Evidence of breastfeeding the newborn are well-supported in research to possess innumerable health benefits for infants and is associated with incidence of fewer diseases. The breastfeeding rate according to the Centers of Disease Control was 76.9% of births in 2009, but unfortunately, not all mothers breastfeed. If there is no strong contraindication, breastfeeding should be done for a minimum of 6 months, but ideally one year or longer. According to the Centers of Disease Control (CDC) children who are not breast-fed are at higher risk for diabetes, eczema , obesity, lung infections, ear infections, and require more clinic visits, medication, and admissions to the hospital. The information expressed here should disperse a mother’s hesitation to breastfeed a newborn. We cover baby nutritional needs.
American Academy of Pediatrics (AAP) breastfeeding recommendations (1):
Duration of breastfeeding: As of March 1, 2012 the American Academy of Pediatrics (AAP) continued to recommend exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.
Oral supplementation of vitamin D:
According to the CDC, breast milk alone does not provide infants with an adequate intake of vitamin D. Oral supplementation of vitamin D (400 U/day) is recommended for all breastfed infants starting when they first leave the hospital.
Fluoride supplementation:
Babies should not be given fluoride supplementation until the age of 6 months. From the age of 6 months to 3 years, fluoride supplementation is recommended only if local fluoride water concentration is low (<0.3 ppm).
Iron and zinc rich foods:
Iron and zinc rich foods should be given starting at the age of 6 months. If iron is low, then oral iron drops may be given before the age of 6 months.
Premature infants:
Premature babies should be given multivitamins and iron supplements until they are consuming a mixed diet and other body systems are normal.
When not to breastfeed or use breast milk:
Conditions for which to avoid breastfeeding infants: There are a number of conditions that should be mentioned in which infants should not be breastfed. Avoid all medications prior to breast feeding unless known to be safe and after seeking guidance from the obstetrician. Mothers should obtain guidance/approval from the obstetrician for any infections prior to breastfeeding including (but not limited to) varicella (chicken pox virus), herpes zoster virus (shingles), HIV, hepatitis, influenza, human T-lymphotrophic virus, herpes simplex virus, and tuberculosis. Pregnant mothers are usually screened as a standard of care for most of these infections during pregnancy by the obstetrician but this must not be assumed since failure of this responsibility by health care providers is possible.
Special formulas are required for some infants:
According to the World Health Organization (WHO), there are some instances where infants should not receive breast milk or any other milk except for specialized formula. Infants with galactosemia, a condition in which the body is unable to use the simple sugar galactose, need a special galactose-free formula. Infants with maple syrup urine disease, a metabolism disorder in which the body cannot break down certain parts of proteins (amino acids), require a special formula free of the following amino acides: leucine, isoleucine and valine. Additionally, infants without the ability to properly break down an amino acid called phenylalanine (phenylketonuria) need a special phenylalanine-free formula (some breastfeeding is possible, under careful monitoring). (2)
Breast feeding and type 1 diabetes mellitus:
Breast feeding and type I diabetes mellitus: Breastfeeding for at least 5 months (versus two weeks or less) and late start of bottle feeding were associated with a 29% and 20% risk reduction of type 1 diabetes, respectively. Type 1 diabetes was also found to be more frequent if the mother was older than 40 years old when giving birth, baby had a low birth weight, or if there was a family history of type 1 diabetes. Some factors that reduced diabetes risk included, current cow’s milk intake, higher social status, and a larger family. (3)
Breast feeding and type 2 diabetes mellitus:
Researchers reviewed 7 studies involving 76,744 subjects comparing later frequency of type 2 diabetes in breastfed vs. non-breastfed subjects. Breastfed individuals had a 39% lower risk of developing type 2 diabetes in adulthood. Breastfeeding was also associated with lower blood glucose and insulin concentrations than those who were formula fed. (4)
Breast feeding and autism:
Breast milk may protect against autism: It was suggested by a study called Autism and Diet by M. Potts et al that breast feeding may protect against the development of autism. The cause of autism has been in public debate for decades. Latest studies by the School of public Health, University of California, Berkeley, USA, show links between stomach and intestinal diseases and autism. In the study, children with autism displayed unusual eating patterns such as lower appetites, being picky eaters, and having digestive problems. Links between diet and autism are thought to be a possible cause, warranting additional investigation. For now, it is suggested that breast feeding may protect against the development of autism. Breast feeding has been linked to lowering the risks of pneumonia and bronchiolitis, two illnesses correlated with autism. Breast milk offers certain protections against these illnesses, and may also lower the risks of autism. (5)
