studies in other groups that have found similar protective effects against blood pressure issues in early middle age (the 40s) but not as much difference in older ages (after 65 or so).

It's disappointing that breastfeeding doesn't have the long-term, permanent effect everybody hoped for, but even so, this delay in development of high blood pressure is very important because the longer you have high blood pressure, the more complications like heart disease or kidney disease develop. Even just delaying it can reduce the cumulative disease burden on the body.

Breastfeeding can hopefully help people minimize their risk for these diseases. This is especially important for African-Americans, who are particularly susceptible to early onset of hypertension and cardiovascular issues.

More support  is needed in helping African-American women initiate and breastfeed long-term because it could make a critical difference in their health, as well as their babies' health. Here are some resources that might be helpful:

• Black Women Do Breastfeed Facebook Page and Website
• African American Breastfeeding Network
• Lactation Support Groups for Families of Color
• Black Mothers Breastfeeding Association
• Planning Ahead
• National Association of Professional and Peer Lactation Supporters of Color

And here are some general breastfeeding resources:

• KellyMom.com: Breastfeeding and Parenting - Evidence-based answers to breastfeeding questions
• Newman Breastfeeding Clinic and Institute - Breastfeeding resources and videos
• La Leche League- Breastfeeding resources and mother support groups
• Infant Risk Center- Information on use of medications while breastfeeding
• Womenshealth.gov- Information and support to help women breastfeed successfully
• Work and Pump - Support and information for working mothers
• International Lactation Consultant Association - Find a lactation consultant
• LactMed - Database of information on drugs and potential effects on nursing babies

Implications Beyond Hypertension 

Photo Credit: Center for Disease Control

Breastfeeding has important lifelong benefits beyond the obvious immediate benefits to the baby.

One of these is the delay of development of hypertension in the mother. Research also shows the breastfeeding, especially long-term breastfeeding, helps prevent or delay diabetes and heart problems, and lowers the incidence of cardiovascular mortality (see studies in References below).

Biologically speaking, women evolved to have children and then breastfeed them for extended periods of time. When women have children but don't breastfeed (or breastfeed only briefly), there is inadvertent metabolic fallout. As one study summarizes:

Researchers hypothesize that pregnancy and lactation are part of a continuum, with lactation meant to "reset" the adverse metabolic profile that develops as a part of normal pregnancy, and that when lactation does not occur, women maintain an elevated risk of cardio-metabolic diseases.

This is not to shame or scold women who don't or can't breastfeed long-term. Not every woman can breastfeed fully, some women's situations prevent breastfeeding for long, and of course it's always up to the woman to decide how she will feed her baby.

But from an evolutionary point of view, breastfeeding, especially long-term breastfeeding, keeps women healthier longer. 

We need to do everything we can to help support breastfeeding women, and especially breastfeeding women of color.


References

Breastfeeding and Hypertension

Am J Epidemiol. 2017 Oct 15;186(8):927-934. doi: 10.1093/aje/kwx163. Cumulative Lactation and Onset of Hypertension in African-American Women. Chetwynd EM, Stuebe AM, Rosenberg L, Troester M, Rowley D, Palmer JR. PMID: 28535171

Hypertension affects nearly 1 of 3 women and contributes to cardiovascular disease, the leading cause of death in the United States. Breastfeeding leads to metabolic changes that could reduce risks of hypertension. Hypertension disproportionately affects black women, but rates of breastfeeding among black women lag behind those in the general population. In the Black Women's Health Study (n = 59,001), we conducted a nested case-control analysis using unconditional logistic regression to estimate the association between breastfeeding and incident hypertension at ages 40-65 years using data collected from 1995 to 2011... Overall, there was little evidence of association between ever breastfeeding and incident hypertension (odds ratio = 0.97, 95% confidence interval: 0.92, 1.02). However, age modified the relationship (P = 0.02): Breastfeeding was associated with reduced risk of hypertension at ages 40-49 years (odds ratio = 0.92, 95% confidence interval: 0.85, 0.99) but not at older ages. In addition, risk of hypertension at ages 40-49 years decreased with increasing duration of breastfeeding (P for trend = 0.08). Our results suggest that long-duration breastfeeding may reduce the risk of incident hypertension in middle age. Addressing breastfeeding as a potential preventative health behavior is particularly compelling because it is required for only a discrete period of time.

Am J Obstet Gynecol. 2013 Jun;208(6):454.e1-7. doi: 10.1016/j.ajog.2013.02.014. Epub 2013 Feb 7. Association between parity and breastfeeding with maternal high blood pressure. Lupton SJ, Chiu CL, Lujic S, Hennessy A, Lind JM. PMID: 23395924

...Baseline data for 74,785 women were sourced from the 45 and Up Study, Australia. These women were 45 years of age or older, had an intact uterus, and had not been diagnosed with high blood pressure before pregnancy...The combination of parity and breastfeeding was associated with lower odds of having high blood pressure (adjusted OR, 0.89; 99% CI, 0.82-0.97; P < .001), compared with nulliparous women...Women who breastfed for longer than 6 months in their lifetime, or greater than 3 months per child, on average, had significantly lower odds of having high blood pressure when compared with parous women who never breastfed. The odds were lower with longer breastfeeding durations and were no longer significant in the majority of women over the age of 64 years....

Breastfeed Med. 2015 Apr;10(3):163-7. doi: 10.1089/bfm.2014.0116. Epub 2015 Mar 18. Breastfeeding and maternal hypertension and diabetes: a population-based cross-sectional study. Zhang BZ, Zhang HY, Liu HH, Li HJ, Wang JS. PMID: 25785993

...A cross-sectional study was conducted in four urban communities of Beijing, China, with 9,128 parous women 40-81 years of age who had had only one lifetime birth...After the analysis was adjusted for the potential confounders...the odd ratio (OR) of hypertension was 1.18 (95% confidence interval [CI], 1.05-1.32) for women who did not breastfeed, compared with women who did. In addition, the ORs for >0 to 6 months, >6 to 12 months, and >12 months of breastfeeding were 0.87 (95% CI, 0.76-0.99), 0.83 (95% CI, 0.68-1.00), and 0.79 (95% CI, 0.65-0.97), respectively, compared with women who did not breastfeed. With adjustment for age, WHR, working status, educational level, family history of diabetes, and postpartum BMI, women who did not breastfeed increased the risk of diabetes (OR=1.30; 95% CI, 1.11-1.53) compared with women who did. Moreover, women who breastfed for >0 to 6 months (OR=0.81; 95% CI, 0.67-0.98) and >6 to 12 months (OR=0.46; 95% CI, 0.26-0.84) had a lower risk of diabetes, compared with women who did not breastfeed. CONCLUSIONS: Chinese mothers who did not breastfeed were more likely to develop hypertension and diabetes in later life.

Am J Epidemiol. 2011 Nov 15;174(10):1147-58. doi: 10.1093/aje/kwr227. Epub 2011 Oct 12. Duration of lactation and incidence of maternal hypertension: a longitudinal cohort study. Stuebe AM, Schwarz EB, Grewen K, Rich-Edwards JW, Michels KB, Foster EM, Curhan G, Forman J. PMID: 21997568

Never or curtailed lactation has been associated with an increased risk for incident hypertension, but the effect of exclusive breastfeeding is unknown. The authors conducted an observational cohort study of 55,636 parous women in the US Nurses' Health Study II... In conclusion, never or curtailed lactation was associated with an increased risk of incident maternal hypertension, compared with the recommended ≥6 months of exclusive or ≥12 months of total lactation per child, in a large cohort of parous women.

