Clinical Lactation

Breastfeeding is a physical function for mothers and infants. The societal relevance ought to be undoubted en as a medical discipline it should belng among the highest ranked, for its population (all newborn children!) is huge. In daily practice the knowledge of human lactation and the counseling of breastfeeding dyads amongst medical and nursing health professionals is on average rather low. Many advices and treatments are not based on scientific evidence, but on tradition, hear-say and the influences of pharmaceutical and infant formula industries. And this is not so for a lack of available  scientific knowledge. Most medical and nursing professional journals do publish about breastfeeding research and even more knowledge surrounding human lactation and breastfeeding counseling is published in specialized peer reviewed lactation journals. Today I would like to highlight some articles from the Fall, 2010 issue of Clinical Lactation. Genna, Walker and Kendall-Tackett are great names in lactation science. They write about breastfeeding as the norm in feeding and caring for infants and young children. Kendall-Tackett addresses sense and non-sense in her article about safe-sleep campaigns, and stresses that it is not sharing a bed with a parent that raises SIDS risks, but other factors, mostly a combination of factors. Walker discusses the special needs late-premature infants have and the special care breastfeeding them is needed for breastfeeding counseling. Genna addresses the importance of maternal and infant positions in order to facilitate the baby to use his hands in finding the breast and latching on.
Kathleen Kendall–Tackett, Zhen Cong, Thomas W. Hale: Mother–Infant Sleep Locations and Nighttime Feeding Behavior; U.S. Data from the Survey of Mothers’ Sleep and Fatigue. Clinical Lactation Vol. 1, Fall 2010
Marsha Walker: Breastfeeding Management for the Late Preterm Infant; Practical Interventions for “Little Imposters”. Clinical Lactation Vol. 1, Fall 2010
Catherine Watson Genna, Diklah Barak: Facilitating Autonomous Infant Hand Use During Breastfeeding. Clinical Lactation Vol. 1, Fall 2010.

Research and development

Research around the health outcome effects of certain interventions follows a certain structure an complicated mathematics to diminish the influence of  ‘’confounding factors’’ on the study findings, in order for the researcher to be sure it is his intervention that made the difference. SES (socio-economic situation) and education level are well known and often used variables used to dim study-results. Result from targeted studies comparing results from developing and developed countries show that these variables are not as stable and sure as they are traditionally accounted for. A large-scaled study by Brion et al Compared results from studies varying countries with different SES and educational structures about the influence of breastfeeding on blood pressure, obesity and diabetes in children. In more developed countries A higher SES was positively correlated to higher breastfeeding rates, but not in less developed countries. In developed countries a clear positive correlation was found between breastfeeding and lower blood pressure, better BMI’s and higher IQ’s, but in less developed countries this was only true for breastfeeding and higher IQ. IQ positively turns out to be not only a matter of inherited benefits, but of infant feeding choices as well. And evenly evident it seems to be that besides and after breastfeeding BMI and blood pressure in later life are influenced by more than infant feeding alone. The COHORTS study revealed amongst others that in the developing countries participating in these studies breastfeeding or not hardly has any measurable influence on blood pressure, obesity and diabetes later in life. The researchers point out that more research, that fine-tunes the categories of ‘’ever or never breastfed’’, duration of breastfeeding and of exclusive breastfeeding might change these findings. In many developing countries breastfeeding incidence is high, but breastfeeding duration and more so duration of exclusive breastfeeding may be quite low.
Brion M-JA, Lawlor DA, Matijasevich A, Horta B, Anselmi L, Araújo CL, Menezes AMB,
Victora CG, Smith GD:  What are the causal effects of breastfeeding on IQ, obesity and blood pressure? Evidence from comparing high-income with middle-income cohorts Int. J. Epidemiol. (2011) dyr020 first published online February 24, 2011
Fall CHD, Borja JB, Osmond C, Richter, Bhargava SK, Martorell R, Stein AD, Barros FC, Victora CG, and the COHORTS group: Infant-feeding patterns and cardiovascular risk factors in young adulthood: data from five cohorts in low- and middle-income countries Int. J. Epidemiol. (2011) 40(1): 47-62 first published online September 17, 2010

