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KATHLEEN KENDALL-TACKETT, PHD, IBCLC, FAPA

Originally published August 2016 and republished with the express permission of the author.
Photo: Adriana Mesec maj
Great for babies. What's in it for mothers?

A colleague recently sent me an Op-Ed from the Washington Post written by a group of mental health professionals who had horrid personal breastfeeding experiences and concluded that breastfeeding was too hard and didn't make that much difference any way. Now they encourage all the mothers in their practice to wean. Think about that. How many women have needlessly been told to wean because of these women's negative experiences? Unfortunately, it's another example of an anecdote being used as evidence. Their experience was bad, so they generalize that for everyone, and it's impacted thousands of women.

The underlying assumption is that there is no benefit for mothers when they breastfeed. It's something I've heard in mental health circles for years-and it's absolutely wrong! In terms of survival of the species, it doesn't make sense that breastfeeding would only benefit the baby. Mothers may not be inclined to do something that does not benefit them and that wouldn't be good for the baby. So it makes sense, in terms of survival, that mothers and babies both get something out of breastfeeding.

Here's a quick summary of some of the big benefits for mothers.

Big benefits for moms

During pregnancy, mothers enter a temporary state of metabolic syndrome (insulin resistance, higher triglycerides and lipids, more visceral fat), which is necessary to sustain a pregnancy. During the postpartum period, breastfeeding resets the mother's metabolism to pre-pregnancy levels, and turns off the symptoms of metabolic syndrome. Otherwise, these symptoms continue into the postpartum period and beyond, eventually resulting in higher risk for diabetes and cardiovascular disease-the number one killer of women in the U.S. (Stuebe & Rich-Edwards, 2009). This is why you see significantly lower rates of diabetes and heart disease in older women who have breastfed for at least 12 months (Schwartz et al., 2009; Stuebe, Rich-Edwards, Willett, Manson, & Michels, 2005). Lowering risk for these debilitating, possibly fatal, diseases is benefit enough. But breastfeeding's physiological effects for mothers are even more extensive.

The human stress response involves three main components: catecholamine (fight or flight response); HPA axis (where we get the stress hormone, cortisol); and the inflammatory response system (Kendall-Tackett, 2007). In response to physical or psychological threat, all three of these systems engage. The stress response is meant to be short-term. Unfortunately, chronic stress can keep this system on all the time, and when it is on, mothers are at risk for depression and a wide range of health problems. So here's the good news. Exclusive breastfeeding actually turns off the stress response (Groer & Kendall-Tackett, 2011). It's one way that breastfeeding protects against cardiovascular disease. In addition, exclusive breastfeeding protects maternal mental health because it lowers the inflammatory response, and studies have consistently shown that mothers exclusively breastfeeding their babies are at lower risk of suffering depression. That does not mean that a mother who is exclusively breastfeeding her baby won't get depressed. It means that her risk is lower, and if she does get depressed, breastfeeding will help her cope.

Exclusive breastfeeding increases both the quality and quantity of mothers' sleep. Many assume (as I once did) that breastfeeding mothers get less sleep. Not true. We've now had several large studies showing that mothers who are exclusively breastfeeding their babies report longer sleep times and feel better and more energetic during the day (Dorheim, Bondevik, Eberhard-Gran, & Bjorvatn, 2009a; Kendall-Tackett, Cong, & Hale, 2011). The number of hours of sleep can predict depression and women who report more hours of sleep have lower rates (Dorheim, Bondevik, Eberhard-Gran, & Bjorvatn, 2009b). Moreover, if mothers sleep well, they are better able to cope with the demands of new motherhood, so even if they do get depressed, they are likely to recover more quickly.

Finally, breastfeeding increases mothers' sense of wellbeing. When breastfeeding is going well, oxytocin is upregulated. That is the general feel-good hormone. It makes us want to be around other people and do things for them. It helps us cope with some of the not-too-fun tasks of motherhood. Breastfeeding helps mothers overcome past trauma and not pass it along to their children (Kendall-Tackett, Cong, & Hale, 2013; Strathearn, Mamun, Najman, & O'Callaghan, 2009). It's a chance for mothers to make a fresh start, and learn to parent differently than they were parented. For many mothers this may be the most important reason of all to breastfeed.