Breastfeeding and Diabetes

Obstet Gynecol. 2016 Nov;128(5):1095-1104. Breastfeeding Initiation Associated With Reduced Incidence of Diabetes in Mothers and Offspring. Martens PJ, Shafer LA, Dean HJ, Sellers EA, Yamamoto J, Ludwig S, Heaman M, Phillips-Beck W, Prior HJ, Morris M, McGavock J, Dart AB, Shen GX. PMID: 27741196

This retrospective database study included 334,553 deliveries (1987-2011) in Manitoba with up to 24 years of follow-up for diabetes using population-based databases... RESULTS: Breastfeeding initiation was recorded in 83% of non-First Nations mothers and 56% of First Nations mothers (P<.001)... With 24 years of follow-up or less, breastfeeding initiation was associated with a 17% lower risk of youth-onset type 2 diabetes in offspring (HR 0.83, CI 0.69-0.99, P=.038)... CONCLUSION: Breastfeeding initiation is associated with a reduced risk of diabetes among women and their offspring in Manitoba. The results suggest that breastfeeding might be a potentially modifiable factor to reduce the risk of diabetes in both First Nations and non-First Nations women and children.

Diabetes Care. 2010 Jun;33(6):1239-41. doi: 10.2337/dc10-0347. Epub 2010 Mar 23. Parity, breastfeeding, and the subsequent risk of maternal type 2 diabetes. Liu B, Jorm L, Banks E. PMID: 20332359

...Using information on parity, breastfeeding, and diabetes collected from 52,731 women recruited into a cohort study, we estimated the risk of type 2 diabetes using multivariate logistic regression... Among parous women, there was a 14% (95% CI 10-18%, P < 0.001) reduced likelihood of diabetes per year of breastfeeding... CONCLUSIONS: Compared with nulliparous women, childbearing women who do not breastfeed have about a 50% increased risk of type 2 diabetes in later life. Breastfeeding substantially reduces this excess risk.

JAMA. 2005 Nov 23;294(20):2601-10. Duration of lactation and incidence of type 2 diabetes. Stuebe AM1, Rich-Edwards JW, Willett WC, Manson JE, Michels KB. PMID: 16304074

...Prospective observational cohort study of 83,585 parous women in the Nurses' Health Study (NHS) and retrospective observational cohort study of 73,418 parous women in the Nurses' Health Study II (NHS II)...RESULTS: ...Among parous women, increasing duration of lactation was associated with a reduced risk of type 2 diabetes. For each additional year of lactation, women with a birth in the prior 15 years had a decrease in the risk of diabetes of 15% (95% confidence interval, 1%-27%) among NHS participants and of 14% (95% confidence interval, 7%-21%) among NHS II participants, controlling for current body mass index and other relevant risk factors for type 2 diabetes. CONCLUSIONS: Longer duration of breastfeeding was associated with reduced incidence of type 2 diabetes in 2 large US cohorts of women....

Diabetologia. 2008 Feb;51(2):258-66. Epub 2007 Nov 27. Duration of breast-feeding and the incidence of type 2 diabetes mellitus in the Shanghai Women's Health Study. Villegas R1, Gao YT, Yang G, Li HL, Elasy T, Zheng W, Shu XO. PMID: 18040660

...This was a prospective study of 62,095 middle-aged parous women in Shanghai, China, who had no prior history of type 2 diabetes mellitus, cancer or cardiovascular disease at study recruitment... RESULTS: Women who had breastfed their children tended to have a lower risk of diabetes mellitus than those who had never breastfed [relative risk (RR)=0.88; 95% CI, 0.76-1.02; p=0.08]. Increasing duration of breast-feeding was associated with a reduced risk of type 2 diabetes mellitus. The fully adjusted RRs for lifetime breast-feeding duration were 1.00, 0.88, 0.89, 0.88, 0.75 and 0.68 (p trend=0.01) for 0, >0 to 0.99, >0.99 to 1.99, >1.99 to 2.99, >2.99 to 3.99 and >or=4 years in analyses adjusted for age, daily energy intake, BMI, WHR, smoking, alcohol intake, physical activity, occupation, income level, education level, number of live births and presence of hypertension at baselines....

Breastfeeding and Cardiovascular Health/Mortality

Annu Rev Nutr. 2016 Jul 17;36:627-45. doi: 10.1146/annurev-nutr-071715-051213. Epub 2016 May 4. Lactation and Maternal Cardio-Metabolic Health. Perrine CG, Nelson JM, Corbelli J, Scanlon KS. PMID: 27146017

Researchers hypothesize that pregnancy and lactation are part of a continuum, with lactation meant to "reset" the adverse metabolic profile that develops as a part of normal pregnancy, and that when lactation does not occur, women maintain an elevated risk of cardio-metabolic diseases. Several large prospective and retrospective studies, mostly from the United States and other industrialized countries, have examined the associations between lactation and cardio-metabolic outcomes. Less evidence exists regarding an association of lactation with maternal postpartum weight status and dyslipidemia, whereas more evidence exists for an association with diabetes, hypertension, and subclinical and clinical cardiovascular disease.

Am J Obstet Gynecol. 2009 Feb;200(2):138.e1-8. doi: 10.1016/j.ajog.2008.10.001. Epub 2008 Dec 25. Duration of lactation and incidence of myocardial infarction in middle to late adulthood. Stuebe AM, Michels KB, Willett WC, Manson JE, Rexrode K, Rich-Edwards JW. PMID: 19110223

We assessed the relation between duration of lactation and maternal incident myocardial infarction. STUDY DESIGN: This was a prospective cohort study of 89,326 parous women in the Nurses' Health Study. RESULTS:... Compared with parous women who had never breastfed, women who had breastfed for a lifetime total of 2 years or longer had 37% lower risk of coronary heart disease (95% confidence interval, 23-49%; P for trend < .001), adjusting for age, parity, and stillbirth history. With additional adjustment for early-adult adiposity, parental history, and lifestyle factors, women who had breastfed for a lifetime total of 2 years or longer had a 23% lower risk of coronary heart disease (95% confidence interval, 6-38%; P for trend = .02) than women who had never breastfed. CONCLUSION: In a large, prospective cohort, long duration of lactation was associated with a reduced risk of coronary heart disease.

BMC Public Health. 2013 Nov 13;13:1070. doi: 10.1186/1471-2458-13-1070. A prospective population-based cohort study of lactation and cardiovascular disease mortality: the HUNT study. Natland Fagerhaug T, Forsmo S, Jacobsen GW, Midthjell K, Andersen LF, Ivar Lund Nilsen T. PMID: 24219620

...In a Norwegian population-based prospective cohort study, we studied the association of lifetime duration of lactation with cardiovascular mortality in 21,889 women aged 30 to 85 years who attended the second Nord-Trøndelag Health Survey (HUNT2) in 1995-1997. The cohort was followed for mortality through 2010 by a linkage with the Cause of Death Registry...RESULTS:...Parous women younger than 65 years who had never lactated had a higher cardiovascular mortality than the reference group of women who had lactated 24 months or more (HR 2.77, 95% confidence interval [CI]: 1.28, 5.99)...CONCLUSIONS: Excess cardiovascular mortality rates were observed among parous women younger than 65 years who had never lactated. These findings support the hypothesis that lactation may have long-term influences on maternal cardiovascular health.

