Breast Feeding. Raanan Shamir, MD. ESPGHAN Goes Africa Capetown, October 2013

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1 Breast Feeding Raanan Shamir, MD ESPGHAN Goes Africa Capetown, October 2013

2 Learning objectives Human milk Available meta-analyses Mental Development Protection, promoting and supporting ESPGHAN recommendations

3 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

4 Breast milk is the natural food for infants and is the optimal exclusive food for infants up to the age of 6 months

5 Composition of Breast Milk Whey 20% Protein fractions (%) Whey 60% Casein 40% Casein 80% Whey lactoferrin immunoglobulins serum albumin ß-lactoglobulin α-lactalbumin Casein κ-casein γ-casein ß-casein α-casein 10 0 Human Milk Cow s Milk Comparison of protein fractions from human and cow s milk

6 Composition of Whey Protein Breast Milk Cow s Milk Alfa-Lactabumin 40% of protein 20% Beta-Lactalbumin 45% Lactoferrin 25% Trace Lysozyme 7% Trace Immunoglobulines 15% 10% 95% IgA 90% IgG

7 Variation in human milk content Colostrum Transitional Mature D1 D14 D30+ Volume (ml) Fat (g/l) Protein (g/l) Sodium (mg/l) From Kung, et al. Clin Perinatol 1 999

8 Variation in human milk content 3 mo 14 mo CHD (g/dl) NS Fat (g/dl) NS Protein (g/dl) p<0.01 Calcium (mg/dl) p<0.001 Sodium (mg/dl) NS Insulin (microu/ml) NS From Shehadeh and Shamir, J Pediatr 2006 During lactation, between lactations, between women, and over time

9 Human milk protein properties Digestion Bile-salt stimulated lipase Lactoferrin Haptocorrin (B 12 binding protein) Folate-binding protein α Lactalbumin

10 Human milk protein properties Antimicrobial activity Immunoglobulins Lysosyme Lactoferrin BSSL K-casein Lactoperoxidase Haptocorrin α Lactalbumin

11 Human milk protein properties Cytokines IL β 1 IL 6 IL 8 IL 10 TGF β

12 Human milk protein properties Growth factors IGF1 IGF2 EGF Insulin Lactoferrin

13 Hormones in Human milk Insulin Cortisol Thyroxin IGF I EGF TGF-α TGF-β, 1&2 Nerve growth factor Estrogen Gastric inhibitory polypeptide Gastric releasing peptide Somatostatin Vasoactive intest. polipeptide Motilin

14 Influence of Maternal Diet on Breast Milk Severely malnourished mothers: production of milk Influence of the diet on the composition : vitamin D, vitamin A, water soluble vitamins, iodine, FA Vegetarian lactating mother: no supplementation Vegan lactating mother: supplementation with vitamin B 12

15 ESPGHAN Comment on BF. JPGN 2009

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17 Prevention of Disease in Adults: Summary of AHRQ Results 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%

18 AHRQ Evidence Report (2007) Benefit for mothers Women who breastfed their infants had up to a 12% reduced risk of type 2 diabetes for each year they breastfed. Decreased the risk of ovarian cancer by up to 21% Decreased the risk of breast cancer by up to 28% in those whose lifetime duration of breastfeeding was 12 months or longer.

19 AHRQ Evidence Report (2007) Benefit for mothers Women who did not BF were more likely to have postpartum depression, but unmeasured factors, such as depression that was undiagnosed prior to giving birth, may have increased depression rate seen in this group. BF did not increase the risk of fractures due to osteoporosis. The effect of BF on a woman s weight could not be determined based on the available studies.

