Breastfeeding increases the risk of newborn readmission. Now what do we do?
© 2019 Roy Benaroch, MD
An August 2018 paper in Academic Pediatrics found an unsettling conclusion: breast-fed newborns have about double the risk of needing to be hospitalized in their first month of life, compared to babies who were formula-fed. The numbers are solid, and they jibe with the real-life experience of many pediatricians, including me. So what should we do about it?
The study itself looked at about 150,000 healthy, normal newborns born in Northern California hospitals from 2009 to 2013. The study authors were able to collect data on how these babies were fed in the few days following birth from hospital records (dividing them into groups of all-breast, all-formula, and a mixed group that did some of both.) They were then able to track these babies over the first month of their lives to see which ones ended up hospitalized for any reason. Most of the hospitalizations were related to dehydration and jaundice, which are closely linked to inadequate feeding.
The good news is that relatively few of these babies ended up back in the hospital – whether bottle-fed, breast-fed, or both, most babies did great. But babies who were breast-fed were much more likely than formula-feeders to end up underfed and hospitalized. Among vaginal deliveries, the risk of rehospitalization was 2.1% for bottle-fed babies versus 4.3% for breast-fed babies (the risk for mixed feeders was in between.) That’s about double the risk. Mathematically, the “number needed to harm” was 45. That is, for every 45 babies exclusively breast fed, one extra baby would end up in the hospital. Not good.
Among Caesarian births, the differential was less, with an increased risk of hospitalization of 2.1% (breast) versus 1.5% (formula). Both of these numbers are lower than the risk of rehospitalization for vaginal deliveries, probably because c-section babies already spend an extra day or two in the hospital. This provides more time for good feeding to be established (whether breast, bottle, or both.)
Does this mean we should discourage breast feeding? Of course not. Most breast-fed babies do great, and there are some health advantages of breastfeeding. But we need to be honest with ourselves, and honest with moms who are trying to do the best thing for their babies. Nursing isn’t perfect. It’s not a perfect food*, and it’s not a perfect method. There are pros and cons to both nursing and formula feeding, and parents (and babies) deserve an honest appraisal.
Nursing moms also need support. That includes “technical support” (ie “How to do it”) but also emotional and medical support – which should include time for rest, and an honest evaluation of how both moms and babies are doing. There is a role for formula, both for moms who choose to use it and for situations where babies aren’t getting enough to eat. Families, pediatricians, nurses, and lactation specialists all need to work together, without guilt or finger-pointing, to help keep babies and moms healthy.
*Human breast milk is an inadequate source of vitamin D from birth, and an inadequate source of iron by 4-6 months of life.
Tags: bottle feeding, breast feeding, newborns
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The Pediatric Insider 
January 9, 2019 at 10:14 am
This topic is near and dear to me – I was decided to exclusively BF, and between early birth, complicated CS, and feeding issues I had to supplement my baby’s feeding with formula. I am lucky to have had an amazing support system from a truly amazing lactation consultant and the pediatrician who both supported me through my determination to keep giving my baby breast milk, but also made sure the baby was healthy and instructed the supplementation as needed. What’s best is for the baby to be healthy, and getting both types of milk are completely acceptable.
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January 9, 2019 at 10:44 am
I think moms need more breastfeeding support at birth if they choose to breastfeed instead of being referred to specialized clinics in future checkups and wait for a long time for a spot. I do not know if it is routine to check for tongue and lip ties for latch, but they do affect how newborn feed and mom’s comfort, especially if they have nipple vasospasm.
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January 9, 2019 at 11:09 am
Could it be that the mothers were dehydrated themselves? My mother weighed me after every feeding (1940) so she knew how much I got.
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January 10, 2019 at 10:00 am
I tried to exclusively breastfeed but had to supplement for the first two weeks of my sons life. This was at the hospital pedi’s recommendation and our own pedi’s recommendation. Luckily our pedi’s office has a lactation consultant on site one day a week and I was able to meet with her from the start and regularly thereafter for help. After two weeks I was able to successfully exclusively breastfeed. I don’t know what I would have done without her!
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January 19, 2019 at 9:50 pm
I am a pediatrician who support breastfeeding and parents wh want to do so and honestly find some hiccups in the initial period of helping them with both end lack of time from a bussy practice and lack of resources and parental anxiety, but if you stick to it 95-99% successfully accomplished. I also was ready to jump at “no perfect” and then noticed the clarification , thank you so much.i think we should have step down breast feeding center 24hours open.
I am a fan of Dr. Benaroch.
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January 20, 2019 at 6:13 am
It would be interesting to know the data for weight loss/gain in the three arms of the study, I bet it will come with similar numbers as the jaundice. The answer are the results of the CS group having less problem with one or two more days of support in the hospital. We rush our moms out of the hospital mainly for economical reasons without an adequate support afterwards. A close visit to the pediatrician’s office or even better, a home visit by a lactation nurse in 24 to 48 hours would be very helpful to minimize the risk of exclusive breastfeeding babies, is this practice cheaper than an extra day at the hospital?
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January 20, 2019 at 6:03 pm
If mother’s choose to exclusively breast feed their first infant they need lactation/nursing support in the first week that includes a visit 2-3 days after delivery to assess latch and milk production. Supplement as needed until mom’s milk comes in while using a breast pump to stimulate production. The older the mom the longer it takes for milk to come in. Teenagers who have babies generally have no problem making milk in my experience. There are very few health plans/hospitals/physician offices that offer adequate support of breastfeeding in the early newborn period.
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February 19, 2019 at 12:57 pm
It’s also possible that many of those babies don’t really need to be hospitalized. Apparently losing a little weight after birth is so common as to be effectively normal, something often not understood by growth-oriented Americans. Do I believe that one in 25 otherwise normal babies would shrivel up and die from failure to nurse if not hospitalized, assuming there was access to lactation consulting (or the traditional equivalent)? Probably not. I would like to see this same study redone in one of the European countries that does not use hospitalization as aggressively.
As for vitamin D, how could any of our ancestors’ babies have been healthy before vitamin supplements were invented? I surmise that a ray of sunlight must have been allowed to fall on their skin once in a while…
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September 1, 2023 at 8:58 am
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