Growth, overweight and menarche

According to Kramer c.s. of the large PROBIT study (Belaraus) children who are breastfed show slower growth than those who are not (however it would be more correct to phrase this as ‘’children who are not breastfed will grow faster than breastfed children or even grow too fast). The fact that parents, too, will compare the growth of their breastfed infants with the growth of their formula fed counterparts, may according to the researchers lead to the phenomenon of starting earlier than planned with formula supplements or weaning to formula altogether. ‘’More is better’’ seems to be a well-established adagio in both health care providers and parents, but in the case of body weight this may very well be untrue. Several studies have linked a higher body weight in young girls to early onset of puberty. Early puberty exposes girls to an increased risks of prolonged exposure to estrogens. Duration of breastfeeding and of exclusive breastfeeding, too, are linked to the age at menarche. It is possible that more than breastfeeding per se, the role of breastfeeding in weight gain as infant and the effect of not breastfeeding on obesity in pre-puberal children is the central factor in this theme.
Kramer MS, Moodie EEM, Dahhou M, Platt RW: Breastfeeding and Infant Size: Evidence of Reverse Causality Am. J. Epidemiol. (2011) first published online March 23, 2011
Al-Sahab B, Adair L, Hamadeh MJ, Ardern CI, Tamim H: Impact of Breastfeeding Duration on Age at Menarche Am. J. Epidemiol. (2011) kwq496 first published online March 23, 2011 
Terry MB, Ferris JS, Tehranifar P, Wei Y, Flom JD: Birth Weight, Postnatal Growth, and Age at Menarche Am. J. Epidemiol. (2009) 170(1): 72-79 first published online May 13, 2009

Is breast best?

(Photo: my dog Dora and her first and only litter)

Does breastfeeding make smarter kids? Does breastfeeding cause less infection? Are breastfed children less often and less severe ill? No. Doesn’t breastfeeding have any benefits then? No, that’s right: breastfeeding does not have any benefits. Breastfeeding can not have benefits, because it is the norm for feeding, nurturing and protecting newborns and children in their first years of life. Biologically speaking, humans are mammalians. Most significant feature of mammalians is that the young are fed from the mammae (milk secreting glandular tissue clusters) of their mothers for a certain amount of time following birth. In the course of hundreds of thousands of years of evolution this has become a tried and proven  system, which has led to, amongst others, the great overall success of mammalian species. Part of this perfection is specialization: the lactation process and the composition of milk are fine tuned to the specific needs of the young of each single species. The duration of the lactation period, for example is linked to the eruption of teeth: many mammalians start eating other foods besides milk around the time the first teeth start erupting and drink their last drops of milk around the time the teeth start changing. The composition of milk is related to the way the young are cared for and the needs for developing systems that are crucial for the survival of the species. Species who leave their young in nests provide milk low in water, but very high in energy and protein; carriers on the other hand feed their young with milk high in water and milksugar, but very low in protein. Animals who need to run with the herd get milk with lots of protein and calcium, while species who survive because they’re smarter than others provide their young with nutrients that promote mind-development. Being breastfed by his own mother, or at least a mother from his own species, is essential for every young animal, inclusing the human. Breastfeeding is not an added bonus; non-breastfeeding is the deprivation of a basic need. Non-breastfeeding has disadvantages.

Just milk

Breastfeeding is the most elaborate gift a mother can ive her child: it’s fluid love, food, nurturing and protection; medication and vaccination; developmentl support for body and mind. Throughout history and the world to be breastfed or not could mean life or death. And still, breastfeeding is just a bodily function and a mother’s milk is just milk. Breastfeeding is ultimately special and very normal. Mom’s milk is a magical substance and still just milk. That can make things difficult to understand for moms and others. Breastfeeding extraordinary extra-special and still there this woman is nursing in the train; mom’s milk is almost as sacred as church-wine and still that mom makes pancakes with it. Much has been said about what can or may or should or not be done with human milk and most of it is based on nothing. Guidelines for mom’s milk storage are just the same guidelines used for all protein rich foods and those ignore the magical powers (pro-active pathogen attackers) of fresh human milk. It is ‘’forbidden’’ to cook with mother’s milk, that will destroy the previously ignored protective powers in it, while not taking into account that in the end it’s just milk that can be used in almost every recipe calling for milk. (Note: it is not a good idea to boil all milk a child will have, because than indeed he will suffer from insufficient protection!). Oh, and do remember moms: do not run, twist or jump, because your milk may never been shaken, because that just might break down the proteins. Does anyone worry about broken down proteins in their cappuccino’s?
http://eurolacen.blogspot.com/2011/04/human-milk.html