All of the benefits I've described above happen if breastfeeding is going well. But what if it isn't? Then there can be problems. The author of the Op-Ed from the Washington Post described some pretty grim experiences. One of the women pumped constantly and wishes she had thrown away the pump and spent more time with her baby. I had to wonder why she was pumping so furiously, especially since she described the later heartbreak of having to throw all her milk away. Why dump it? And why stockpile so much? I wish someone could have told her that it didn't need to be that way. Not using her pump so much may have been a good idea. Similarly, her colleague described weeks of shredded nipples and toe-curling pain. Again, why? Think how much better things would have been if she had had good lactation support.

So once again, the criticism about breastfeeding really points to a lack of support for new mothers, rather than problems with breastfeeding per se. If we continue to treat mothers so badly and expect them to fend for themselves, they may turn around and blame breastfeeding for their troubles rather than seeing the bigger picture: namely, why did they have to do it all alone?

Supporting new mothers means fewer breastfeeding problems. And if we have fewer breastfeeding problems, mothers benefit, babies benefit, and there may be less of a backlash against breastfeeding. Supporting new mothers is work worth doing.

Thanks to any of you who help mothers have a positive breastfeeding experience, whether as an LLL Leader, health professional, peer supporter, or family member. Each life you touch can possibly influence thousands.
Importance of Breastfeeding Article
References

Dorheim, S. K., Bondevik, G. T., Eberhard-Gran, M., & Bjorvatn, B. (2009a). Sleep and depression in postpartum women: A population-based study. Sleep, 32(7), 847-855.

Dorheim, S. K., Bondevik, G. T., Eberhard-Gran, M., & Bjorvatn, B. (2009b). Subjective and objective sleep among depressed and non-depressed postnatal women. Acta Psychiatrica Scandinavia, 119, 128-136.

Groer, M. W., & Kendall-Tackett, K. A. (2011). How breastfeeding protects women's health throughout the lifespan: The psychoneuroimmunology of human lactation. Amarillo, TX: Hale Publishing.

Kendall-Tackett, K. A. (2007). A new paradigm for depression in new mothers: The central role of inflammation and how breastfeeding and anti-inflammatory treatments protect maternal mental health. International Breastfeeding Journal, 2:6. doi:doi:10.1186/1746-4358-2-6

Kendall-Tackett, K. A., Cong, Z., & Hale, T. W. (2011). The effect of feeding method on sleep duration, maternal well-being, and postpartum depression. Clinical Lactation, 2(2), 22-26.

Kendall-Tackett, K. A., Cong, Z., & Hale, T. W. (2013). Depression, sleep quality, and maternal well-being in postpartum women with a history of sexual assault: A comparison of breastfeeding, mixed-feeding, and formula-feeding mothers Breastfeeding Medicine, 8(1), 16-22.

Schwartz, E. B., Ray, R. M., Stuebe, A. M., Allison, M. A., Ness, R. B., Freiberg, M. S., & Cauley, J. A. (2009). Duration of lactation and risk factors for maternal cardiovascular disease. Obstetrics & Gynecology, 113(5), 974-982.

Strathearn, L., Mamun, A. A., Najman, J. M., & O'Callaghan, M. J. (2009). Does breastfeeding protect against substantiated child abuse and neglect? A 15-year cohort study. Pediatrics, 123(2), 483-493. doi:123/2/483 [pii]10.1542/peds.2007-3546

Stuebe, A. M., & Rich-Edwards, J. W. (2009). The reset hypothesis: Lactation and maternal metabolism. American Journal of Perinatology, 26(1), 81-88.

Stuebe, A. M., Rich-Edwards, J. W., Willett, W. C., Manson, J. E., & Michels, K. B. (2005). Duration of lactation and incidence of type 2 diabetes. Journal of the American Medical Association, 294(20), 2601-2610.

Dr. Kathleen Kendall-Tackett is a health psychologist and an International Board Certified Lactation Consultant and has been a La Leche League Leader over 20 years. She is the owner and editor-in-chief of Praeclarus Press , a small press specializing in women's health, and is the author or editor of 38 books and 470 articles or chapters.