Breast milk vs. formula and autism: Kost et al conducted a study on 90 infants who, in the first 3 months of life, were fed with either breast milk (n=37) or with formula containing cow milk (n=53). Researchers were interested in analyzing casomorphins (protein fragments, derived from the digestion of milk protein casein) levels during the first year of life. Researchers found that bovine BCM-7, a small milk opioid peptide, is present in the blood of infants fed cow’s milk formula and that the higher blood levels found in some infants correlated with delays in psychomotor development and for other diseases such as autism. Therefore the research suggests that breast feeding has an advantage over artificial feeding for infants’ development during the first year of life. (6)
Infant diet, gluten, and casein:
Infant formulas with casein, a milk protein likely has better alternatives. A hydrolyzed whey protein formula has significant benefits over casein formulas. A study found that cow milk peptides in baby’s blood were on average three times higher in babies which had a near-sudden infant death syndrome event compared with healthy infants. The peptide tested for was beta-casomorphin-7 (BCM-7) which is similar to a protein but is much smaller and can induce somnolence similar to opiate medications. This compound is able to stimulate mucin secretion and opioid receptor activation. BCM-7 is able to cross the blood-brain and can activate opioid receptors. This study confirmed that bovine BCM-7 exists in the blood of human babies BCM-7 which may be a risk factor for near-sudden infant death syndrome events compared to a group of healthy infants. (15)
It is suggested that abnormal levels of peptides by excessive opioid activity caused by the ingestion of gluten and casein may play a role in autism. Gluten is found in many common foods made from wheat, barley, rye grains or flour from these grains. Casein is a protein found in dairy products. As part of this study, several randomized clinical trials including diets free of gluten and/or casein were reviewed. One small trial out of several reviewed reported a reduction of autistic traits, but a benefit in cognitive skills, linguistic ability and motor ability was not seen. (16)
Behavior in infants with autism improved after eliminating milk and wheat intake. A study conducted on the effects of food allergies and infantile autism shows that there is a possible relationship. According to a study in Italy entitled “Food allergy and infantile autism” done at the Department of Paediatrics(sic), University of Rome Las Sapienza found that worsening neurological symptoms has been reported in autistic patients after consuming milk and wheat containing foods. In a study group of 36 autistic patients and 20 healthy controls, antibodies for milk proteins including casein, lactalbumin and beta-lactoglobulin were seen. After the elimination of these foods for an 8 week period, there was improvement in the behaviors of the autistic patients despite the fact that the milk antibodies were found to be higher in the controls. (17)
Breastfeeding and gastrointestinal tract diseases:
Gastrointestinal tract infections in infants: Gastrointestinal tract infections occurred 64% less in infants with any history of being breastfed compared to infants fed commercial formula. The reduction of risk continued for as long as 2 months after breastfeeding was stopped. (7)
Breastfeeding and inflammatory bowel disease (IBD):
A meta-analysis of 7 studies that investigated the relationship between breastfeeding and inflammatory bowel disease (IBD) demonstrated a possible protective effect for breast milk in the early development of IBD. Breastfeeding was found to have a 31% lower risk of inflammatory bowel disease in childhood. (8)
Breastfeeding, celiac disease, and gluten:
A review of 6 case-control studies found that a longer duration of breastfeeding was associated with a risk reduction of celiac disease (CD), which is an intestinal intolerance to gluten (found in wheat, rye, barley and oats). Compared to babies not breastfed, breastfeeding at the time of the introduction of gluten into the diet was associated with a 52% reduced risk of CD. (9)
Breastfeeding and necrotizing enterocolitis (NEC) in premature babies:
According to the American Academy of Pediatrics (AAP), evidence from 4 randomized clinical trials found that breast milk significantly reduces the rate of necrotizing enterocolitis (NEC), a condition where intestinal tissue dies, in premature babies by 58%. Findings from a more recent study comparing premature babies being fed only breast milk to premature babies on a combined milk diet (breast milk plus cow milk) reported a 77% reduction in NEC (associated with an exclusive breast milk diet). (1)
Breast feeding and atopic (allergic) diseases:
