What 'breast is best' gets wrong

Deep dive: The hidden costs of breastfeeding

Dear community,

Earlier this year, I published a piece in Slate about the hidden costs of breastfeeding that I’d like to share with you here — along with messages from readers.

When I was expecting my first baby, my psychiatrist was unequivocal: She recommended that I not breastfeed — for my health and my son’s.

Looking back, I know that choosing not to breastfeed played a key role in my entering parenthood as the healthiest version of myself and in my son thriving.

But as a medical community, our approach to feeding doesn’t yet routinely account for potential health costs for parents, or take a holistic view of the entire family’s needs. And despite there being no evidence of long-term harms from formula feeding, ready support for families making choices other than exclusive breastfeeding is lacking, both within medicine and more broadly in society. I’d love to hear your reactions in the comments or by email.

You can listen to the full interview I conducted with perinatal psychiatrists Dr Nancy Byatt and Dr Crystal Clark here on Substack, Spotify, Apple, or wherever you listen to podcasts. Here’s a snippet:

Wishing you light and the freedom to make decisions that are best for you,

Dr Devika Bhushan

How not breastfeeding preserved my mental health

When I was expecting my first baby, my psychiatrist was unequivocal: She recommended that I not breastfeed — for my health and my son’s.

I had always pictured breastfeeding my kids, but there was good reason for her recommendation. Sleep protection is essential to managing bipolar disorder, which I’ve maintained in remission for years. The pregnancy and postpartum period could put me at high risk for its return, and continuing my medications, stepping up therapy, and protecting sleep would be vital to preventing that.

Formula feeding was core to our plan to protect my sleep after my son was born. Breastfeeding or chest-feeding parents have to wake up throughout the night to pump or feed, and sleep disruption is a well-known risk factor for mental illness episodes at any time, as well as specifically in the postpartum period; these include depression, suicidal thoughts and behavior, mania and hypomania, psychosis, anxiety, and substance-use disorder. Formula feeding, on the other hand, enables anyone to take on this nighttime work, spreading out sleep loss and offsetting health risks.

But, at least at first, this didn’t sit right with my obstetrician or pediatrician. “Don’t you at least want to try to breastfeed?” I remember them saying.

I knew where they were coming from, and the decision was initially hard for me, too. As a pediatrician and public health professional myself, I was unrelentingly trained that breast is best. Guidelines from pediatric, obstetric, and public health authorities recommend exclusive breastfeeding through six months, and supplemental breastfeeding for up to two years.

As I considered formula feeding, I learned that these breastfeeding guidelines that many clinicians use as gospel overstate benefits from available data: The best (randomized) breastfeeding data do show small short-term benefits for babies, like 4 percent fewer gut infections and 3 percent less eczema in the first year, along with lower risk of breast and ovarian cancer for mothers. But claims about enhanced intelligence, better parent-child relationships, and longer-term child health impacts (including lower risk for high blood pressure, diabetes, asthma, or obesity) are not supported by high-quality randomized data.

So: Breastfeeding is great if it’s in the cards for you. But forgoing it does not consign your child to long-term issues.

Existing guidelines also fail to sufficiently consider the potential costs of breastfeeding, including the sheer time and sleep loss it requires of the breastfeeding parent—which, in turn, can lead to inequities in parenting labor and the ability to work outside the home.

If it goes well, breastfeeding can boost maternal mental health — but research also shows that wanting to breastfeed and having challenges can worsen mental health. When you’re unable to give your baby something you’ve been told is essential, guilt and shame can take hold.

Take Ann Mary Olson, a lawyer and new parent in the Bay Area who struggled to meet her baby’s needs with breast milk alone. To boost supply, Olson, who is a friend of mine, was spending up to five hours a day (not counting cleanup) hooked up to a hospital-grade pump — the most efficient kind — eking out every last drop of breast milk. While pumping, she couldn’t hold her baby, sleep, or do much else.

But despite her efforts, on a good day, Olson produced enough milk for less than half of her baby’s caloric needs. She told me she “felt like a failure” and was left sleep-deprived, time-strapped, stressed, and irritable. “It was undeniable to me that what I was doing was unsustainable,” she said. “I wasn’t being the best mother I could be … when I was so completely exhausted from this feeding regimen.”

For Olson, the “persistent messaging from the medical establishment that breastfeeding is the clear best choice” added to the pressure she felt—and made her eventual switch to formula even trickier. But when she switched, Olson felt a weight lift. “The effect on my mental health was immediate,” she said. Her sleep quality and quantity went up, and her stress levels and self-recrimination went way down. Five additional hours per day were freed up to bond with her baby and tend to her own needs.

Recommending that parents exclusively breastfeed—and continue attempting to breastfeed even when it’s not going well—is common medical practice. What clinicians and guidelines don’t routinely recognize is that there “are risks associated with breastfeeding, particularly when there’s challenges,” said Nancy Byatt, a perinatal psychiatrist and professor at the University of Massachusetts Chan Medical School.

Throughout my own pediatric education and practice, my peers and I were never trained to explicitly consider parental mental health as a factor in a family’s decision-making around feeding—at odds with the standard of care in perinatal psychiatry. “Breast is great,” Byatt said, “but not at the expense of parental mental health.”

Byatt and the other psychiatrists I interviewed for this piece routinely recommend against breastfeeding to protect maternal mental health in clear-cut cases—including for parents with serious mental illness, any illness known to be triggered by sleep loss, and those who have tried to breastfeed but have simply struggled with it too much.