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Breastfeeding: What's in it for Mothers? | La Leche League International

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KATHLEEN KENDALL-TACKETT, PHD, IBCLC, FAPA Originally published August 2016 and republished with the express permission of the author. Photo: Adriana Mesec maj Español Great for babies. What's in it for mothers? A colleague recently sent me an Op-Ed from the Washington Post written by a group of mental health professionals who had horrid personal breastfeeding experiences and concluded ...

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This report details the savings to the NHS if there was even a modest increase in breastfeeding

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Good summary of the effects of breastfeeding 

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Good summary of the effects of breastfeeding 

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There's a simple reason we have missed the critical importance of breast milk for lifelong health. "It's because science has been completely focused on the diseases of rich, middle-aged white men" says the UC Davis professor and researcher Dr Bruce German. Heart disease, high cholesterol, high blood pressure - these are the ailments that science has been focused on treating since the 1950s.

Around that same time, infant formula became readily available and doctors and hospitals began recommending it widely. It was seen as an advance that went largely unquestioned in mainstream culture and society. The idea that formula was comparable to breast milk persisted for decades, and it wasn't until the 1980s that it came under intense public scrutiny when it was revealed that after aggressive marketing to women in poor countries, Nestlé infant formula was responsible for the deaths of 66,000 babies when formula was mixed with contaminated water.

Despite the scandal and the sheer immensity of the tragedy, formula marketing persisted and is now a $70bn industry controlled by just a handful of corporations.

The public was reminded of the power these companies wield when it was reported that Donald Trump's UN delegation was threatening other countries with trade sanctions and the removal of military aid if they did not agree to water down the language of a breastfeeding resolution. The resolution urged governments to "protect, promote and support breastfeeding" as well as restrict the advertising of harmful food products, according to the New York Times report.

This stunned the international health community which has long been in agreement about the irrefutable benefits of breastfeeding. Well-established health benefits of breastfeeding for the baby include: decreased risk of asthma, childhood leukemia, childhood obesity, ear infections, eczema, diarrhea and vomiting, sudden infant death syndrome, and type 2 diabetes. The American Academy of Pediatrics recommends breastfeeding at least 12 months and until the child is two years of age, if possible. The World Health Organization recommends two years or more.

What else is lost when we ignore the overwhelming evidence for the health benefits of breastfeeding? First, the threat to women and babies in poor countries is still a major concern - 25,000 babies a year still die after drinking formula mixed with contaminated water, according to Mother Jones.

But there are some other crucial and less well-known factors that we are just beginning to understand about the vital role that breast milk plays in our long-term health.

With the discovery of the microbiota - the trillions of bacterial cells that live in and on us, and without which we could not survive - researchers are learning about the critical role breast milk plays in establishing a healthy microbiota. Breast milk, as well as the closeness to a mother's body that breastfeeding allows, provides the transfer of important beneficial bacteria to the baby. Then, a mother's milk provides a complex array of carbohydrates that the bacteria need to live and reproduce - something infant formula does not have.

Flavors in a mother's diet come through in her breast milk, teaching the baby what to expect with solid foods

A healthy infant microbiota educates the immune system, which protects the baby immediately from acute illness, but it also programs the immune system for life during this important developmental window. What researchers are beginning to understand is that the disruption to the natural processes of forming a protective microbiota through breastfeeding seems to have disastrous consequences leading to the development of autoimmune diseases and conditions, ranging from increased risk for allergies to certain cancers.

What's more, when a baby is not breastfed, she is less likely to be accepting of the wide array of flavors found in natural, whole foods. Flavors in a mother's diet come through in her breast milk, teaching the baby what to expect with solid foods. In contrast, formula's flavor never changes. Researchers believe the baby could be less likely to eat a diverse and healthy whole foods diet later in life.

But we have completely ignored the importance of breast milk for decades, moving toward an industrialized way of feeding babies: infant formula. Infant formula - the first processed food - undermines the life-promoting benefits of mother's milk and is a poor substitute for breast milk nutritionally. It also deprives babies of their ability to develop a healthy and robust microbiota, and may set them up for a preference for less healthy foods and greater risk for diet-related disease.