Breast feeding may improve risk of atopic (allergic) diseases such as asthma and atopic dermatitis (eczema). A review of breast feeding vs. formula on prevention of atopic (allergic) disease: Thygarajan A performed a review clinical trials and studies from 1980 through 2007 on the prevention of atopic (allergy related) disease in infants and children. Researched found that for infants at high risk of developing atopic disease, there is evidence that exclusive breastfeeding for at least 4 months compared with feeding intact cow milk protein formula decreases the cumulative incidence of atopic disease and cow milk allergy in the first 2 years of life. Furthermore, among babies which were breastfed or formula fed exclusively for 4 to 6 months, there is modest evidence that atopic disease may be delayed or prevented by the use of extensively or partially hydrolyzed formulas, compared with cow milk formula, in early childhood. For infants after 4 to 6 months of age, there are insufficient data to support a protective effect of any dietary intervention for the development of atopic disease. (10)
The American Academy of Pediatrics (AAP), breastfeeding and atopic disease:
The AAP expressed that at least 3- 4 months of breastfeeding is associated with a reduced rate of asthma and chronic skin disorders that involve scaly and itchy rashes (atopic dermatitis, eczema) of 27% in infants at low-risk and 42% for infants at high risk. Research examined by the AAP found conflicting data on whether the addition of food after 4 months reduces the risk of allergies (food allergies, atopic dermatitis, and asthma). Additionally, the AAP found that waiting to introduce food until after the age of 6 months has also not been proven to reduce allergies. (1)
A systematic review on whey protein formula and atopic dermatitis:
A systematic review of 18 articles assessed the evidence that 100% whey protein partially hydrolyzed formula (PHWF) may help reduce atopic dermatitis (AD), an inflammatory, non-contagious itchy skin disorder, in infants. Researchers report a significant 44% reduction in AD symptoms in infants receiving PHWF compared to infants receiving cow’s milk formula. An additional analysis of studies considered superior in methodological quality reported a 55% reduction in AD incidence in infants given PHWF. (11)
The American Academy of Pediatrics (AAP) and sudden infant death syndrome (SIDS):
The AAP has commented on the risk of SIDS. This source explained that the unexpected death of a child under age 1 was reduced by 36% in infants who were breastfed. About 21% of infant deaths in the US are thought to be due to the increase in SIDS in babies who were never breastfed. A baby’s sleeping position did not contribute to the beneficial effect of breastfeeding on SIDS. (1)
Breastfeeding and intelligence:
Kramer MS et al found that the IQ of 17,046 children whose mothers provided exclusive breastfeeding for 3 months or longer found that these children scored higher on the IQ test than those who were not breastfed (+7.5 on a verbal IQ test, +2.9 on performance IQ test, and +5.9 for full-scale IQ). Reading and writing scores assigned by teacher evaluations were also significantly better in the breastfed group. (12)
Breastfeeding and childhood obesity:
Researchers studied children and adolescents (9-19 years of age) who were breastfed and compared them with their formula-fed siblings. A total of 976 subjects were included (488 sibling pairs). Researchers reported that breastfed siblings were significantly less likely to reach a body mass index (BMI) which categorized them as ‘overweight’ and ‘obese’ than their non-breastfed siblings. Breastfed siblings had a BMI that was 0.39 standard deviations lower then their non-breastfed sibling. In other words, an averaged height 14 year old who had been breastfed weighed an average of 13 pounds less than his formula fed sibling. (13)
Breastfeeding and otitis media:
The American Academy of Pediatrics (AAP) compared the evidence of infants fed only formula to the evidence of babies who are breastfed and found a 23% reduced risk of (middle) ear infections (otitis media [OM]) in breastfed children. Babies fed breast milk exclusively for more than three months had a 50% risk reduction of OM and, if breastfed exclusively for 6 months, the risk of OM in babies was reduced by 63%. (1)
Breastfeeding and leukemia:
According to the American Academy of Pediatrics (AAP), breastfeeding was reported to have a protective benefit against acute lymphocytic leukemia (cancer that starts from white blood cells called lymphocytes) and acute myeloid leukemia (cancer in the myeloid line of white blood cells). Babies breastfed for 6 months or longer had a 20% and 15% risk reduction of acute lymphocytic leukemia and acute myeloid leukemia, respectively. Corresponding values associated with breastfeeding for less than 6 months were 12% and 10%, respectively. (1)
Concerns for infants which are formula fed:
Vitamin and mineral deficiencies in vegetarian formula fed infants: Vitamin and mineral deficiencies may occur in vegetarian infants which are not breast fed. According to the World Health Organization (WHO), children 6 to 24 months old raised to be vegetarians who are not breast fed may develop deficiencies of zinc, calcium, vitamin B12, and possibly vitamin A. According to the WHO, children between the ages of 6 and 24 months who are not breast fed and on plant-based diets generally will not receive adequate nutrition. WHO recommendations for appropriate feeding of non-breastfed children from 6 -24 months include food enriched with iron that provides 8-10 mg/d at 6-12 months, decreasing to 5-7 mg/d at 12-24 months. If animal source foods are limited, fortified foods or supplements should also include zinc, calcium, and vitamin B12. This does not apply to the Untied States, but according the WHO, vitamin A at a once time dose of 100,000 IU at 6-12 months and 200,000 IU twice a year at 12-23 months is recommended in regions with a high prevalence of vitamin A deficiency or where mortality rates for children under 5 is greater than 50 per 1000. (14)
Prematurity and iodine deficiency:
Premature babies which are not breast fed may be at high risk of iodine deficiency. A study of the iodine content of mothers’ breast milk and 159 different formula brands found mothers’ milk to have an average of more than 10 micrograms per deciliter of iodine than most formulas. Premature babies (born to mothers pregnant for 27-30 weeks) were found to consume an average 3.1 micrograms per day of iodine at 5 days of age and 29.8 micrograms by 2 months of age. Iodine content in formulas from several different countries was found to be below the recommended daily amount for babies. Authors conclude that formula fed premature babies are at high risk of iodine deficiency. (18)
Solid food introduction to infants:
Solid food introduced too early can risk aspiration or other problems due to poor ability to chew or have good head control. The American Academy of Pediatrics recommends children start eating solid foods when they are between 4 to 6 months of age. The importance of this was stressed in a case study. An 8-month-old infant who refused solid foods revealed the infant to be vitamin B12 deficient. After receiving vitamin B12 via other routes besides the mouth, the infant’s health improved and solid foods were introduced successfully. Researchers suggest refusal of solid foods could be used as an early sign of insufficient vitamin B12 levels in breastfed infants. (19)
Assessment and Plan: Breast Feeding and Formula Feeding of Infants
- Breastfeeding the newborn is well supported by evidence for fewer infant and childhood diseases. If breastfeeding is not possible, hydrolyzed whey formula is the next best choice.
- Infants with galactosemia, maple syrup urine disease, phenylketonuria require special formula.
- Seek guidance from the obstetrician regarding any infections prior to breastfeeding an infant and prior to breast feeding while taking medication.
- Breastfeeding for at least 5 months (versus two weeks or less) and late start of bottle feeding were associated with a 29% and 20% risk reduction of type 1 diabetes, respectively. Breastfed individuals had a 39% lower risk of developing type 2 diabetes in adulthood. Breastfeeding was also associated with lower blood glucose and insulin concentrations than those who were formula fed.
- Breast feeding may protect against the development of autism but there is no direct link to breastfeeding and more research is needed.
- Children who were breastfed had a lower risk of gastrointestinal tract infections, celiac disease, inflammatory bowel disease, and necrotizing enterocolitis.
- There appears to be modest reduction in atopic (allergic) diseases for least 4 months of breast feeding or at least 4 months of hydrolyzed whey formula when each was compared with cow milk formula. Cow milk or casein formula should be avoided. A study found that cow milk peptides in baby\’s blood were on average three times higher in babies which had a near-sudden infant death syndrome event compared with healthy infants.
- Children who are breastfed score higher on IQ tests than those who are not breastfed.
- Researchers reported that breastfed siblings were significantly less likely to develop obesity than non-breastfed siblings.
- The American Academy of Pediatrics (AAP) expressed that compared to formula fed infants, breastfed infants had a 23% reduction in risk of middle ear infections. Babies fed breast milk exclusively for more than three months had a 50% risk reduction of OM and, if breastfed exclusively for 6 months, the risk of OM in babies was reduced by 63%.
- Babies breastfed for 6 months or longer had a 20% and 15% risk reduction of acute lymphocytic leukemia and acute myeloid leukemia, respectively.
- According to the World Health Organization, (WHO), children 6 to 24 months old raised to be vegetarians who are not breast fed may develop deficiencies of zinc, calcium, vitamin B12, and possibly vitamin A. The daily intake recommendations for these nutrients are available in those sections. Once daily children\’s multivitamins are available which contain these nutrients.
- Premature babies which are not breast fed may be at high risk of iodine deficiency. See the iodine section to see recommended daily intake.
- Behavior in infants with autism improved after eliminating milk and wheat intake.
- The American Academy of Pediatrics (AAP) recommends children start eating solid foods when they are between 4 to 6 months of age. Refusal of solid foods could be an early sign of insufficient vitamin B12 levels in breastfed infants.