Questionable Claims and Obesity Stigma in Breastfeeding Promotion

Image from the Center for Disease Control

It's World Breastfeeding Week ─ time to highlight the importance of breastfeeding! But not in the way this poster is doing.

I'm all for increasing breastfeeding rates. I've attended La Leche League meetings. I nursed my own four children for several years each. I've promoted breastfeeding on my website and my blog. I've helped other women with breastfeeding issues. It's hard to find a more ardent breastfeeding supporter than me.

However, today I'm going to be a heretic and offer up some criticism of breastfeeding advocacy. In particular, I have concerns with people trying to increase breastfeeding rates by promoting its potential for maternal weight loss or obesity prevention in children.

One press release from 2012 shows a typical example of hyperbole from the U.K.:

Breast-feeding may help mothers reduce the risk of obesity later in life, according to a study of 740,000 post-menopausal women in the U.K. 

For every six months women breast-fed, their body mass index was 0.22, or 1 percent, lower, even decades after giving birth, according to the research

A 1 percent reduction in BMI may seem small, but spread across the population of the U.K., that could mean about 10,000 fewer premature deaths per decade from obesity-related conditions, such as diabetes, heart disease and some cancers,” Valerie Beral, co-author of the study and director of the Cancer Epidemiology Unit at the University of Oxford, said in a statement.

Similarly, many breastfeeding advocates try to raise breastfeeding rates by promoting its potential for obesity prevention in children. The United States Breastfeeding Committee, for example, has a huge campaign promoting breastfeeding as the first step to preventing obesity in children (see graphic from the CDC above). 

These two approaches go unquestioned among many breastfeeding advocates, but they are problematic for several reasons.

First, the evidence is not that strong, and second, public health campaigns using breastfeeding to promote obesity prevention are often highly stigmatizing and full of negative stereotypes. In fact, they may alienate some of the very people they want to reach out to.

A Closer Look at the Evidence

Unfortunately, if you really look at the research, evidence for breastfeeding as obesity prevention in either mother or baby is modest at best.

Maternal Effects

Care providers are concerned about the potential for postpartum weight retention to increase a woman's weight long-term. I understand the concern. Long-term retention of pregnancy weight gain can be a factor in obesity for some women.

But although long-term breastfeeding after birth does result in quicker loss of pregnancy weight for some women, the effect tends to be modest in the research, and not all women find breastfeeding is helpful in postpartum weight loss. A few even find that they don't really lose those final pregnancy pounds until after weaning.

A large research review from the USDA's Center for Nutrition Policy and Promotion (Evidence Analysis Library Division) found:

A moderate body of consistent evidence shows that breastfeeding may be associated with maternal post-partum weight loss. However this weight loss is small, transient, and depends on breastfeeding intensity and duration.

Other meta-analyses have found that the relationship between breastfeeding and post-partum weight retention is very complicated, and definitive proof of benefit is difficult to show.

For maternal weight loss, breastfeeding can be helpful for some women, but in large groups, the effect is not particularly strong.  

The 2012 press release quoted above argues that a 1% reduction in BMI across the board could prevent 10,000 deaths per decade. This is highly speculative. A 1% reduction of BMI is very small and its effects would also probably be small. Their conclusion likely inflates the impact by using questionable data on the relationship between weight and mortality. Note they don't defend their statement or back it up with data; they just make broad, sweeping proclamations about the amount of lives it would save. This is the kind of overreach that is typical of these campaigns.

Furthermore, promoting breastfeeding for weight loss can backfire. A 2011 study found:

Belief that breastfeeding could aid postpartum weight loss was initially high, but unrelated to breastfeeding initiation or intensity. Maintenance of this belief over time, however, was associated with lower lactation scores. BMI was negatively correlated with breastfeeding initiation and intensity. Among overweight and obese women, unrealistic expectations regarding the effect of breastfeeding on weight loss may negatively impact breastfeeding duration.

If you promote breastfeeding as THE way to control weight and then that effect doesn't appear, there is likely to be a backlash. Stop creating unrealistic expectations in women and focus on breastfeeding's other benefits to them.

Effects on Offspring Obesity

Some studies do link breastfeeding with lower obesity rates in children later in life, especially in children at higher risk. While I believe this effect is real to some extent, I have real reservations about touting these studies.

There is more than a tinge of fat-phobia and mother-blaming in the media spin on these studies. The implication is that if you would just breastfeed your baby, it's very unlikely he'll be fat. And that just doesn't match the experience of many people.

Anecdotally, many high-BMI women have breastfed children for a year or more and still have children with weights considered "above normal." Unlike what researchers assume, this is not because we are force-feeding our children junk food or letting them play video games all day. Clearly, there are multiple influences on a child's weight, but genetics is one of the strongest. Breastfeeding does not overcome a strong genetic predisposition to obesity.

Yes, there are some studies that suggest that breastfed babies tend to be less heavy on average, but there are so many other confounding variables in these studies that it's hard to draw definitive conclusions. When other variables are controlled for, not all studies show that breastfeeding is protective against obesity.

For example, a recent large study from the Netherlands shows that breastfeeding did not protect against higher body weight. Although the study did the usual hyperventilating about the "dangers" of pediatric obesity, the authors did acknowledge the weaknesses of promoting breastfeeding for obesity prevention. One of the authors stated:

"It's important not to say things like, 'if you breast-feed your baby, he will not become obese.' " 

This is not the only study that found that breastfeeding was not protective against overweight status. A 2007 study found that having been breastfed as a child did not significantly influence women's adult weight status.

In addition, a randomized controlled trial in Belarus aimed to examine whether increasing breastfeeding rates at the population level prevented pediatric obesity. They succeeded in substantially raising the breastfeeding rates, yet this did not translate into reduced childhood obesity rates. The authors concluded:

Breastfeeding has many advantages but population strategies to increase the duration and exclusivity of breastfeeding are unlikely to curb the obesity epidemic.

This study has been criticized because it increased breastfeeding only modestly and mostly short-term. It still had low long-term breastfeeding rates and did not compare fully formula-fed babies with fully breastfed babies. These are legitimate criticisms. It may be that more differences between the groups would become clear with higher rates of extended breastfeeding and more clear delineations between exclusive formula use and exclusive breastfeeding. Yet the fact that little effect was found despite increased rates is troubling. You would think there would have been some impact.

Another unique study attempted to correct for other variables by looking at siblings within the same family who were fed differently. The strength of this study is that by using siblings in the same family, it corrects for education and socio-economic status and other variables which can strongly influence outcomes. Tellingly, it found virtually no difference in adiposity levels between breastfed and formula-fed siblings.

The majority of the research seems to suggest that while breastfeeding might be somewhat protective against obesity, this effect is small, may not last throughout life, and might be less important than other factors. One very pro-breastfeeding review concluded:

From current available data, any effects of breastfeeding on childhood obesity are likely not large, and tend to be most noted when formula feeding is compared with longer durations of breastfeeding.

The research picture on the effect of breastfeeding on obesity rates is far more muddled than clear. We need to be careful about overstating its effects, and we need to be careful about the language we use when we talk about certain benefits. In particular, its promotion for obesity prevention is questionable. A more accurate description is that breastfeeding may lower the risk for obesity. Although even that is not proven, this phrasing is much more defensible.

From my own review of the research, I believe that breastfeeding probably is associated with a modestly reduced risk of obesity on a population-wide basis, but that most of this effect is due to other variables and probably only short-term. Whatever the impact of exclusive breastfeeding on weight is, it's debatable how important that really is for public health.

Since breastfeeding has many other benefits that are quite clear, it seems more logical to be promoting these, rather than touting breastfeeding as a cure-all for obesity. 