The United States alone has invested billions of dollars researching treatments for these diet-related diseases instead of focusing on prevention. In the words of the researcher, Dr German, we should be regarding the exchange between the mother-infant dyad as the foundation for lifelong health. He refers to breast milk as the Rosetta Stone for nutrition - it provides the blueprint for what human beings need not only to survive but to grow and thrive in sometimes harsh conditions.

He emphasizes how lactation is therefore the model for how to nourish humans completely, comprehensively, preventatively, and safely, as well as sustainably and deliciously.

Prevention is not something our healthcare system is well-known for. But the foundation for lifelong health begins with giving women the support they need to be able to breastfeed their babies. The Trump delegation's latest tactic at the UN is turning the clock back on important policy advances and ignores the well-documented evidence in support of breast milk for optimal health.

And the great irony of all this is, that once we finally recognize the deep importance of breastfeeding for lifelong health, those seemingly intractable diseases of rich, middle-aged white men could disappear.

Kristin Lawless is the author of Formerly Known as Food: How the Industrial Food System Is Changing Our Minds, Bodies, and Culture.

Topics

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Breastmilk offers lifelong health benefits. Let's promote it better | Kristin Lawless

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There's a simple reason we have missed the critical importance of breast milk for lifelong health. "It's because science has been completely focused on the diseases of rich, middle-aged white men" says the UC Davis professor and researcher Dr Bruce German.

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Breastfeeding is not something women simply choose to do, it is an instinct, a biological imperative. Tomsickova Tatyana/Shutterstock

Women are increasingly opening up about their breastfeeding struggles. However, as individual as each story is, many have a core theme - it wasn't working and no one could tell them why.

Given the breadth and depth of medical knowledge, why do women still not have answers if they can't breastfeed? Why do GPs have such little training on the breast, breastfeeding and human milk? Why are women who are struggling left to hunt down their own support, due to cuts in breastfeeding support services?

Why? Because for some reason breastfeeding is still seen as a lifestyle choice that women can give or take, rather than it being a primary physiological function of a bodily organ, which helps to protect maternal physical and mental health. If you ask a mother why she wanted to breastfeed, she will say how it helped her baby's health. True, but there is another primary reason why breastfeeding is important - a woman's right to have her body function as she expects.

Breastfeeding is a biologically normal function for women's breasts. This is not to be confused with a biological or social imperative (something someone feels like they should do). It is not the breasts' only function - far from it - but we are mammals, with mammary glands to feed babies. "Biologically normal" doesn't necessarily mean easy, or that it will always work, however. But plenty of normal physiological functions - including walking and talking - are aided in their development by guidance and support, just like breastfeeding should be.

So as with any other bodily function, the breast deserves a bank of research and knowledge to enable it to function well, and answers and treatment options if it does not. If you can't smell anything you can usually visit a doctor who will perform tests on your nose, rather than telling you that your sense of smell doesn't matter and that someone else can just smell your dinner for you. But many women experiencing breastfeeding difficulties are simply told there are no tests, to stop persevering, and to give their baby a bottle of formula. They should remember that the main thing is that their baby is fed.

Breastfeeding is not simply a logical choice based on some health benefit, but an urge, an instinct. And breastfeeding is useful to women, not just as a milk delivery system but as a convenience and means of mothering. Just as we quite enjoy having a sense of smell, women can enjoy breastfeeding. They can feel empowered, healed and calmed by it. And wanting that - expecting that - is fine.

Tomsickova Tatyana/Shutterstock

Formula milk can be life saving and some women may feel it works best for their family, but for others it can never replace the experience they hoped to have as a mother. They don't want to simply give a bottle instead. Complications and stopping breastfeeding before a woman is ready can be a huge strain on maternal mental health. Women will grieve their loss - and should be allowed to.

Reproductive health

When men's bodies don't work, the impact on their physical and mental health is widely recognised. The effect of erectile dysfunction, for example, is well recognised. There is even research into whether men are satisfied with treatment of it. In fact, five times as much research is conducted into erectile dysfunction than premenstrual syndrome and dysphoric disorder, despite the latter affecting five times as many women.

