GOES

Breast FeedingCape Town Sept-Oct 2015

“Formula milk is just a food, whereas breast milk is a complex

living nutritional fluid that contains antibodies, enzymes, and hormones,

all of which have health benefits”

Hoddinott P, et al. BMJ 2008;336:881-7

Breast milk is the natural feed for infants and is the optimal exclusive food for infants up

to the age of 6 months

Breast Milk

Functional food

Living food

Dynamic food

Composition of Breast Milk

Comparison of protein fractions from human and cow’s milk

0

10

20

30

40

50

60

70

80

90

100

Human Milk Cow’s Milk

Whey 60%

Casein 40%

lactoferrinimmunoglobulinsserum albumin ß-lactoglobulin-lactalbumin

Whey

-casein-caseinß-casein-casein

Casein

Casein 80%

Whey 20%

Prot

ein

fra

ctio

ns (

%)

Composition of Breast Milk

Alfa-Lactabumin 40% of protein 20%

Beta-Lactoglobulin - 45%

Lactoferrin 25% Trace

Lysozyme 7% Trace

Immunoglobulines 15% 10%

95% IgA 90% IgG

Breast Milk Cow’s Milk

Composition of Milk Whey Proteins

Colostrum “Transitional “ Mature

D1 D14 D30+

Volume (mL) 56 668 726

Fat (g/L) 21 39 40

Protein (g/L) 31 9 8

Sodium (mg/L) 810 370 340

Dynamic FoodVariation in human milk content

From Kung, et al. Clin Perinatol 1999

During lactation, between lactations, between women, and over time

3 mo 14 mo

From Shehadeh and Shamir, J Pediatr 2006

CHD (g/dL) 7.6 7.6 NSFat (g/dL) 3.6 3.7 NSProtein (g/dL) 1.2 1.0 p<0.01Calcium (mg/dL) 26 21 p<0.001Sodium (mg/dL) 16 17 NSInsulin (microU/mL) 44 43 NS

Variation in human milk content

Average composition of goat, sheep, cow, and human milk

High digestibility

Suited for human baby growth

Antibacterial

Immune protection and immune modulation

• High content of whey

• Bile-salt stimulated lipase

• Lactoferrin

• Haptocorrin (B12 binding protein)

• Folate-binding protein

• Lactalbumin

Human milk protein propertiesDigestion

Human milk protein propertiesAntimicrobial activity

Immunoglobulins

Lysosyme

Lactoferrin

BSSL

Human milk protein propertiesCells, Cytokines, Growth factors, Hormones

• IL 1• IL 6• IL 8• IL 10• TGF

IGF1 IGF2 EGF Insulin LactoferrinNerve GF

EstrogenGastric inhibitory PPGastric releasing peptideSomatostatinVasoactive intestinal PPMotilin

Immune cells: leucocytes, monocytes,macrophages, neutrophils, T and B lymphocytes

Breast Milk: epigenetic effects

Advantages of BF

Advantages to infant

Advantages to mother

Cheep and clean

Bulletin of the World Health Organization 2013;91:398-406

• BF is beneficial to the health of both women and infants• BF lowers the risk of diarrheal disease by X 4-14 and the

risk of respiratory illness by X 5• Women who breastfeed have lower rates of breast

cancer rates before menopause and potentially lower risks of ovarian cancer, osteoporosis and coronary heart disease.

WHO recommends exclusive breastfeeding for at least 6 months

• Studies around the world in affluent and poor nations alike have shown a 1.5- 5 fold decrease in mortality among breastfed infants

• Breastfeeding has also been associated with lower rates of chronic diseases such as diabetes, and inflammatory bowel disease and with improved neurocognitive development

Bulletin of the World Health Organization 2013;91:398-406

Breastfeeding

Initiation of BF, problems

Exclusive BF for 6 months

Any BF advantage for baby and mother

Initiation of Breastfeeding

Breast feeding initiation rates (2001-2009)Initiation of BF Initiation of BF, 2009

All cause mortality LBW all cause mortality Infections mortality

Barriers to BF initiation

Related to mother and baby education and health status

Related to staff workload and education

Likely to achieve EBF

Married

Multipara

BF within 1 hour of birth

No supplemental feedings or pacifiers

Less likely to achieve EBF

Obese

Smoking

Absence of supplemental feedings remained significant (adjusted OR= 2.3, 95% CI= 1.8, 3.1).

Baby Friendly HospitalInitiative (UNICEF-WHO)

Exclusive Breast Feeding

WHO and the American Academy of Pediatrics, recommends that breastfeeding should be

exclusive for about the first six months of lifeand should continue, with the introduction of

appropriate complementary foods,to at least age 12 months or beyond,

as desired by mother and child

Duration of EBF

EBF from 0-5 months, 2006

Exclusive breast feeing at 4 months (Unicef Data; BMJ 2008;336:881-7)

EBF Africa 2009 who statistics

Percentage of infants and children meeting recommended breast feeding practices.