Obesity Bias in Research 

Why might breastfeeding lower the risk for obesity at all? No one knows for sure, but even in the speculations obesity bias rears its ugly head.

The reasoning from the experts is filled with fat-phobic assumptions. For example, experts often imply that bottle-fed babies develop "unnaturally large" appetites because of passive intake vs. breastfed babies' self-regulated intake. This plays into the stereotype that fat kids have little self-control and over-consume food.

Or they state that breastfed babies are more likely to be willing to try new foods like fruits and vegetables. This plays into the stereotype that that obese kids don't eat fruits and vegetables. Because everyone knows that fat kids mostly eat junk food, right?

It's hard to separate researchers' fat-phobic stereotyping from plausible biological mechanisms. The best size-neutral guess is that breastfeeding lowers the risk for insulin resistance among children (which may in turn blunt the risk for diabetes and lower the tendency to gain weight), and it may promote a healthier gut microbiome, which in turn might lead to a lower risk for obesity. That seems quite plausible without relying on obesity stereotypes of over-consumption and poor eating habits.

So there could a biological foundation to the argument that breastfeeding might lower the risk for obesity. But prevent obesity completely? Probably not. There are too many other factors at work. It's far too simplistic to say that breastfeeding protects against obesity.

Furthermore, we need to watch the parent-blaming in these studies. For example, a short-term recent study found that longer breastfeeding was more protective in infants at the most risk for obesity, but that the effect wasn't as strong as hoped. An analysis of the study pointed out that maternal smoking and low education levels were also associated with higher weight, and that there was a lack of information about other feeding behaviors. The implication is that breastfeeding is not enough to overcome bad behavior in the parents. The author concludes:

So, does breastfeeding lower the risk of childhood obesity? My conclusion is yes; but only in infants at higher risk for obesity and [who] are breastfed for longer durations. In addition, as obesity is multifactorial, breastfeeding alone is unlikely to entirely prevent it.

Another author, writing about breastfeeding and childhood obesity, concludes:

The overall consensus is that breastfeeding provides protective factors, but can be mitigated by other factors (i.e. maternal health, environmental, SES, etc.) and should not be considered as an independent factor for obesity prevention.

In other words, those ignorant fat parents can overcome the benefits of breastfeeding by providing an unhealthy home environment and being too uneducated to change their own obesity or develop better health habits. Genetics? Total excuse. Any obesity must be the parents' fault, even if they breastfeed.

Yeah. As a fat parent, that sure makes me want to breastfeed.

Public Health Campaign Stigma

Another problem with promoting breastfeeding to prevent obesity is the biased attitudes these campaigns reinforce and the highly stigmatizing images they use.

(Because formula-feeding your baby is like feeding him candy bars.
And heaven knows that all formula-fed babies are fat and all
breastfed babies are skinny, right?)

Here is an image from a doctor's presentation that basically compares formula use with feeding your baby multiple candy bars a week. The apparent result is a chubby-cheeked sumo baby with multiple fat folds. What, no breastfed baby has ever had chubby cheeks and fat dimples?

And if the figure cited at the bottom is true, surely 30,000 more calories would ensure that all formula-fed babies would be fat and all breastfed ones would be thin. Unless perhaps there are other factors at work too? But heaven forbid those be acknowledged.

Even the articles that admit that a breastfed baby can be at the top of the weight charts usually then blame the baby's weight on the mother's nursing too much and suggest restricting nursing or giving a pacifier. Always a child's weight is blamed on over-consumption and restriction is promoted as the answer. Yet the answers are usually far more complex.

Image from article called
"Breastfeeding is the First Defense Against Obesity"

Here is another image from an article about breastfeeding for preventing obesity. The image has since been taken off of the article, but the fact that it was ever on there in the first place says a great deal about the assumptions and biases of the people promoting these campaigns.

Notice how the little boy (wearing too-small clothes) is gleefully surrounded by cake, ice cream, and lots of candy. Articles like this often use troubling images that strongly reinforce stereotypes about obesity and which likely increase obesity stigma and discrimination.

The image used for a blog post about preventing obesity
through breastfeeding, written by a lactation consultant (IBCLC)

Here's another image from a similar article ─ written by an influential professional lactation consultant, no less! Notice the too-small shirt, the hanging belly, and the prominent sweets (not one but TWO ice cream cones). Because you know that all obese children are that way because they are gorging on sweets and stuffing themselves to the max.

Here is an image from an article about a U.S. breastfeeding promotion campaign. It has the image of a breastfeeding woman of size, which is so rare that it should be a positive thing ─ but it's not. How typical that one of the very few images you can find of a woman of size breastfeeding is from a campaign that assumes that the diet of a high-BMI woman couldn't possibly be normal or healthy. The fact that the woman of size is also a woman of color makes it even more stigmatizing.

As a fat mother, I can tell you that these kinds of ads and articles make me want to breastfeed less, not more. In fact, they piss me off no end.

My Experience

In defiance of images like these, I breastfed my four kids for about 2.5 to 4 years each. That's a cumulative total of somewhere around 10 years. So if anyone should have seen a reduction in maternal BMI due to breastfeeding, it should have been me! Yet I didn't. I know many other women of size who also had a similar experience.

But surely all that breastfeeding reduced obesity in my children, right? I did all the "right" things. Not only was each child breastfed for multiple years (not months), I don't smoke, I am highly educated, I had a very small weight gain in pregnancy, we are in a higher socio-economic group, I didn't work outside the home for years, and I didn't introduce solids before 6 months. According to the research, they should be close to average-sized, right?

Nope. My first three children have a BMI near the top of the Class I obesity range, about where I was at their ages. I'm sure that critics will blame me by claiming that an obesogenic environment trumps everything (no doubt believing I force-fed them chocolate-covered french fries), but really, we did a great deal to promote healthy eating and exercise. Their habits were better than many of the children around them, but they were still fat.

On the other hand, my fourth child is skinny as the day is long, despite eating the same food and having the same genetic background as the rest of the kids. She didn't breastfeed longer or exercise more than the others; she simply seems to have benefited from a lucky throw of the genetics dice. She just took after a different branch of the family tree, apparently.

Same parents, same gene pool, same food, same environment, similar basic breastfeeding period ─ yet they have far different outcomes. Sure, that's only one family's experience, but I think it demonstrates that there are no simple answers here. And that's what I object to ─ the simplistic and stigmatizing messages that experts are putting out about breastfeeding and obesity.

Conclusions

Breastfeeding is amazing. So many health benefits come along with breastfeeding! It has a lot of short-term benefits in lowering the risk for illness in young children. It has a lot of long-term benefits in terms of metabolic improvements, lower risk for breast cancer, ovarian cancer, diabetes, heart disease etc. in mothers.

In this country (and many others), far too few babies are breastfed. Even among those whose mothers do nurse, breastfeeding last only a few months, instead of the years it was biologically designed for. The public health implications from such low rates of breastfeeding are perfectly valid topics for discussion.

But when breastfeeding is promoted as a well-intentioned but biased bludgeon to "prevent" obesity, I start getting cranky. I've held my tongue about it for too long. It's time to call out the breastfeeding advocates who distort the science and promote obesity stigma in trying to increase breastfeeding rates.

Look at the following breastfeeding advocacy poster.

Lowering the risk of obesity is the top benefit listed. Really? If there is an effect on obesity, it's quite small. Frankly, other benefits are FAR more important. (At least the poster does use the phrase, "lowers the risk for." That's something. Too many campaigns are using words like "prevent" or "protect from" obesity.)