Looking deeper into the issue of reproductive health, a trial into the male contraceptive pill was halted because men were experiencing a few of the complications that many women put up with daily. Research is even conducted into men's satisfaction with their sex lives when they have a partner with endometriosis - an excruciatingly painful condition which many women are left battling alone each month because it receives little funding.

We don't ask what the health benefits are to our bodies working as they should in other ways. We just accept people want their bodies to work. Yet the debate over whether investing in breastfeeding is worth it or not, based on whatever the latest confusing write up of a research study shows, is battled frequently in the press.

Recognising breastfeeding as a bodily function rather than a lifestyle choice, and investing in the scientific field of human milk would benefit everyone, not just those who are able to breastfeed. We would have better answers for those who cannot breastfeed, and for those who are struggling to produce sufficient milk. We would have greater investment in donor human milk facilities so that more sick and premature babies could have the option. Rather than some women being forced to choose between breastfeeding or medication (despite evidence showing that the majority of medications are safe), we would have a clear evidence bank that medical professionals could refer to. Those breastfeeding would be part of a system that protected their decision rather than simply promoting it with support.

Women's bodies matter too. And that is the real reason why investing in breastfeeding matters.

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Breastfeeding isn't just about the baby - women's bodies matter too

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Women are increasingly opening up about their breastfeeding struggles. However, as individual as each story is, many have a core theme - it wasn't working and no one could tell them why. Given the breadth and depth of medical knowledge, why do women still not have answers if they can't breastfeed?

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The known components of human milk.

FATS

Docosahexaenoic acid (DHA) - A fatty acid shown to have an important role in infant brain development, particularly with association and short term memory.

Arachidonic acid (AHA) - A fatty acid required for the synthesis of molecules involved in pain and inflammation. Also thought to play a role in infant brain development.

Linoleic acid (Omega 6)/ Alpha-linolenic acid (ALA) (Omega 3) - An essential fatty acid which is thought to have numerous roles in the body, from possible anti-cancer properties to the reduction of cholesterol levels.

Eicosapentaenoic acid (EPA)

Conjugated linoleic acid (Rumenic acid- active omega 6)

Free Fatty Acids

Oleic acid

Palmitoleic acid

Heptadecenoic acid

Stearic acid

Palmitic acid

Lauric acid

Phosphatidylcholine - Important phospholipid fat found in every cell in the body, thought to have a role in reducing the risk of inflammatory bowel disease and tissue repair.

Phosphatidylethanolamine

Phosphatidylinositol - A phospholipid essential for cell structure, which is partially prevalent in brain tissue

Lysophosphatidylcholine - A compound derived from phospholipids, thought to have potential anti-cancer properties.

Lysophosphatidylethanolamine

Plasmalogens

Sphingolipids

Sphingomyelin

GM1

GM2

GM3

Glucosylceramide

Galactosylceramide

Lactosylceramide

Globotriaosylceramide (GB3)

Globoside (GB4)

Sterols

Squalene

Lanosterol

Dimethylsterol

Methosterol

Lathosterol

Desmosterol

Triacylglycerol (triglyceride)

Cholesterol 7-dehydrocholesterol

Stigma-and campesterol

7-ketocholesterol

Sitosterol

β-lathosterol

VITMAINS AND MINERALS

Vitamin A - An essential vitamin required for vision and healthy skin.

Beta carotene

Vitamin B6

Vitamin B8 (Inositol)

Vitamin B12 - Needed for early development of the central nervous system.

Vitamin C

Vitamin D

Vitamin E  - Important for the protection of delicate tissues against oxidant induced injury such as the lungs and retina.

a-Tocopherol

Vitamin K

Thiamine

Riboflavin

Niacin

Folic acid

Pantothenic acid

Biotin

Calcium - Essential mineral and is the most abundant mineral in the body, functions range from heart contractions to development of teeth and bones.

Sodium

Potassium

Iron

Zinc - Shown to be protective against some rare but serious congenital conditions.

Chloride

Phosphorus

Magnesium

Copper

Manganese

Iodine

Selenium

Choline

Sulphur

Chromium

Cobalt

Fluorine

Nickel

Molybdenum

GROWTH FACTORS AND INFLAMMATORY MEDIATORS

Cytokines - Involved in the regulation of the immune system. In babies they have an important role in protection from disease.