“I’m trying to cut out anything that’s going to increase that risk for destabilization,” said Crystal Clark, a perinatal psychiatrist and associate professor at the University of Toronto. Clark remembers working at a hospital where a “breast is best” campaign was underway: “It was rough … moms up 24 hours trying to breastfeed,” she said. She recalls some patients becoming very sick as a result.

Although some 83 percent of mothers attempt breastfeeding, only 1 in 4 still exclusively breastfeed by six months, for many reasons: parental health impacts; difficulties with supply; lack of support or time, such as for pumping at work; and insufficient parental leave. Ninety-five percent of U.S. fathers and 1 in 4 mothers return to work within two weeks.

Whether the risks of breastfeeding outweigh benefits is an individual calculation, and one that can even change over the course of the postpartum period. Ideally, parents would be checking in with their care team to tweak their feeding plans as needed in the weeks after birth. Instead, parents frequently fall off the postpartum “cliff.” After frequent visits throughout pregnancy, typically only one or two visits are allotted for postpartum needs in the six months after birth, while the baby might have as many as six visits. In focus groups, Byatt has heard new mothers describe feeling like a “hot potato”—“dropped as soon as the baby’s born.”

In reality, parents and children are a unit whose health is intertwined, and a health challenge for a parent can fundamentally affect the baby’s health, Joanna Jarecki, a psychiatrist and assistant professor at McMaster University, told me in an email.

Given all this, we need to ensure that all clinicians caring for a family are on the same page. “Some patients are going to believe their OB and pediatrician over their psychiatrist,” Clark said, to the possible detriment of their health. Luckily, there are some efforts to better align care across specialties, though they need to expand. Byatt, for example, leads a program in Massachusetts for other clinicians to consult perinatal psychiatrists in creating optimal care plans for new or expecting parents who have mental health challenges, including inputs on feeding.

What I would tell any new parent is: If sleep deprivation could put you at risk for illness, consider all your feeding options — the only “right” choice is the one that allows you to be the best parent you can be.

In my own case, I’ve never regretted my decision to formula feed my son to protect sleep during my highest-risk period for a relapse. It allowed me to enter parenthood as the healthiest version of myself — and for my son to thrive.

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Reader reactions

Thank you!!! Finally someone said it out loud. -@uzmab on X

YES! I’m so glad you are speaking about this. As a former sleep researcher and new mother I found the sleep advice for parents (particularly moms) to be completely bizarre and wholly dismissive of the health and wellness of the adults. Babies need parents who are mentally and physically well and resilient — sometimes that means making other kinds of tradeoffs like breastfeeding. -Stephanie Greer, LI

Ohhh this is so wonderful and I wish I had read it before [my baby] was born. It’s spot on. I had so many layers of feeding support… and not a single one told me it was ok to just give up and formula feed her. I was checking in weekly with a breastfeeding support group, a research study PI, pediatricians, and a lactation consultant and they were all dug in so deep on the ‘breast is best’ — it was like a cult! I remember calling in finally to the breastfeeding support group in like week 5 and asking how to switch to formula feeding because [breastfeeding] wasn’t working and the woman just gave me this look of pity…. like she was so disappointed to even hear this question. -Anonymous

I chose not to breastfeed my second because I viscerally hated breastfeeding my first… Incidentally, I had much a much easier time bonding with my youngest, probably because all the time spent holding him was not also associated with nausea and pain. -@hubbstercat on X

My brother shared your article with me and I just want to say THANK YOU. You’ve changed so many people’s perceptions and I’ve shared it with many people… some who were getting pressured by family members to breastfeed… and it’s made a difference. -Anonymous

This is such an important article. Perinatal mental health teams well know the role breastfeeding difficulties can play in maternal mental health, but it is not something that other health professionals seem encouraged to consider. That has to change. —Rhiannon Cosslett

Reminders for the year’s end

1. You are enough just as you are — regardless of how much you accomplish (or ‘leave undone’) in 2024. There’s nothing magical about turning the page on one year to the next — we don’t have to perfectly wrap anything up.

2. You don’t have to earn rest: it is already yours. That is, you don’t have to work yourself to the bone to earn time off to rejuvenate. Rest is yours because you are human and humans need rest to thrive. And it is yours regardless of how much you finish or leave undone before the holidays (see 1).

3. Consider deferring tasks to the new year. Many somewhat urgent items are still not necessarily right now items. Given how much we juggle in this season (both professional and personal), I encourage you to ask: Could I reasonably defer this to later? Many times, if you let yourself consider it, the answer will be yes.

   Ask yourself: What else do I need space for in this moment? This might include planning, decompressing, honoring grief or loss, and creating opportunities for joy and presence. Give yourself permission to make that space.

4. This holiday season, choose presence over perfection. Embrace slowing down and showing up exactly as you are.

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   Revisit top Ask Dr Devika B posts:

   • My top 9 mental health tips

   • 5 ways to bolster kids’ self-esteem

   • Overcoming imposter syndrome

   • Simone Biles; my ‘coming out’ anniversary

   • Let’s gift experiences

   • Let’s get distance from screens…

     • The waiting game

     • The ‘other room’ strategy

     • Back in the driver’s seat

     • Breaking up with your bedfellow

   • Let’s sleep better…

     • With morning sunlight

     • By capturing darkness

     • By creating a simple bedtime routine

     • To nap or not to nap?

     • Beating jet lag