Protection for mother and child

In this issues some fragments from a Unicef document about the effect of infant feeding choice on the survival chances of children and women’s health. Unicef states: ‘’Breastfeeding Saves More Lives Than Any Other Preventive Intervention’’. And this is not only true in the developing world, but in our rich Western society as well. ‘’Non-breastfed children in industrialized countries are also at greater risk of dying - a recent study of post-neonatal mortality in the United States found a 25% increase in mortality among non-breastfed infants. In the UK Millennium Cohort Survey, six months of exclusive breast feeding was associated with a 53% decrease in hospital admissions for diarrhoea and a 27% decrease in respiratory tract infections.’’ Unicef cooperated with the WHO in formulating recommendations for optimal breastfeeding: ‘’Initiation of breastfeeding within the first hour after the birth; exclusive breastfeeding for the first six months; and continued breastfeeding for two years or more, together with safe, nutritionally adequate, age appropriate, responsive complementary feeding starting in the sixth month.’’ Formula is not an acceptable substitute for breastmilk because formula, at its best, only replaces most of the nutritional components of breast milk: it is just a food, whereas breast milk is a complex living nutritional fluid containing anti-bodies, enzymes, long chain fatty acids and hormones, many of which simply cannot be included in formula.  Furthermore, in the first few months, it is hard for the baby’s gut to absorb anything other than breastmilk. Even one feeding of formula or other foods can cause injuries to the gut, taking weeks for the baby to recover.‘’  The major problems for living up to the recommendations to exclusively breastfeed fo 6 months and continue for 2 years or more are the societal and commercial pressure to stop breastfeeding, including aggressive marketing and promotion by formula producers. ‘’These pressures are too often worsened by inaccurate medical advice from health workers who lack proper skills and training in breastfeeding support. In addition, many women have to return to work soon after delivery, and they face a number of challenges and pressures which often lead them to stop exclusive breastfeeding early.’’ Mothers and children need protection: children by being breastfed and mothers from being pressured to quit breastfeeding and from having to take hurdles and barriers to breastfeed.
http://www.unicef.org/nutrition/index_24824.html

Unwanted ingredients

Although breastfeeding and human milk are the furst choice for the nurturing, protection and feeding of infants, many parents choose to use substitutes to feed and nurture. The infant food industry happily jumps in on this trend by broadly marketing their product to be ‘’even better now’’ and ‘’most like human milk’’ (makes you wonder how inferior the previous variations were). Ingredient after ingredient of human milk is researched and (if not to difficult and pricey to duplicate) added to the human milk substitute. Infant formulas nowadays contain quite some of the hundreds of ingredients of human milk and is more or less suitable to supply the basic nutrition needs of infants. But the basic ingredients used and the methods used also unwanted and not-asked for (and not appearing on the labels) ingredients will end up in the powder. Minerals and spores that need to be in the milk may appear in unwanted-high quantities. A Scandinavian study by Ljung et al found that a serving of human milk substitute contained significant more Fe, Mn, Mo, As, Cd, Pb and U than one feeding of breast milk, but less Ca, Cu and Se. Rice-based products in particular contained elevated As concentrations. Drinking water used to mix powdered formula may add significantly to the concentrations in the ready-made products. Evaluation of potentially adverse effects of the elevated element concentrations in infant formulas and foods are warranted. In Italy, Meucci c.s. studied samples of the leading brands of infant formula milks and meat-based infant foods commonly marketed in Italy to determine the concentrations of zearalenone and its metabolites (zearalenone is a yeast-toxin of the fusarium species, which is slightly toxic, possibly carcinogenic and has estrogenic charateristics). This study shows the presence of mycoestrogens in infant (milk-based and meat-based) food, and this is likely to have great implications for subsequent generations, suggesting the need to perform occurrence surveys in this type of food.
Ljung K, Palm B, Granderm, Vahter M: High concentrations of essential and toxic elements in infant formula and infant foods - A matter of concern. Food Chemistry, 2011, 127(3):943-951.
Meucci V, Soldani G, Razzuoli E, Saggese G, Massart F: Mycoestrogen Pollution of Italian Infant Food. The Journal of Pediatrics, In Press, Corrected Proof, Available online 10 March 2011.