Stem cells - These are a unique kind of cell which can divide and self-renew to create and repair different organs and systems.

Interleukin-1β (IL-1β), IL-2, IL-4, IL-6, IL-8, IL-10

Interleukins - a group of chemical signalling molecules. Generally involved in regulating the immune system and promoting a response to infection and inflammation.

Granulocyte-colony stimulating factor (G-CSF) - a growth factor which stimulates the development of white blood cells involved in the protection of the body against infection.

Macrophage-colony stimulating factor (M-CSF) - A growth factor, which stimulates the development of white blood cells involved in the protection of the body against infection.

Interferon-γ - Involved in coordinating T and B cells to combat infection, particularly against viral infection.

Epithelial growth factor (EGF) - Stimulates the production of intestinal mucosa and gut wall lining, important barriers that prevent pathogens and allergens entering a babyʼs blood stream.

Transforming growth factor-α (TGF-α), TGF β1, TGF-β2.

Insulin-like growth factor-I (IGF-I) (also known as somatomedin C), Insulin-like growth factor- II

Erythropoietin, Stimulates the development of red blood cells.

HMGF I (Human milk growth factor), HMGF II, HMGF III - Thought to be involved in stimulating growth via DNA synthesis and cellular proliferation

Nerve growth factor (NGF)

β-endorphins - Thought to help to overcome stress on the neonatal system following a vaginal delivery.

Parathyroid hormone (PTH)

Parathyroid hormone-related peptide (PTHrP)

β-defensin-1

Calcitonin

Gastrin

Motilin

Bombesin

Neurotensin

Somatostatin

Platelet derived growth factors (PDGF)

Vascular endothelial growth factor (VEGF)

Hepatocyte growth factor -α (HGF-α)

HGF-β

Tumour necrosis factor-α

Peptides (combinations of amino acids)

HORMONES

Cortisol, Insulin, Thyroxine and Cholecystokinin - Help develop the baby’s intestinal system and the intestinal defence system. Thyroxine is essential for growth, and Cholecystokinin helps with digestion, sedation, and a feeling of well-being.

Triiodothyronine (T3), Thyroid stimulating hormone (TSH), Thyroid releasing hormone (TRH)

Prolactin - Enhances the development of lymphocytes (T and B cells) and hence has a protective role against infection.

Oxytocin - Squeezes muscles in the breast that start the faster flow of milk, also promotes emotional connection between mother and baby. Helps them both to relax and go back to sleep after a feed at night. Reduces the risk of bleeding following vaginal delivery by promoting contraction of the uterus.

Corticosterone

Thrombopoietin

Gonadotropin-releasing hormone (GnRH) GRH

Leptin - Regulates appetite, food intake and energy metabolism. The higher the milk leptin concentration, the lower the infants BMI indicating that leptin could play a part in preventing obesity.

Ghrelin - aids in regulation of food intake

Adiponectin

Feedback inhibitor of lactation (FIL)

Eicosanoids

PG-E1, PG-E2 - Prostaglandins, important for mounting an inflammatory response to injury and infection. They are also protective towards cells.

PG-F2

Leukotrienes, Thromboxanes, Prostacyclins - Mediators of inflammatory response required to fight infection and promote healing.

ENZYMES AND CARBOHYDRATES

Amylase - Helps the baby to digest the starches found in milk, thought to promote better digestion of solid foods once the baby is weaned of milk.

Arysulfatase

Catalase

Histaminase

Lipase - Helps babies to digest fat when their own pancreatic function is still immature.

Lysozyme - Both bactericidal and anti-inflammatory actions. Increases in concentration as babies get older and more mobile.

PAF-acetylhydrolase

Phosphatase

Xanthine oxidase

Antiproteases - Thought to prevent allergic and anaphylactic reactions.

a-1-antitrypsin

a-1-antichymotrypsin

ANTIMICROBIAL FACTORS

Leukocytes (white blood cells) - These are the cells found in blood which fight infections and other harmful objects.

Phagocytes - absorb harmful molecules and organisms and consequently destroy them, they also then have a role in protection from future infection.