Let's be clear about what needs to change in breastfeeding advocacy:

1. Breastfeeding campaigns need to stop overstating the evidence. The research shows that breastfeeding is unlikely to prevent obesity. We can mention that it might lower the risk somewhat, but even then most of the difference is attributable to other variables
2. We need to de-emphasize weight loss or obesity prevention as motivations in breastfeeding advocacy materials. Focus instead on other benefits that are far more clear and evidence-based
3. We need to be very careful about the language and images we use to discuss weight and breastfeeding. We need to eliminate the assumptions and stereotyping about obesity in breastfeeding research and drop the stigmatizing images used in breastfeeding campaigns

I'm ALL for promoting breastfeeding, but the truth is that weight is complex. A lot of fat women breastfeed and never lose weight, and a lot of fat women breastfeed for years and still have fat children. There are also plenty of formula-fed children who are thin. Breastfeeding is just not the weight cure-all that authorities want it to be and we need to stop telling people that it is. 

Stop using "obesity prevention" as a way to promote breastfeeding. Focus on the MANY other benefits which are far more clear in the research. And stop playing on societal fears and obesity stigma in breastfeeding advocacy materials. 

The Many Benefits of Doula Care

The word "doula" comes from Greek and means "woman's servant." It referred to the women who traditionally provided support to mothers in labor.

The Doulas of North America organization (DONA) defines a modern-day doula in the following way:

A birth doula is a person trained and experienced in childbirth who provides continuous physical, emotional and informational support to the mother before, during and just after childbirth.

Some doulas only work during labor itself, but most doulas work with women before and just after the birth as well. They give emotional support and information as needed during pregnancy, provide support and encouragement during labor, and then give early post-partum and breastfeeding support.

Research has shown that having a doula during labor can help lower the risk for a cesarean, and may also help increase breastfeeding initiation rates. 

Professional labor support is probably even more important for women of size because women of size tend to be subjected to more labor interventions and restrictions and have higher cesarean rates and lower breastfeeding rates than women of average size. Doulas may be one powerful way of improving outcomes among high-BMI women. 

Here is the most recent research supporting the importance of more wide-spread access to doulas.


References

Am J Manag Care. 2014 Aug 1;20(8):e340-52. Potential benefits of increased access to doula support during childbirth. Kozhimannil KB1, Attanasio LB, Jou J, Joarnt LK, Johnson PJ, Gjerdingen DK. PMID: 25295797

...Retrospective analysis of a nationally representative survey of women who delivered a singleton baby in a US hospital in 2011- 2012 (N = 2400)...Six percent of women reported doula care during childbirth. Characteristics associated with desiring but not having doula support were black race (vs white; adjusted odds ratio [AOR] = 1.77; 95% CI,1.03-3.03), and publicly insured or uninsured (vs privately insured; AOR = 1.83, CI, 1.17-2.85; AOR = 2.01, CI, 1.07-3.77, respectively). Doula-supported women had lower odds of cesarean compared without doula support and those who desired but did not have doula support (AOR = 0.41, CI, 0.18-0.96; and AOR = 0.31, CI, 0.13-0.74). The odds of nonindicated cesarean were 80-90% lower among doula-supported women (AOR= 0.17, CI, 0.07-0.39; and AOR= 0.11, CI, 0.03-0.36)...Increasing awareness of doula care and access to support from a doula may facilitate decreases in nonindicated cesarean rates.

Am J Public Health. 2013 Apr;103(4):e113-21. doi: 10.2105/AJPH.2012.301201. Epub 2013 Feb 14. Doula care, birth outcomes, and costs among Medicaid beneficiaries. Kozhimannil KB1, Hardeman RR, Attanasio LB, Blauer-Peterson C, O'Brien M. PMID: 23409910

...We calculated descriptive statistics for Medicaid-funded births nationally (from the 2009 Nationwide Inpatient Sample; n = 279,008) and births supported by doula care (n = 1079) in Minneapolis, Minnesota, in 2010 to 2012; used multivariate regression to estimate impacts of doula care; and modeled potential cost savings associated with reductions in cesarean delivery for doula-supported births. RESULTS: The cesarean rate was 22.3% among doula-supported births and 31.5% among Medicaid beneficiaries nationally. The corresponding preterm birth rates were 6.1% and 7.3%, respectively. After control for clinical and sociodemographic factors, odds of cesarean delivery were 40.9% lower for doula-supported births (adjusted odds ratio = 0.59; P < .001). Potential cost savings to Medicaid programs associated with such cesarean rate reductions are substantial but depend on states' reimbursement rates, birth volume, and current cesarean rates. CONCLUSIONS: State Medicaid programs should consider offering coverage for birth doulas to realize potential cost savings associated with reduced cesarean rates.

J Midwifery Womens Health. 2013 Jul-Aug;58(4):378-82. doi: 10.1111/jmwh.12065. Epub 2013 Jul 9. Doula care supports near-universal breastfeeding initiation among diverse, low-income women. Kozhimannil KB1, Attanasio LB, Hardeman RR, O'Brien M. PMID: 23837663

...We compared breastfeeding initiation rates (means and 95% confidence intervals) for 1069 women who received doula care from Everyday Miracles, a Minnesota-based organization that employs a diverse group of certified doulas, to a state-based sample of women with Medicaid coverage who gave birth in 2009 or 2010 and participated in the Minnesota Pregnancy Risk Assessment Monitoring System survey (weighted n = 51,721). RESULTS: Women who had doula-supported births had near-universal breastfeeding initiation (97.9%), compared with 80.8% of the general Medicaid population. Among African American women, 92.7% of those with doula support initiated breastfeeding, compared with 70.3% of the general Medicaid population. DISCUSSION: These results suggest that access to culturally appropriate doula care may facilitate higher rates of breastfeeding initiation. When supported in their nonmedical needs by birth doulas, the diverse, low-income patients of midwives and other maternity care providers may have a greater likelihood of initiating breastfeeding and experiencing the maternal and infant health benefits associated with breastfeeding.

Cochrane Database Syst Rev. 2013 Jul 15;7:CD003766. [Epub ahead of print] Continuous support for women during childbirth. Hodnett ED1, Gates S, Hofmeyr GJ, Sakala C. PMID: 23857334

BACKGROUND: Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide,continuous support during labour has become the exception rather than the routine...Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data...Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95)...AUTHORS' CONCLUSIONS: Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.

Breastfeeding And Gestational Diabetes, Part One: Vital Benefits to Mother and Baby

More and more research is showing how important breastfeeding is after a Gestational Diabetes (GD) pregnancy, both for mother and baby.

Yet research consistently also shows lower rates of breastfeeding after Gestational Diabetes.

Promoting and improving breastfeeding rates in GD mothers is one easy way to improve the long-term health of mothers and babies exposed to GD, yet there are still far too many barriers to it.

Let's start with the many benefits of breastfeeding after GD, both for mother and baby.

How Breastfeeding Helps After Gestational Diabetes

Image credit: Much 2014

Breastfeeding improves the mother's blood sugar and insulin levels very quickly post-partum, and improves glucose utilization. It may also improve pancreatic beta cell mass, proliferation, and function, which should improve the mother's capacity to produce insulin adequate to compensate for any insulin resistance.

GD women who breastfeed have lower rates of abnormal blood sugar at their 6-week follow-up glucose tolerance test postpartum.

Breastfeeding also lowers insulin levels and improves insulin sensitivity more long-term.