References:
1.Eidelman AI, Schanler RJ, Johnston M, Landers S, et al.” Breastfeeding and the use of human milk. Pediatrics Vol. 129 No. 3 March 1, 2012:e827-41. Epub 2012 Feb 27. http://pediatrics.aappublications.org/content/129/3/e827.full
2.World Health Organization. Acceptable medical reasons for use of breast-milk substitutes. 2009. http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_09.01_eng.pdf
3.Rosenbauer J, Herzig P, Giani G. Early infant feeding and risk of type 1 diabetes mellitus-a nationwide population-based case-control study in pre-school children. Diabetes Metab Res Rev. 2008 Mar-Apr;24(3):211-22. http://www.ncbi.nlm.nih.gov/pubmed/17968982
4.Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Am J Clin Nutr. 2006 Nov;84(5):1043-54. http://www.ncbi.nlm.nih.gov/pubmed/17093156
5.M. Potts, B. Bellows. “Autism and Diet”.School of Public Health. http://ncbi.nlm.nig.gov/pmc/articles/PMC2563974/pdf/375.pdf
6.Kost NV, Sokolov OY, Kurasova OB, Dmitriev AD, Tarakanova JN, Gabaeva MV, et al. Beta-casomorphins-7 in infants on different type of feeding and different levels of psychomotor development. Peptides. 2009 Oct;30(10):1854-60. http://www.ncbi.nlm.nih.gov/pubmed/19576256
7.Pediatrics Vol. 129 No. 3 March 1, 2012:e827-41. doi: 10.1542/peds.2011-3552. Epub 2012 Feb 27. Breastfeeding and the use of human milk. http://pediatrics.aappublications.org/content/129/3/e827.full
8.Barclay AR, Russell RK, Wilson ML, Gilmour WH, Satsangi J, Wilson DC. Systematic review: the role of breastfeeding in the development of pediatric inflammatory bowel disease. J Pediatr. 2009;155(3):421–426. http://www.ncbi.nlm.nih.gov/pubmed/19464699
9.Akobeng AK, Ramanan AV, Buchan I, Heller RF. Effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies. Arch Dis Child. 2006;91(1):39–43pmid:16287899. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2083075/?report=abstract
10.Thygarajan A, Burks AW. American Academy of Pediatrics recommendations on the effects of early nutritional interventions on the development of atopic disease. Curr Opin Pediatr. 2008 Dec;20(6):698-702. http://www.ncbi.nlm.nih.gov/pubmed/19005338
11.Alexander DD, Cabana MD. Partially hydrolyzed 100% whey protein infant formula and reduced risk of atopic dermatitis: a meta-analysis. J. Pediatr. Gastroenterol. Nutr. 2010; 50(4), 422–430. http://www.ncbi.nlm.nih.gov/pubmed/20216095
12.Kramer MS, Aboud F, Mironova E, et al. Breastfeeding and child cognitive development: new evidence from a large randomized trial. Arch Gen Psychiatry. 2008 May;65(5):578-84. http://www.ncbi.nlm.nih.gov/pubmed/18458209
13.Metzger MW, McDade TW. Breastfeeding as obesity prevention in the United States: a sibling difference model. Am J Hum Biol. 2009 May-Jun; 22 (3): 291-296. http://www.ncbi.nlm.nih.gov/pubmed/19693959/
14.World Health Organization. Guiding Principles For Feeding Non-Breastfed Children 6-24 Months of Age. http://whqlibdoc.who.int/publications/2005/9241593431.pdf
15.Wasilewska J, Sienkiewicz-Sz?apka E, Ku?bida E, Jarmo?owska B, Kaczmarski M, Kostyra E. The exogenous opioid peptides and DPPIV serum activity in infants with apnoea expressed as apparent life threatening events (ALTE). Neuropeptides. 2011 Jun;45(3):189-95. http://www.ncbi.nlm.nih.gov/pubmed/21334743
16.“Gluten- and casein-free diets for autistic spectrum disorder.” Cochrane Database Syst Rev. 2004:92):CD003498. http://www.ncbi.nlm.nih.gov/pubmed/15106205
17.“Food allergy and infantile autism” Department of Paediatrics(sic), University of Rome Las Sapienza, Itally. Panminerva Med. 1995 Sep; 37(3): 137-41. http://www.ncbi.nlm.nih.gov/pubmed/8869369
18.Ares S, Quero J, Durán S, et al. Iodine content of infant formulas and iodine intake of premature babies: high risk of iodine deficiency. Arch Dis Child Fetal Neonatal Ed. 1994 Nov;71(3):F184-91. http://www.ncbi.nlm.nih.gov/pubmed/7820714
19.Ide E, Van Biervliet S, Thijs J, Vande Velde S, De Bruyne R, Van Winckel M. Solid food refusal as the presenting sign of vitamin B12 deficiency in a breastfed infant. Eur J Pediatr. 2011 Nov;170(11):1453-5. http://www.ncbi.nlm.nih.gov/pubmed/21735052