How Long Before Infant Feeding Research Has to Conclude that Fed is Best? (The RCT Edition)

We all know that breastfeeding is supposed to have a gazillion health benefits and will save the world from certain disaster. So, it is perplexing that recent trials looking at the effect of interventions to increase exclusive breastfeeding in Uganda and Guinea-Bissau found not only an increase in exclusive breastfeeding, but also an increase in severe growth stunting and wasting.

Stunting has detrimental effects on brain development, cognitive functioning and immunity. It can leave children vulnerable to infection and death. What is more, these studies didn’t find any effect of increasing exclusive breastfeeding on death or illness.

No benefits in a developing country and very significant harm?! You read that correctly. So much for breastfeeding being a cornerstone public health intervention! Yes, this is heresy. It is also science.

The RCT I am going to look at today attempted to test whether 30 ml of formula a day for the first month of life could prevent growth stunting. The researchers decided that because the first month of life is so critical for infant growth, they would randomise babies to either exclusive breastfeeding (EBF), or to breastfeeding plus 30 ml formula per day for one month. Mothers were provided with the formula.

The results were that more babies in the control (EBF) group were given non-formula supplementary food (e.g. tea, water and juice). There was no effect on breastfeeding cessation. There was no effect on adverse events (fever, jaundice, breathing issues, diarrhoea or vomiting). There was no effect on growth metrics.

So, formula supplementation made no difference, other than to dissuade parents from using other forms of supplementation? Let’s give up! Not quite. This study is notable in that it demonstrates the possibility of safely distributing infant formula in a low-income context. It is also notable that there was an absence of adverse effects.

30 ml of formula a day for one month can hardly be expected to make much of a difference. While there may be challenges to increasing provision (e.g. here they used sterile pre-made formula, which is expensive, not powder), what’s really needed now is to increase the dose of formula supplementation and ensure the baby is getting a sufficient volume of breastmilk and/or formula. Then we can see what happens to health outcomes.

To my ears, this sounds a bit like testing parachutes vs no parachutes when jumping out of a plane. But if research keeps going in this direction, it won’t be long until the world of infant feeding is forced to conclude that fed is best. It will soon have to accept that the reliance on exclusive breastfeeding is a woefully inadequate infant nutrition strategy, and that the safe supply of infant formula to babies in low-income settings ought to be a matter of public health urgency.

Ruth Ann Harpur

This blog was adapted from a Twitter thread.

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