As a result, breastfeeding lowers a mother's risk for developing diabetes later in life.

Even only a short period of breastfeeding offers some protection. However, the more you breastfeed and the longer the duration, the more your risk for diabetes may be diminished. That's HUGE.

Image credit: Much 2014, adapted from Ziegler 2012

Look at the graph above. Although many women were lost to follow-up, there was a clear and strong trend towards less diabetes in the women who breastfed their babies for more than three months. 72.6% of those who did not breastfeed or who breastfed for three or fewer months developed diabetes by 15 years post-partum, vs. 42% of those who breastfed for more than three months.

And really, three months of breastfeeding isn't that long in the scheme of things. Studies that looked at moderately longer periods found much lower insulin levels and better insulin sensitivity in those that nursed more than 10 months.

And 10 months does not even meet the American Academy of Pediatric's recommendation to nurse at least a year, or the World Health Organization's recommendation to nurse at least two years. How much more protection might there be for longer periods of breastfeeding?

One very large 2005 study found that the risk for diabetes declined about 15% for each additional cumulative year of breastfeeding, and another 2008 study found that the relative risk for diabetes was 0.68 in those with 4 or more years of lifetime lactation duration.

Breastfeeding may also offer some degree of protection against certain types of cancer which GD mothers may be more at risk for, including breast, endometrial, ovarian and possibly pancreatic cancers.

Even more imporantly, long-term breastfeeding may also offer some protection against heart disease and mortality. 

Some studies have found lower rates of cardiovascular risk factors in women with long-term breastfeeding. Most importantly, research has shown that breastfeeding translates into fewer heart attacks and lower mortality rates too. That's also HUGE.

One theory to explain all this is that pregnancy induces temporary changes in glucose and lipid metabolism that are beneficial for baby but not for the mother, and that these changes are even more marked in women with Gestational Diabetes. In this theory, breastfeeding is nature's way of "re-setting" the mother's metabolism back to normal afterwards. If breastfeeding does not occur (or is brief), the mother's metabolism doesn't really return to normal and she is much more likely to develop diabetes, hypertension, and heart disease with time.

Although this is still just a theory at this point, it is a logical one, and one with some data to support its premise. Obviously, the human body is complex and many different factors play a role in the development of disease, but long-term breastfeeding may be an effective, low-cost, and extremely practical way to lower the risk for later disease.

Clearly, breastfeeding (and especially long-term breastfeeding) has important potential benefits for GD mothers.

Extra Benefits for GD Babies

Breastfeeding has so many benefits for all babies. We've known this for quite a while, yet it's surprising how often this does not get communicated well to pregnant women or the general public.

The general benefits of breastfeeding include lower risk for infections, asthma, diarrhea, ear infections, celiac disease, Sudden Infant Death Syndrome (SIDS), necrotizing enterocolitis in pre-term infants, and many other things. That's all pretty important right there.

But breastfeeding has extremely important immunological functions that are under-appreciated even among care providers. When in utero, the baby depends on the mother's placenta for immunological protection. After the baby is born, its own immunological system is quite immature. Nature designed breastfeeding to help bridge the gap between in utero protection and when the baby's own immunological system matures.

The first milk, colostrum, plays a vital role in "coating" the surface of the baby's intestines to help them be less vulnerable to pathogens. Later, human milk encourages the growth of the villi in the intestine and develops antibody responses specific to the pathogens the mother encounters. It also helps the baby strengthen and develop its own immuno-responses to pathogens, which may provide enhanced immuno-protection even after breastfeeding ends. Thus, breastfeeding is crucial in protecting the baby's immune system both short- and long-term. Its benefits do not end with weaning.

These are all important reasons to raise breastfeeding rates in the general population. However, there are additional potential benefits for babies of GD pregnancies.

The biggest benefit of breastfeeding after a GD pregnancy is that it lowers the risk of the baby developing diabetes as he/she grows to adulthood.

This is another HUGE advantage. Babies exposed to higher blood sugar rates in utero tend to have poorer glucose metabolisms, more insulin resistance, and more metabolic syndrome later in life.

If breastfeeding can prevent or delay many cases of metabolic syndrome and diabetes in a GD mother's offspring, it has tremendous public health implications for babies as well as mothers.

And this may be a particularly important finding for people of color, because of their increased risk for diabetes. One early study in a particularly vulnerable population (Pima Indians) found about half the risk for diabetes in adults who were breastfed for at least two months compared to those who were not. Imagine what the difference might be with longer periods of breastfeeding!

One study projected that if 90% of families in the U.S. breastfed exclusively for 6 months, about 911 deaths would be prevented each year. Of course, data projections like this are merely speculative, but even so, a clear trend in the statistical model implies that increasing breastfeeding rates would be a low-cost, effective strategy for improving public health in babies as well as in mothers.

And this may especially be true for babies of GD pregnancies.

Conclusion

Breastfeeding is a vital part of the so-called "fourth trimester" of pregnancy...and well beyond.

In other words, the mother's biological role in protecting her baby does not end with the baby's birth. It extends into breastfeeding and even beyond weaning.

Nature intended babies to be breastfed for significant periods of time in order to protect them while they are immunologically immature and to produce optimal and healthy growth and development. Nature also intended breastfeeding to benefit the mother by re-setting her metabolism and lowering her risk for heart disease and some cancers. Breastfeeding's benefits to both baby and mother do not end with weaning but appear to last for years afterwards.

Obviously, there are times when breastfeeding isn't possible, doesn't work out, or isn't wanted for various reasons, and it's good that we have substitutes available for these situations. Formula isn't "bad" or "evil," and it's a reasonably good substitute when human breastmilk is not available. Although uncommon, there are women who are truly unable to breastfeed and it's important that we have respect for that experience and support for those women even as we promote breastfeeding.

However, we must remember that Nature's design results in the most optimal outcomes and we subvert that design at the risk of significant harm on a population-wide basis. 

How much of our public health woes today are due to the widespread and very strong discouragement of breastfeeding by physicians in the last century? We may never know, but I would bet that at least some of the increase in diabetes and other problems we see today is at least partly due to the tremendous pressure on women from the mid-20th century not to breastfeed.

Even today, when most care providers at least pay lip service to the benefits of breastfeeding, many women are subtly discouraged from nursing or are told that there is little benefit to continuing to breastfeed past a few months. (Yep, I heard this one).

Even more alarming, despite evidence of EXTRA benefits to breastfeeding after a GD pregnancy, women with Gestational Diabetes have lower rates of breastfeeding than other women. 

Although some of this may have some basis in biological differences like PCOS (Polycystic Ovarian Syndrome), much of it is rooted in routine practices and interventions common during and after births in women with Gestational Diabetes. Yet care providers often fail to recognize that breastfeeding "failure" often begins with the interventions that occur during and after birth. 

There is much that can be done to raise breastfeeding rates in women with GD, if only caregivers and hospitals would recognize the role that common interventions plays in interfering with establishment of breastfeeding.

That's not to say that interventions should never take place. Sometimes interventions are truly necessary, especially in complicated cases of GD, but the reality is that they are often overused, and reducing them is a good first step in increasing breastfeeding rates. And even when interventions are truly necessary, there is much that can be done to protect and promote breastfeeding under less than ideal conditions, yet full implementation of these measures is lacking in many hospitals.

In our next post, we will discuss specifics on how to remove barriers and raise breastfeeding rates in women with GD. For the long-term health of babies and mothers, it is critical that we do this.


