Booby Traps Series: What part of “six months of exclusive breastfeeding” don’t our providers understand?

This post is the 55th in a series on Booby Traps, made possible by the generous support of Motherlove Herbal Company.

Have you heard any of these statements at your four or five month well child visit?

“She looks great!  Ready to start solids?”

“Won’t sleep through the night?  Try some cereal in a bottle.”

“If he’s still feeding really often, maybe it’s time to start solids.”

“Her growth seems to be slowing (looking at CDC or older growth chart).  Why don’t you add some formula or start solids?”

If you heard any of these statements at your baby’s four or five month visit, you aren’t alone.  And it’s actually not that surprising, given what the research says about how pediatricians view exclusive breastfeeding, which I’ll describe in a minute.

But first, why do we care that babies are breastfed exclusively to 6 months, as recommended by the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the Academy of Breastfeeding Medicine, the World Health Organization, and the United Nations Children’s Fund?

In their breastfeeding policy, the AAP explains:

Support for this recommendation of exclusive breastfeeding is found in the differences in health outcomes of infants breastfed exclusively for 4 vs 6 months, for gastrointestinal disease, otitis media, respiratory illnesses, and atopic disease, as well as differences in maternal outcomes of delayed menses and postpartum weight loss.

Compared with infants who never breastfed, infants who were exclusively breastfed for 4 months had significantly greater incidence of lower respiratory tract illnesses, otitis media, and diarrheal disease than infants exclusively breastfed for 6 months or
longer.  When compared with infants who exclusively breastfed for longer than 6 months, those exclusively breastfed for 4 to 6 months had a fourfold increase in the risk of pneumonia.

In spite of this, a survey of pediatricians conducted in 2004 found that nearly 30% of pediatricians routinely recommended the introduction of solid foods or formula for exclusively breastfed infants before 5 months of age.  This figure was unchanged since the prior survey in 1995.  And while 74% of pediatricians reported recommending exclusive breastfeeding in the first month, one in four either recommended exclusive formula feeding (3%), breastfeeding and formula (8%), or had no opinion at all (16%).

This is reflected in mothers’ own reports of what they think their providers recommend.  Data from the CDC’s Infant Feeding Practices II study show that only 34% of mothers believe that their doctor favors exclusive breastfeeding, and nearly an equal number (32%) said that they believed that their doctor had no preference for breastfeeding or formula feeding at all.

The problem, of course, is compounded by the slow adoption of the World Health Organization’s growth charts.  Use of outdated growth charts, based on formula fed and mixed fed growth patterns, can make a normally growing exclusively breastfed baby appear to be slowing down, resulting in recommendations to supplement or start solids before six months.

As Dr. Lori Feldman-Winter pointed out in my interview with her, pediatrician training is part of the problem:  “Clearly, the lack of training [on breastfeeding] makes for pediatricians who are not supportive – particularly if mothers have problems, have poor attitudes, don’t think exclusive breastfeeding can work out for many women.”

But as the 2004 survey of pediatricians shows, those doctors who have had personal experience breastfeeding (a number on the rise) are more likely to make evidence-based recommendations and more likely to believe that breastfeeding is “worth it” and possible for almost all women.  This, coupled with better training in residency, shows that there is in fact hope.

Did your pediatrician support exclusive breastfeeding to six months?



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13 Comments | Last revised on 09/12/2012


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13 Responses to Booby Traps Series: What part of “six months of exclusive breastfeeding” don’t our providers understand?

  1. Bree says:

    I WISH the comments from my pedi at our 4 month had been that innocuous. Instead she told me “if you don’t start her on solids before 6 months, she’ll never learn how to eat!” I’m glad I have a brain and could determine that eating isn’t rocket science, or even a second language, and you can in fact learn it after you reach 6 months of age. But if I hadn’t been as confident that what I was doing was right I could have easily been scared into doing the wrong thing.