Basophils, Neutrophils, Eoisinophils, Macrophages - Important in protection against infection.

Lymphocytes- T cells and B cells - responsible for targeted destruction of harmful organisms.

sIgA (Secretory immunoglobulin A) - The most important anti-infective factor)

IgA2, IgG, IgD, IgM, IgE

Maternal immunoglobulins - coordinate a targeted immune response against infection and also give some immunity to infections.

Complement C1, Complement C2, Complement C3, Complement C4, Complement C5, Complement C6, Complement C7, Complement C8, Complement C9

The complement proteins are part of the body’s defence mechanism against potentially harmful agents such as bacteria.

Mucins - Attach to bacteria and viruses to prevent them from clinging to mucosal tissues.

Alpha-lactalbumin - A protein that induces death in cancerous cells when studied in the laboratory. It has antiviral actions against HIV components, and acts as pain relief.

Oligosaccharides (HMO) - Each mother produces a unique signature of HMOs, tailored to her own baby. Many HMOs cannot be digested by humans, but instead act as food for particular bacteria. These bacteria help the baby to resist infection with harmful bacteria and to develop a normal gut microbiome. The microbiome plays an enormous role in making sure the gut and immune system develops properly. HMOs can also trick bacteria and viruses into binding to them, instead of the gut wall, preventing them infecting the baby. Some studies suggest that HMOs may provide essential nutrients to the developing brain in the first 2 years of life.

Lactadherin

Alpha-2 macroglobulin

Lewis antigens

Ribonuclease

Haemagglutinin inhibitors

Bifidus Factor - Increases growth of Lactobacillus bifidus, a good bacteria protective in the gut, and discourages replication of dangerous bacteria.

Lactoferrin - Binds to iron, which prevents harmful bacteria from using the iron to grow. Helps babies to absorb their own iron stores. It has an anti-tumour effect and has been found to significantly inhibit the growth of some cancerous cells. Also inhibits infection by Hepatitis B, Hepatitis C, Adenovirous (causes the common cold), Poliovirus, Enterovirus (diarrhoeal virus) and others.

Lactoperoxidase - B12 binding protein Deprives microorganisms of vitamin B12 (antibacterial function).

Fibronectin - Makes phagocytes more aggressive, regulates inflammation, and repairs damage caused by inflammation.

AMINO ACIDES

Alanine

Arginine

Aspartate

Clycine

Cystine

Glutamate

Histidine

Isoleucine

Leucine

Lyscine

Methionine

Phenylalanine

Proline

Serine

Taurine: The second most abundant amino acid in human milk. It plays an important role in early brain maturation.

Theronine

Tryptophan

Tyrosine

Valine

Carnitine

NUCLEOTIDES

5’-Adenosine monophosphate (5”-AMP)

3’:5’-Cyclic adenosine monophosphate (3’:5’-cyclic AMP)

5’-Cytidine monophosphate (5’-CMP)

Cytidine diphosphate choline (CDP choline) - Important for the maintenance of cell membrane proteins particularly in the nervous system, some evidence to suggests it has a protective role against hypoxic brain damage, and helping to improve memory and learning.

Guanosine diphosphate (UDP)

Guanosine diphosphate – mannose

Uridine monophosphate (3’-UMP)

Uridine diphosphate (UDP)

Uridine diphosphate hexose (UDPH)

Uridine diphosphate-N-acetylhexosamine (UDPAH)

Uridine diphosphoglucuronic acid (UDPGA) - Important for the production of essential sugars, required for normal growth and development.

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Human milk oiligosaccharides have antibacterial properties 

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Human milk oiligosaccharides have antibacterial properties 

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The close-up image on the left illustrates how Strep bacteria normally clump together to form a protective biofilm. The image of the right shows that the biofilm breaks down when a Strep culture is dosed with human milk sugars, exposing more of the bacteria to attack by antibacterial agents. Courtesy of Steven Townsend, Vanderbilt University
Mother's milk, which consists of a complex and continually changing blend of proteins, fats and sugars, helps protect babies against bacterial infections. In the past, scientists have concentrated their search for the source of its antibacterial properties on the proteins it contains. However, an interdisciplinary team of chemists and doctors at Vanderbilt University have discovered that some of the carbohydrates in human milk not only possess antibacterial properties of their own but also enhance the effectiveness of the antibacterial proteins also present.