References

Breastfeeding and Short-Term Maternal Glucose Tolerance

Ir Med J. 2012 May;105(5 Suppl):31-6. Breast-feeding is associated with reduced postpartum maternal glucose intolerance after gestational diabetes. O'Reilly M, Avalos G, Dennedy MC, O'Sullivan EP, Dunne FP. PMID: 22838108

...We prospectively examined the prevalence of postpartum dysglycaemia after GDM and examined the effect of lactation on postpartum glucose tolerance. We compared postpartum 75g oral glucose tolerance test (OGTT) results from 300 women with GDM and 220 controls with normal gestational glucose tolerance (NGT). Breast-feeding data was collected at time of OGTT...The prevalence of persistent hyperglycaemia was significantly lower in women who breast-fed versus bottle-fed postpartum (8.2% v 18.4%, p < 0.001). Breast-feeding may confer beneficial metabolic effects after GDM and should be encouraged.

Diabetes Care. 2012 Jan;35(1):50-6. doi: 10.2337/dc11-1409. Epub 2011 Oct 19. Lactation intensity and postpartum maternal glucose tolerance and insulin resistance in women with recent GDM: the SWIFT cohort. Gunderson EP, Hedderson MM, Chiang V, Crites Y, Walton D, Azevedo RA, Fox G, Elmasian C, Young S, Salvador N, Lum M, Quesenberry CP, Lo JC, Sternfeld B,Ferrara A, Selby JV. PMID: 22011407

OBJECTIVE: To examine the association between breastfeeding intensity in relation to maternal blood glucose and insulin and glucose intolerance based on the postpartum 2-h 75-g oral glucose tolerance test (OGTT) results at 6-9 weeks after a pregnancy with gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: We selected 522 participants enrolled into the Study of Women, Infant Feeding, and Type 2 Diabetes (SWIFT), a prospective observational cohort study of Kaiser Permanente Northern California members...RESULTS:...Exclusive or mostly breastfeeding groups had lower prevalence of diabetes or prediabetes (P = 0.02). CONCLUSIONS: Higher intensity of lactation was associated with improved fasting glucose and lower insulin levels at 6-9 weeks' postpartum. Lactation may have favorable effects on glucose metabolism and insulin sensitivity that may reduce diabetes risk after GDM pregnancy.

Obstet Gynecol. 2012 Jul;120(1):136-43. doi: 10.1097/AOG.0b013e31825b993d. Influence of breastfeeding during the postpartum oral glucose tolerance test on plasma glucose and insulin.
Gunderson EP, Crites Y, Chiang V, Walton D, Azevedo RA, Fox G, Elmasian C, Young S, Salvador N, Lum M, Hedderson MM, Quesenberry CP, Lo JC, Ferrara A,Sternfeld B. PMID: 22914402

...Participants were enrolled in the Study of Women, Infant Feeding, and Type 2 Diabetes, a prospective observational cohort study of 1,035 Kaiser Permanente Northern California members who had been diagnosed with GDM...RESULTS: Of 835 lactating women, 205 (25%) breastfed their infants during the 2-hour 75-g OGTT at 6-9 weeks postpartum....CONCLUSION: Among postpartum women with recent gestational diabetes mellitus, breastfeeding an infant during the 2-hour 75-g OGTT may modestly lower plasma 2-hour glucose (5% lower on average) as well as insulin concentrations in response to ingestion of glucose.

Breastfeeding and Subsequent Maternal Diabetes

Diabetes Care. 2010 Jun;33(6):1239-41. doi: 10.2337/dc10-0347. Epub 2010 Mar 23. Parity, breastfeeding, and the subsequent risk of maternal type 2 diabetes. Liu B, Jorm L, Banks E. PMID: 20332359

...Using information on parity, breastfeeding, and diabetes collected from 52,731 women recruited into a cohort study, we estimated the risk of type 2 diabetes using multivariate logistic regression. RESULTS A total of 3,160 (6.0%) women were classified as having type 2 diabetes. Overall, nulliparous and parous women had a similar risk of diabetes. Among parous women, there was a 14% (95% CI 10-18%, P < 0.001) reduced likelihood of diabetes per year of breastfeeding. Compared to nulliparous women, parous women who did not breastfeed had a greater risk of diabetes (odds ratio 1.48, 95% CI 1.26-1.73, P < 0.001), whereas for women breastfeeding, the risk was not significantly increased. CONCLUSIONS: Compared with nulliparous women, childbearing women who do not breastfeed have about a 50% increased risk of type 2 diabetes in later life. Breastfeeding substantially reduces this excess risk.

Diabetes. 2012 Dec;61(12):3167-71. doi: 10.2337/db12-0393. Epub 2012 Oct 15. Long-term protective effect of lactation on the development of type 2 diabetes in women with recent gestational diabetes mellitus. Ziegler AG, Wallner M, Kaiser I, Rossbauer M, Harsunen MH, Lachmann L, Maier J, Winkler C, Hummel S. PMID: 23069624

...To investigate whether breastfeeding influences short- and long-term postpartum diabetes outcomes, women with GDM (n = 304) participating in the prospective German GDM study were followed from delivery for up to 19 years postpartum for diabetes development. All participants were recruited between 1989 and 1999. Postpartum diabetes developed in 147 women and was dependent on the treatment received during pregnancy (insulin vs. diet), BMI, and presence/absence of islet autoantibodies. Among islet autoantibody-negative women,breastfeeding was associated with median time to diabetes of 12.3 years compared with 2.3 years in women who did not breastfeed. The lowest postpartum diabetes risk was observed in women who breastfed for >3 months. On the basis of these results, we recommend that breastfeeding should be encouraged among these women because it offers a safe and feasible low-cost intervention to reduce the risk of subsequent diabetes in this high-risk population. 

Lactation Duration and Subsequent Maternal Diabetes

Eur J Endocrinol. 2013 Mar 15;168(4):515-23. doi: 10.1530/EJE-12-0939. Print 2013 Apr. Relationship between lactation duration and insulin and glucose response among women with prior gestational diabetes. Chouinard-Castonguay S, Weisnagel SJ, Tchernof A, Robitaille J. PMID: 23302255

...The study group comprised 144 women with a history of GDM between 2003 and 2010. Plasma insulin and glucose concentrations were obtained from a 75 g oral glucose tolerance test (OGTT). Total lactation duration (exclusive breastfeeding and breast and bottle-feeding) for all infants was self-reported in months. RESULTS: Mean age was 36.5±5.0 years. Time between delivery and metabolic testing was 4.0±1.9 years. Women breastfed for an average of 13.9±16.8 months. Most women (80.6%) reported a history of lactation...Compared with women who lactated for <10 months, women who lactated for ≥10 months had improved insulin sensitivity-secretion index, higher HOMA-IS and Matsuda indices, lower fasting and 2-h post-OGTT insulin concentrations as well as AUC for insulin, and lower incidence of impaired glucose intolerance (P≤0.05 for all). In multiple linear regression analyses, lactation duration emerged as an independent predictor of fasting insulin concentrations (β=-0.02) and insulin sensitivity indices (β=0.02) (P≤0.05 for all). CONCLUSIONS: These results suggest that longer duration of lactation is associated with improved insulin and glucose response among women with prior GDM.

