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    This study found that exclusive bottle feeding of either formula or breast milk is associated with greater infant weight gain in the first year compared to exclusive breastfeeding. However, the findings do not necessarily reflect a causal relationship between bottle feeding and increased weight gain, as it is possible that infants with a faster growth trajectory may be more likely to receive bottles. While previous studies have generally assumed feeding method causes growth differences, factors like an infant's demand and mother's milk supply could better explain the associations. More research is still needed to fully understand these relationships.

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    This study found that exclusive bottle feeding of either formula or breast milk is associated with greater infant weight gain in the first year compared to exclusive breastfeeding. However, the findings do not necessarily reflect a causal relationship between bottle feeding and increased weight gain, as it is possible that infants with a faster growth trajectory may be more likely to receive bottles. While previous studies have generally assumed feeding method causes growth differences, factors like an infant's demand and mother's milk supply could better explain the associations. More research is still needed to fully understand these relationships.

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    This study found that exclusive bottle feeding of either formula or breast milk is associated with greater infant weight gain in the first year compared to exclusive breastfeeding. However, the findings do not necessarily reflect a causal relationship between bottle feeding and increased weight gain, as it is possible that infants with a faster growth trajectory may be more likely to receive bottles. While previous studies have generally assumed feeding method causes growth differences, factors like an infant's demand and mother's milk supply could better explain the associations. More research is still needed to fully understand these relationships.

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    This study found that exclusive bottle feeding of either formula or breast milk is associated with greater infant weight gain in the first year compared to exclusive breastfeeding. However, the findings do not necessarily reflect a causal relationship between bottle feeding and increased weight gain, as it is possible that infants with a faster growth trajectory may be more likely to receive bottles. While previous studies have generally assumed feeding method causes growth differences, factors like an infant's demand and mother's milk supply could better explain the associations. More research is still needed to fully understand these relationships.

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    Prognosis

    Cohort study

    Exclusive bottle feeding of either formula or breast milk


    is associated with greater infant weight gain than exclusive
    breastfeeding, but ndings may not reect a causal effect
    of bottle feeding
    Michael S Kramer
    10.1136/eb-2012-100905

    Department of Pediatrics and of


    Epidemiology, Biostatistics, and
    Occupational Health, McGill
    University, Montreal, Quebec,
    Canada

    Correspondence to
    Dr Michael S Kramer
    Department of Pediatrics and of
    Epidemiology, Biostatistics, and
    Occupational Health, McGill
    University, 2300 Tupper Street,
    Montreal, Quebec,
    Canada H3H 1P3;
    michael.kramer@mcgill.ca

    Commentary on: Li R, Magadia J, Fein SB, et al. Risk of bottle-feeding for rapid weight gain during the
    rst year of life. Arch Pediatr Adolesc Med 2012;166:4316.

    Context

    Findings

    The paper by Li et al addresses a topic that has been


    much studied and debated over the last several decades:
    the relationship between type of infant feeding and
    growth in the rst year of life. This study adds a new
    twist, however: the consideration of bottle feeding, even
    among infants who receive breast milk via the bottle,
    rather than formula. Although formula and other nonhuman milk can be provided only by bottle, breast milk
    can be provided either via the breast or the bottle. Many
    breastfeeding mothers, particularly those who choose to
    or are obligated to return to work during breastfeeding,
    will pump their milk to provide bottled breast milk for
    their infants during their absence.

    The authors found that bottle feeding itself, even with


    breast milk, was associated with a higher rate of weight
    gain over the rst year of life (adjusted mean difference
    of weight gain velocity in infants who were fed breast
    milk by bottle versus those breastfed only=88.8 (95% CI
    13.2 to 164.5 g/mo)).

    Methods
    This study uses a longitudinal (cohort) design beginning
    at birth. Mothers of infants born 35 weeks gestational
    age with birth weights 2250 g were mailed 10 questionnaires at approximately monthly intervals during
    the rst year. Although 3033 mothers completed neonatal questionnaires, only 1899 motherinfant pairs provided valid weight and feeding data to be included in
    the analysis.

    114

    Evidence-Based Medicine June 2013 | volume 18 | number 3 |

    Commentary
    The major strengths of this study include its longitudinal
    design and its sophisticated statistical analysis, which
    takes into account the repeated observations in the
    infants, the shape of the weight curve as a function of
    age, and a variety of potentially confounding covariates.
    The analytic model does not, however, adjust for regression to the mean: the tendency of infants who are
    heavier at the start of an interval to gain less weight
    during that interval.
    Like most previous authors, Li et al assume that
    associations between infant feeding and growth reect
    causal effects of the former on the latter. The fact that
    babies fed with bottles, even bottles containing breast
    milk, gained weight more rapidly than those receiving
    breast milk only from the breast does not necessarily

    Prognosis
    mean, however, that the bottles caused the infants to
    gain more weight.
    Infant feeding is a dynamic process determined largely
    by the infants demand and the mothers supply. The
    larger the demand, the greater the potential supply,
    because the infants suckling stimulates maternal milk
    production. Infants who are growing along a slower trajectory may well be satised with breastfeeding only, do not
    get hungry between breastfeedings, and thus are less likely
    to receive a bottle.1 In other words, the authors have not
    considered the reverse causality relationship: faster growth
    may lead to bottle feeding, rather than bottle feeding
    leading to faster growth. Indeed, we have shown that a
    randomised controlled trial (RCT) of a breastfeeding promotion intervention yields very different results for infant
    growth when analysed by intention to treat (as randomised) than when analysed observationally (as fed).2
    It is difcult to study the receipt of breast milk via
    bottle versus breast using an RCT. Some mothers will be
    unwilling to bottle-feed their infants, others will be
    unwilling to proscribe the use of bottles if they seem
    needed, and many will be unwilling to accept randomisation. Until RCT evidence is produced, however,
    attempts to replicate these ndings in other cohorts
    would be worthwhile. Animal studies could shed light
    on possible biological mechanisms, if faster growth is
    observed in those who receive bottle feeding.

    Breastfeeding is superior to formula feeding with


    respect to risks of gastrointestinal and respiratory infection, atopic dermatitis in infancy, necrotising enterocolitis in preterm infants, and sudden infant death
    syndrome, as well as long-term neurocognitive development.3 4 Benets for the mother include prolonged
    contraception and reduction in future risk of breast
    cancer and perhaps ovarian cancer.3 Which of these
    health benets for the mother and child depend on
    breastfeeding or also accrue to infants who receive
    breast milk by bottle remains an open question.
    Competing interests None.
    References
    1. Kramer MS, Moodie EEM, Dahhou M, et al. Respond to
    Causation or noitasuaC? Am J Epidemiol 2011;173:
    9889.
    2. Kramer MS, Guo T, Platt RW, et al. Breastfeeding and infant
    growth: biology or bias? Pediatrics 2002;110:3437.
    3. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal and
    infant health outcomes in developed countries. Evidence Report/
    Technology Assessment No. 153. Rockville, MD: Agency for
    Healthcare Research and Quality. AHRQ Publication No.
    07-E007, April 2007.
    4. Kramer MS, Aboud F, Mironova E, et al. Breastfeeding and
    child cognitive development: new evidence from a large
    randomized trial. Arch Gen Psychiatry 2008;65:57884.

    Evidence-Based Medicine June 2013 | volume 18 | number 3 |

    115

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