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GOES
Breast FeedingCape Town Sept-Oct 2015
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“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
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Breast Milk
Functional food
Living food
Dynamic food
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Composition of Breast Milk
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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
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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
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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
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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
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Average composition of goat, sheep, cow, and human milk
High digestibility
Suited for human baby growth
Antibacterial
Immune protection and immune modulation
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• High content of whey
• Bile-salt stimulated lipase
• Lactoferrin
• Haptocorrin (B12 binding protein)
• Folate-binding protein
• Lactalbumin
Human milk protein propertiesDigestion
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Human milk protein propertiesAntimicrobial activity
Immunoglobulins
Lysosyme
Lactoferrin
BSSL
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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
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Breast Milk: epigenetic effects
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Advantages of BF
Advantages to infant
Advantages to mother
Cheep and clean
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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
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• 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
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Breastfeeding
Initiation of BF, problems
Exclusive BF for 6 months
Any BF advantage for baby and mother
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Initiation of Breastfeeding
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Breast feeding initiation rates (2001-2009)Initiation of BF Initiation of BF, 2009
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All cause mortality LBW all cause mortality Infections mortality
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Barriers to BF initiation
Related to mother and baby education and health status
Related to staff workload and education
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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).
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Baby Friendly HospitalInitiative (UNICEF-WHO)
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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
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Duration of EBF
EBF from 0-5 months, 2006
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Exclusive breast feeing at 4 months (Unicef Data; BMJ 2008;336:881-7)
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EBF Africa 2009 who statistics
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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
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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.
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Exclusive breastfeeding prevalence trends
in selected countries, 1990 to 2010.
Disability Adjusted Life Years (DALYs) lost in 2010
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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
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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)
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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)
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J Pediatr 2014
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42 countries with 90% of worldwidechild deaths in 2000
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42 countries with 90% of worldwidechild deaths in 2000
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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
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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
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• 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%
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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
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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
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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
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Breastfeeding is associated with better cognitive development compared to formula feeding.
Hoefer C & Hardy MC. JAMA 1929; 92: 615-20
Mental Development
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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
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Mortensen EL, et al. JAMA 2002;287:2365-71
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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
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• 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)
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Caspi A, et al. PNAS, Nov. 2007
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Krol KM, et al. 2015
Longer breastfeeding duration is associated with a happy bias, whereas shorter breastfeeding duration is associated
with a fear bias
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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.
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Democratic Republic of Congo
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Democratic Republic of Congo
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