  2. Cassandra says:

    My baby is nine months old and still breastfeeding only. Upon recommendations from WIC and my doctor I tried giving her baby food at four months. She had fun with the spoon and with the mess but didn’t like eating the food. I noticed pamphlets and articles that said you have to give a baby the same food about ten times before she will start “liking” it. To me that felt like forcing her to eventually give in and eat what she didn’t want and what she knew she didn’t yet need. So I didn’t try again until a few weeks ago (when I had an OMG my milk is running out moment and then researched online and realized I was just freaking out for no reason) and she still didn’t want it. She loves breastfeeding still and she gains weight just fine still. My mother asks me every time we speak if she is eating solids yet and stresses saying that she needs to learn how to eat. I just calmly tell her she will eat just fine when she wants and needs to.

    • Stephanie says:

      I feel it just depends on the child. With my oldest I started feeding him solids at 4 months of age at my doctors recommendation. And he loved it. He ate baby cereal for breakfast and dinner time and nursed all throughout the day. When my twins were 4 months I tried them on solids and they were just not accepting it so I stopper and waited until they were 6 months. Again they weren’t ready. So exclusively breastfed for 9 months. I think you just have to take the cues of you child. My oldest was ready for solids at 4 months and my twins were ready at 9 months. I still breastfed my oldest until 18 months and am still breastfeeding my twins who are 17 1/2 months. So I don’t really see anything wrong with introducing solids at 4 months if you still continue to breastfeed.

    • Mama says:

      You can tell your mother that my ‘little’ brother was exclusively breastfed for 8mths and slowly started taking the occasional food after that. He didn’t really take to food (apart from breastmilk) until around his first birthday.

      As an adult he is just shy of 7 foot tall and certainly doesn’t have any issues with growth or eating! So no need for any worries there :)

  3. A colleague of mine, Georgette Bartell RN, IBCLC, has reframed the AAP recommendation. I now use this in all my classes. Georgette says “Breastfeed for at least a year with the gradual introduction of solids around 6 months of age.” I love this!!

  4. EC says:

    My own pediatrician said I “could start offering solids” at 4 months if I wanted to, but never pushed it. We tried with our first and she hated it so we backed off. By the second I knew that he didn’t NEED it, so I let him choose when he wanted to start eating and how much.
    I wonder if part of the problem is in training. Doctors learn how to become doctors from other doctors and if the teaching doctors (attendings) are making the recommendation to start solids at 4 months, and pushing formula, then I wouldn’t be surprised if the following generation of doctors is more likely to do the same regardless of the guidelines from the governing body. It would be an interesting thing to study.
    On the flip side, I think my generation (I am a medical student) is not only more comfortable with challenging our attendings’ practices than previous generations, but I think it is even encouraged to an extent.
    In all, I have hope that the climate in the doctor’s office is changing to be more supportive of breastfeeding mothers.

  5. AJD says:

    I am happy to report, that out physician is VERY pro-breast feeding. He encouraged me to wait longer (until 6 months or more) to introducing solids and at every appointment we have had; he has encouraged my continued nursing relationship (with my now 2 year old). I am blessed!

  6. Lise says:

    Wow! Our pediatrician told us that the best time was to start solids after dd turned 6 months (this was at her 4 month appointment). He said some doctors were recommending it earlier, but research supported waiting longer – especially since dd was doing so well on my milk. It shocks me that so many doctors are suggesting to start earlier.

  7. Autumn says:

    I fell into a booby trap with my oldest and stopped bfing by 6 weeks. When she was eating more than 32 oz by 4 months, the doctor told me I HAD to give her rice cereal. I did it, she ate like a champ and I thought all was well. Then we went to our 12 month appointment and was told she was way overweight (She was 30 lbs- I didn’t know any better!), had eczema, and she promptly started having allergic reactions to multiple foods and soaps. I know everyone has anecdotal evidence, their child was formula fed and they’re fine, they’re super smart, etc. Sometimes though, it follows exactly what research tells us will happen. I just wish I had known what I was doing way back then. Good news is that, with my youngest, I breastfed exclusively for 3 months, supplemented about 25% for the next 9 months, gave her no cereal, and she started food at around 8 months. She has no allergies. My story is proof positive that this information is invaluable. I didn’t fix everything the second time around but I feel like I gave my younger daughter a much better start.