20 During active infection in BF infants, total # of WBC, specifically, macrophages, and TNFα levels increase in their mothers breast milk. Although possibly related to maternal stress, these results may support the dynamic nature of the immune defense provided by BF sick infants. Riskin A, et al. Ped Res 2012

21 Food Nutr Res 201 3

22 Convincing evidence Overweight & Obesity in childhood and adolescence Overall infections Acute otitis media GI and respiratory tract infections Probable evidence Protects from celiac disease, IBD, T1DM, T2DM Beneficial effect on IQ and developmental scores Small reduction of blood pressure in adulthood Small reduction of blood cholesterol in adulthood BF> 4mo. Assoc. with slower wt gain in 2 nd half of the 1 st year Food Nutr Res 201 3

23 Strength of evidence for improved health outcomes Maternal Health Outcomes Strong or casual evidence Post partum weight loss Lactational amenorrhea Breast cancer Maternal Health Outcomes Evidence in development Ovarian cancer Type 2 Diabetes CVD Bonding Dieterich CM, et al. Pediatr Clin North Am. December 201 2

24 What is the rate of breast feeding world wide?

25 Breast feeding initiation rates ( )

26 Baby Friendly Initiative (UNICEF-WHO)

27 PROBIT Study (Promotion of Breastfeeding Intervention Trial) 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%

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

29 Percentage of infants and children meeting recommended breast feeding practices. Lutter CK, et al. Science, 21 September 201 2

30 Optimal duration of exclusive breast feeding? GI Infections, developing 4-6 mo Kramer and Kakuma. Cochrane 201 2

31 GI Infections, developed mo Kramer and Kakuma. Cochrane 201 2

32 Hospitalization for respiratory infections, developed 12 mo Kramer and Kakuma. Cochrane 201 2

33 Otitis media, developed mo Kramer and Kakuma. Cochrane 201 2

34 Hemoglobin concentration, developing 4-6 mo Kramer and Kakuma. Cochrane 201 2

35 Infants breastfed exclusively for 6 months have a reduced risk of gastrointestinal infection and no observable deficits in growth No benefits of introducing complementary foods between four and six months have been demonstrated, with the exception of improved iron status in one developing-country setting (Honduras). Kramer and Kakuma. Cochrane 201 2

36 Mental development Breastfeeding is associated with better cognitive development compared to formula feeding. Hoefer C & Hardy MC. JAMA 1929; 92:

37 Mental development Anderson JW, et al. AJCN 1999;70: 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

38 Mortensen EL, et al. JAMA 2002;287:

39 Are 5-6 points important? % with sub-optinmal (<90) Full Scale WAIS IQ score

40 Is it true? (better IQ) Summary of studies that controlled for maternal IQ and other confounders as indicated.

41 Hypothesis: PNAS, Nov Breastfed children attain higher IQ scores than children not fed breast milk, presumably because of the fatty acids uniquely available in breast milk FADS2 is an attractive candidate gene because of its role in the modification of dietary fatty acids (located on chromosome 11q12.2, encodes the delta-6 desaturase that is the rate-limiting step on the metabolic pathway leading to AA and DHA production.)

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43 Steer CD, et al. Plos One 201 0

44 JAMA pediatrics Prospective cohort study (Project Viva), a US prebirth cohort that enrolled mothers from 4/99-7/2002, Followed up children to age 7 years, including 1312 Project Viva mothers and children. MAIN EXPOSURE: Duration of any breastfeeding to age 12 months. MAIN OUTCOMES AND MEASURES Receptive language (3y) Assessment of Visual Motor Abilities at ages 3 & 7 Kaufman Brief Intelligence Test and Wide Range Assessment of Memory and Learning at age 7 years.

45 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 per week (0.24 points/mo/bf compared with less than 2 servings of fish per wk (-0.01 points/mo/bf) Belfort MB, et al. JAMA pediatrics 201 3

46 Verbal IQ Difference Duration of BF (Mo.) Results support causal relationship of BF duration with receptive language and intelligence later in life.

47 Arch Dis Child 2013 In 2 cohorts (n= 17419) BF increased the odds of upward social mobility and decreased the odds of downward mobility

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49 «In industrialized countries, there is at present no scientific evidence that introducing complementary foods to breast-fed infants between 4 and 6 months of age is a disadvantage relative to introduction after 6 months».

50 «EBF for around 6 months is a desirable goal, but partial BF as well as BF for shorter periods of time are also valuable. BF should be continued by mother and child as long as mutually desired, and must be based primarily on considerations other than healtrh outcomes.»

51 ESPGHAN Comment on BF JPGN 2009 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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