Susana Ares Segura
The press release accurately summarises the three main messages of the article: colostrum is usually sufficient for most healthy, full-term newborns; the use of dummies does not appear to reduce the duration of breastfeeding, according to randomised clinical trials; and electric breast pumps should not be used routinely during the first 48–72 hours in healthy mothers and newborns.
However, the press release uses strong language, for example: “Several common clinical practices are not supported by current evidence”, when, in reality, the article makes a more nuanced point: there are discrepancies between clinical practice and the available evidence; the evidence is strong for some issues (dummies); it is moderate or low for others (breast pumps); and the authors themselves acknowledge significant limitations.
In my opinion, it is a good, very up-to-date review article (78 studies), which draws on Cochrane reviews and meta-analyses, but it is neither a systematic review nor a new meta-analysis, which significantly alters the level of evidence. It analyses a very common clinical problem, clearly distinguishes between healthy newborns and pathological conditions, and attempts to debunk myths by drawing on clinical trials.
The conclusions regarding colostrum are well supported; the underlying physiology is very well understood. The article shows that the neonatal stomach is very small, colostrum has a very high immune concentration, and colostrum production matches the physiological needs of the newborn.
Regarding dummies, the evidence is probably the most robust. The article cites a meta-analysis of 10 clinical trials and a Cochrane review; it concludes that restricting dummy use does not increase the duration of breastfeeding. Furthermore, it notes that the AAP recommends the use of dummies during sleep to reduce the risk of sudden infant death syndrome.
As for breast pumps, the evidence is less robust. The authors acknowledge that most of it comes from observational studies; there are only a few small clinical trials, and the overall certainty is low. Therefore, it would be an exaggeration to claim that breast pumps impair breastfeeding; it would be more accurate to say that there is no evidence to support their routine use in healthy mothers during the first few days.
The authors themselves are candid about the limitations of their study: it is a narrative review; they did not carry out a systematic search or a formal assessment of the risk of bias (which means there is some risk of study selection bias); and, furthermore, many of the studies originate from high-income countries, meaning that their conclusions are primarily intended for Europe, the US and Australia, and not necessarily for countries with fewer resources. Another important limitation is that the authors focus on healthy, full-term newborns, and the conclusions do not apply to preterm infants, neonatal intensive care units, mothers with true hypogalactia, breast surgery, endocrine problems, mother-infant separation or unwell babies.
The paper offers a reasonable, though probably somewhat optimistic, interpretation of the factors underlying early cessation of breastfeeding, which is a multifactorial phenomenon. The authors cite factors such as the perception of low milk supply, conflicting messages, family pressure, unrealistic expectations, latching difficulties, medical problems, return to work and formula marketing. Therefore, the three topics studied (colostrum, dummies and breast pumps) do not, on their own, explain the cessation of breastfeeding, although they probably represent part of the problem.
In my opinion, the article’s greatest contribution is to show how these three elements can reinforce a vicious circle of perceived milk insufficiency during the first few days. This mechanism is plausible and well argued, although quantifying its contribution relative to other factors remains difficult.
As for the practical implications of the study, I believe it is quite useful and can help change some widespread practices among healthcare professionals: explaining the normal physiology of colostrum more clearly, avoiding saying ‘you don’t have any milk’ too soon, teaching manual expression before recommending a breast pump, tailoring the use of dummies to individual needs, supplementing only when there is a clear medical indication, and referring mothers to breastfeeding support at an early stage.
For maternity units, the article proposes clear protocols for supplementation, more realistic antenatal education, fewer routine interventions, more expert support in the first 48 hours, and individualised advice rather than blanket bans.