  8. Lindsay says:

    It is so weird to see this. Where I live the doctors and nurses are very pro-breastfeeding, natural childbirth, etc. Every time I tell the doctors I am breastfeeding they give me congratulations! And at every visit prior to six months I was told to wait on solids as they will replace valuable nursing sessions. They also told me that my daughter’s slower weight gain was fine because the charts were based on formula babies. As long as she followed a line she was okay. It is so disheartening to see so many women have issues. I feel bad for the ones who are less informed or don’t already have much support at home. The doctor’s office is a place where they should be able to expect good and correct advice.

  9. Ruth Ann Triplett says:

    At my sons four month appointment, his doctor said that I could start some cereal, that he appeared developmentally ready. I was kind of sad at the remark. Especially since at my daugter’s (first baby) four month appointment the doctor (different doctor) said I could do cereal and even formula if I wanted. But… the next words my son’s docotr said made my day. He said people have been breastfeeding there babies for ages and there really is no reason to start solids, so it really was up to me!!! Yay!

  10. Kelly says:

    We have very few “pro breastfeeding” pediatricians OR family doctors. I’ve been seeing the same docs with all of my kids and they seem to have gotten worse as time has gone on. With my most recent child (daugter, third child and LAST child), they told me at her 1 week checkup to start formula because she had lost 1.5lbs since the day before – and refused to check the calibration of their scales! I went back to the hospital and had her weighed on the same scale and she was exactly the same. They recommended that I start solids at THREE MONTHS. I refused. Refused to start formula after a week. She is almost 8 months now and still primarily breastfed – she gets a little bit of oatmeal with milk and fruit or vegetables every few days if she’s interested in eating, and if not, she just nurses. They HATE that we cosleep. The only bonus: They recently hired a new nurse practitioner who is young and a breastfeeding mother herself, and she is AWESOME. I see her now instead of the docs, because she is so much more informed.

  11. Zoe says:

    My 3 mo. old’s pedi insisted that I supplement with formula at every feeding (specifically: “Only BF about ten minutes, then offer the bottle of formula till she’s full). She also told me I need an extra 1000 calories a day, without even asking me my current weight or caloric intake. At the last check-up she was normal weight again, and the doctor said, “Oh, I guess you’ve been supplementing like we said?” And I grinned and said, “Nope. I knew she’d gain at her own pace. It pays to follow instincts.” Keep in mind, I said this very friendly–and the doctor says, “Instincts? You’re, what, 22? You can’t have any instincts yet!”

    WOW. I switched to a different doctor in the practice, who did say the 1000 calories extra for me were too much–but THEN she tried pushing for the formula supplements again! She even pushed a bunch of formula samples at me–”coincidentally” the same brand that’s plastered all over the practice’s pens, clipboards, you name it.

    Today I finally told them to just deal with the fact I wasn’t going to give my baby formula JUST to make her reach some arbitrary ideal. I give her formula once in a blue moon (food poisoning once, and blocked ducts another day…maybe twice in the early days when I wasn’t producing anything yet and was suffering PPD), but by no means do I enjoy doing so, because with breast milk, she uses it all–no dirty diapers, just wet ones, for two or three days. With formula, it just runs straight on through and fills that diaper in minutes. Not to mention she gets hungry 1 or 2 hours after formula, but 3 or 4 after breastmilk. And she ONLY sleeps through the night with a tummy full of breastmilk! Formula just messes her up.

    Anyway, the doctors told me she was underweight today. THEN when I asked, “Underweight or just off the curve?” they admitted the latter. “She just isn’t getting enough calories,” was the doctor’s reasoning, and then she stuck her own feet in her mouth by saying, “Her length is great, totally normal, and same with head circumference.”

    UUMMM…if she weren’t getting enough calories (which she is; she gets 6 oz every 3 to 4 hours and seems happy and satiated after every feeding) from my mik, HOW would she be growing in those other respects?

    I get it–doctors have to cover their own butts and avoid lawsuits. But there’s a difference between erring on the side of caution, and being ridiculous. Breastmilk is as good as food can get. I personally believe kids today are predisposed to obesity because of formula–not to mention more allergies and weaker immune systems.

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