Lutter CK, et al. Science, 21 September 2012

46 low- and middle-income countries between 2002 and 2008

Absolute Change in EBF rates up to 6 months in Developing Countries 1990-2010

Global trend in breastfeeding behaviors in children under six months, 1990 to 2010.

Exclusive breastfeeding prevalence trends

in selected countries, 1990 to 2010.

Disability Adjusted Life Years (DALYs) lost in 2010

Roberts TJ, et al. BMC Medicine 2013

Disease burden due to suboptimal BF in 2010, as measured by % total child DALYs attributable to suboptimal breastfeeding

Internatioanl Breast Feeding 2013

• 624 women participated, 77% (483) from rural areas. • Prevalence of EBF up to 6 mo. was 20.7%• In multivariable analysis, advice on breastfeeding after delivery

(Adjusted odds ratio, AOR = 2.6, 95% CI 1.5, 4.6) was positively associated with EBF up to 6 mo.

• Less EBF up to 6 mo.:• Single mothers (AOR = 0.4, 95% CI 0.2, 0.9)• Mothers who drank alcohol (AOR = 0.4, 95% CI 0.3, 0.7)

Belarus

17,046 breast-fed infants of whom 81.5% followed up to 6.5 years

Rate of exclusive breastfeeding at 3 months: 43.3% vs 6.4%

PROBIT Study(Promotion of Breastfeeding Intervention Trial)

J Pediatr 2014

42 countries with 90% of worldwidechild deaths in 2000

42 countries with 90% of worldwidechild deaths in 2000

What’s the math about EBF ?

Duration of BFReduction riskDisease

EBF > 3 months50%AOM

EBF > 6 months65%URTI

EBF > 4 months72%LRTI

NICU stay58%, 77%NEC

EBF > 3 months27% , 42%AD

EBF or mixed > 3 months26%Asthma

Any BF advantage Duration of BFReduction riskDisease

Any BF25%AOM

Any BF64%AGE

Any BF31%IBD

Any BF7%, 24%4% risk reduction/m BF

Obesity

BF2 months52%Celiac

Any BF> 3 months19%T1DM

Any BF40%T2DM

Any BF > 6 months30%Leukemia

BF > 1 months38%SIDS

<1.5 mm Hg in sBP and <0.5 mm Hg in dBPHypertension

0.18 mmol/l and 0.2 mmol/l reduction in TC, LDL-CCholesterol levels

Any BF >1 month (MD 4.9, 95% CI 2.97 to 6.92)Cognitivedevelopment

• Systolic BP 1.5 mmHg• Diastolic BP 0.5 mmHg• TC 7 mg/dL• LDL-C 7.7 mg/dL• T1DM 19-27%• T2DM 39%• Overweight 7-24%

In PROBIT, at the age of 11.5 years, improving BF duration & exclusivity among healthy term infants did not influence cardiometabolic risk factors in childhood

No difference in systolic or diastolic BP, glucose, insulin, Apo A1 and adiponectin

Dieterich CM, et al. Pediatr Clin North Am. December 2012

Infant Health Outcomes

Evidence conflictingStrong or casual evidence

Cognitive developmentGI tract infection

Atopic diseasesUpper and lower TRI

Other cancersOtitis media

ObesityALL

SIDS

Strength of evidence for improved infants’ health outcomes

Dieterich CM, et al. Pediatr Clin North Am. December 2012

Maternal Health Outcomes

Evidence less strongStrong or casual evidence

Ovarian cancer (22%)Post partum weight loss

Type 2 Diabetes (12% )Lactational amenorrhea

CVDBreast cancer (28%)

Bonding

Hypertension (11%)

Hyperlipidemia (19%)

CVD (10%)

Strength of evidence for improved mothers’ health outcomes

Breastfeeding is associated with better cognitive development compared to formula feeding.

Hoefer C & Hardy MC. JAMA 1929; 92: 615-20

Mental Development

Results:

• Of 20 studies meeting initial inclusion criteria, 11 studies controlled for > 5 covariates and presented unadjusted and adjusted results.

• An unadjusted benefit of 5.32 (95% CI: 4.51, 6.14) points in cognitive function was observed for breast-fed compared with formula-fed children

Anderson JW, et al. AJCN 1999;70:525-35

Mortensen EL, et al. JAMA 2002;287:2365-71

Peabody Picture Vocabulary Test

Kaufman Brief Intelligence Test

At age 7 years, the effect size of 0.35 verbal IQ points per month of any breastfeeding translates to 4.2 points

• Beneficial effects of BF on the Wide Range Assessment of Visual Motor Abilities at age

3 years seemed greater for women who consumed 2 or more servings of fish/ week• (0.24 points/mo/BF compared with less than 2

servings of fish per wk (-0.01 points/mo/BF)

Caspi A, et al. PNAS, Nov. 2007

Krol KM, et al. 2015

Longer breastfeeding duration is associated with a happy bias, whereas shorter breastfeeding duration is associated

with a fear bias

While it is acknowledged that parents are responsible for decisions on breast feeding of their infants, the role of health care workers, including paediatricians, is to protect, promote, and support breastfeeding.

Democratic Republic of Congo

Democratic Republic of Congo