JAMA. 2005 Nov 23;294(20):2601-10. Duration of lactation and incidence of type 2 diabetes. Stuebe AM1, Rich-Edwards JW, Willett WC, Manson JE, Michels KB. PMID: 16304074

...Prospective observational cohort study of 83,585 parous women in the Nurses' Health Study (NHS) and retrospective observational cohort study of 73,418 parous women in the Nurses' Health Study II (NHS II)...RESULTS: ...Among parous women, increasing duration of lactation was associated with a reduced risk of type 2 diabetes. For each additional year of lactation, women with a birth in the prior 15 years had a decrease in the risk of diabetes of 15% (95% confidence interval, 1%-27%) among NHS participants and of 14% (95% confidence interval, 7%-21%) among NHS II participants, controlling for current body mass index and other relevant risk factors for type 2 diabetes. CONCLUSIONS: Longer duration of breastfeeding was associated with reduced incidence of type 2 diabetes in 2 large US cohorts of women. Lactation may reduce risk of type 2 diabetes in young and middle-aged women by improving glucose homeostasis. 

Diabetologia. 2008 Feb;51(2):258-66. Epub 2007 Nov 27. Duration of breast-feeding and the incidence of type 2 diabetes mellitus in the Shanghai Women's Health Study. Villegas R1, Gao YT, Yang G, Li HL, Elasy T, Zheng W, Shu XO. PMID: 18040660

...This was a prospective study of 62,095 middle-aged parous women in Shanghai, China, who had no prior history of type 2 diabetes mellitus, cancer or cardiovascular disease at study recruitment... RESULTS: Women who had breastfed their children tended to have a lower risk of diabetes mellitus than those who had never breastfed [relative risk (RR)=0.88; 95% CI, 0.76-1.02; p=0.08]. Increasing duration of breast-feeding was associated with a reduced risk of type 2 diabetes mellitus. The fully adjusted RRs for lifetime breast-feeding duration were 1.00, 0.88, 0.89, 0.88, 0.75 and 0.68 (p trend=0.01) for 0, >0 to 0.99, >0.99 to 1.99, >1.99 to 2.99, >2.99 to 3.99 and >or=4 years in analyses adjusted for age, daily energy intake, BMI, WHR, smoking, alcohol intake, physical activity, occupation, income level, education level, number of live births and presence of hypertension at baselines....

Breastfeeding and Cardiovascular Implications

BMC Public Health. 2013 Nov 13;13:1070. doi: 10.1186/1471-2458-13-1070. A prospective population-based cohort study of lactation and cardiovascular disease mortality: the HUNT study. Natland Fagerhaug T1, Forsmo S, Jacobsen GW, Midthjell K, Andersen LF, Ivar Lund Nilsen T. PMID: 24219620

...In a Norwegian population-based prospective cohort study, we studied the association of lifetime duration of lactation with cardiovascular mortality in 21,889 women aged 30 to 85 years who attended the second Nord-Trøndelag Health Survey (HUNT2) in 1995-1997. The cohort was followed for mortality through 2010 by a linkage with the Cause of Death Registry...RESULTS:...Parous women younger than 65 years who had never lactated had a higher cardiovascular mortality than the reference group of women who had lactated 24 months or more (HR 2.77, 95% confidence interval [CI]: 1.28, 5.99)...CONCLUSIONS: Excess cardiovascular mortality rates were observed among parous women younger than 65 years who had never lactated. These findings support the hypothesis that lactation may have long-term influences on maternal cardiovascular health.

Breastfeeding and Maternal Cancer

Am J Clin Nutr. 2013 Oct;98(4):1020-31. doi: 10.3945/ajcn.113.062794. Epub 2013 Aug 21. Breastfeeding and ovarian cancer risk: a meta-analysis of epidemiologic studies. Luan NN1, Wu QJ, Gong TT, Vogtmann E, Wang YL, Lin B. PMID: 23966430

...We performed a meta-analysis to summarize available evidence of the association between breastfeeding and breastfeeding duration and EOC [ovarian cancer] risk from published cohort and case-control studies...RESULTS: Five prospective and 30 case-control studies were included in this analysis. The pooled RR for ever compared with never breastfeeding was 0.76 (95% CI: 0.69, 0.83), with moderate heterogeneity (Q = 69.4, P < 0.001, I(2) = 55.3%). Risk of EOC decreased by 8% for every 5-mo increase in the duration of breastfeeding (RR: 0.92; 95% CI: 0.90, 0.95). The risk reduction was similar for borderline and invasive EOC and was consistent within case-control and cohort studies. CONCLUSIONS: Results of this meta-analysis support the hypothesis that ever breastfeeding and a longer duration of breastfeeding are associated with lower risks of EOC....

Breastfeeding and Diabetes in Children

Am J Clin Nutr. 2006 Nov;84(5):1043-54. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. PMID: 17093156

...DESIGN: A systematic review of published studies identified 1010 reports; 23 examined the relation between infant feeding and type 2 diabetes in later life or risk factors for diabetes...RESULTS: Subjects who were breastfed had a lower risk of type 2 diabetes in later life than did those who were formula fed (7 studies; 76 744 subjects; odds ratio: 0.61; 95% CI: 0.44, 0.85; P = 0.003). Children and adults without diabetes who had been breastfed had marginally lower fasting insulin concentrations than did those who were formula fed (6 studies; 4800 subjects; percentage difference: -3%; 95% CI: -8%, 1%; P = 0.13); no significant difference in fasting glucose concentrations was observed...CONCLUSION: Breastfeeding in infancy is associated with a reduced risk of type 2 diabetes, with marginally lower insulin concentrations in later life, and with lower blood glucose and serum insulin concentrations in infancy.

Lower Rates of Breastfeeding in Women with Diabetes

Diabet Med. 2013 Sep;30(9):1094-101. doi: 10.1111/dme.12238. Epub 2013 Jun 21. Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study. Finkelstein SA, Keely E, Feig DS, Tu X, Yasseen AS 3rd, Walker M. PMID: 23692476

...METHODS: A retrospective cohort analysis was conducted using data from four Ontario hospitals. Women who delivered a viable infant between 1 April 2008 and 31 March 2010 were included in the study...CONCLUSIONS: Women with insulin-treated diabetes had the poorest outcomes with respect to breastfeeding rates. Gestational and non-insulin-treated diabetes were associated with lower rates of breastfeeding in hospital, while gestational diabetes was additionally associated with lower breastfeeding rates on discharge.

Dtsch Med Wochenschr. 2008 Feb;133(5):180-4. doi: 10.1055/s-2008-1017493. [Breastfeeding in women with gestational diabetes]. Hummel S, Hummel M, Knopff A, Bonifacio E, Ziegler AG. PMID: 18213549

...METHODS: Breastfeeding habits (breastfeeding of any duration) were recorded of 257 mothers with gestational diabetes...who participated in a prospective post-partum study between 1989 and 1999 and compared to breastfeeding habits of 527 healthy mothers... all enrolled in the prospective BABYDIAB study between the years 1989 and 2000...RESULTS: Compared to children of healthy mothers, fewer children of mothers with gestational diabetes were breastfed (75% vs 86%; P<0.0001). Among breastfed children the duration of full or any breastfeeding was shorter in children of mothers with gestational diabetes (median for full breastfeeding 9 weeks. [mothers with gestational diabetes] vs. 17 weeks. [healthy mothers]; p<0.0001; median duration of any breastfeeding 16 weeks. vs. 26 weeks.; p<0.0001)...Full and any breastfeeding was shorter in women with insulin-dependent gestational diabetes than in those with diet-controlled gestational diabetes (full breast-feeding 4 weeks. vs. 12 weeks.; p<0.01 and any breastfeeding 10 weeks. vs. 20 weeks,; p<0.0001)....