"This is the first example of generalized, antimicrobial activity on the part of the carbohydrates in human milk," said Assistant Professor of Chemistry Steven Townsend, who directed the study. "One of the remarkable properties of these compounds is that they are clearly non-toxic, unlike most antibiotics."

The results were presented Aug. 20 at the annual meeting of the American Chemical Society in Washington D.C. by doctoral student Dorothy Ackerman and published in the ACS Infectious Diseases journal on Jun. 1 in a paper titled, "Human Milk Oligosaccharides Exhibit Antimicrobial and Anti-Biofilm Properties Against Group B. Streptococcus."

The basic motivation for the research was the growing problem of bacterial resistance to antibiotics, which the Center for Disease Control and Prevention estimates causes 23,000 deaths annually.

"We started to look for different methods to defeat infectious bacteria. For inspiration, we turned to one particular bacteria, Group B Strep. We wondered whether its common host, pregnant women, produces compounds that can either weaken or kill strep, which is a leading cause of infections in newborns worldwide," Townsend said.

Instead of searching for proteins in human milk with antimicrobial properties, Townsend and his colleagues turned their attention to the sugars, which are considerably more difficult to study.

"For most of the last century, biochemists have argued that proteins are most important and sugars are an afterthought. Most people have bought into that argument, even though there's no data to support it," Townsend said. "Far less is known about the function of sugars and, as a trained glycoprotein chemist, I wanted to explore their role."

To do so, the researchers collected human milk carbohydrates, also called oligosaccharides, from a number of different donor samples and profiled them with a mass spectrometry technique that can identify thousands of large biomolecules simultaneously. Then they added the compounds to strep cultures and observed the result under the microscope. This showed that not only do some of these oligosaccharides kill the bacteria directly but some also physically break down the biofilms that the bacteria form to protect themselves.

In a pilot study, Townsend's lab collected five samples. They found that the sugars from one sample nearly killed an entire strep colony. In another sample, the sugars were moderately effective while the remaining three samples exhibited a lower level of activity. In a follow-up study, they are testing more than two dozen additional samples. So far, two broke down the bacterial biofilms and killed the bacteria, four broke down the biofilms but did not kill the bacteria and two killed the bacteria without breaking down the biofilms.

"Our results show that these sugars have a one-two punch," said Townsend. "First, they sensitize the target bacteria and then they kill them. Biologist sometimes call this 'synthetic lethality' and there is a major push to develop new antimicrobial drugs with this capability."

By dosing strep cultures with a mixture of milk sugars and antimicrobial peptides from human saliva, the researchers also showed that the sugars' ability to break down biofilms can also enhance the effectiveness of the other antimicrobial agents that breast milk contains.

In follow-up studies the team has also shown that the milk sugars' antimicrobial activity extends to a number of other infectious bacteria, including two of the six "ESKAPE" pathogens that are the leading cause of hospital infections worldwide.

Townsend is collaborating with colleagues in Vanderbilt's Mass Spectrometry Research Center to identify the specific types of carbohydrate molecules responsible for the antibacterial effects they have discovered.

Also contributing to the research were School of Medicine Fellow Ryan Doster, Associate Professor of Pediatrics Jörn-Hendrick Weitkamp, Associate Professor of Pathology, Microbiology & Immunology David Aronoff and Assistant Professor of Medicine Jennifer Gaddy.

The research was supported by the Department of Veterans Affairs grant CDA-2 1IK2BX001701, National Institutes of Health grants T32A1007474-20 and 2T32HD060554-06A2, National Center for Research Resources grant UL1 RR024975-01, National Center for Advancing Translational Sciences grant 2 UL1 TR000445-06 and the Vanderbilt Institute of Chemical Biology.

Source: Vanderbilt University

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antibacterial properties of mother's milk

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carbohydrates in human milk have antibacterial properties

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Sugars in Human Mother's Milk are New Class of Antibacterial Agents

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Mother's milk, which consists of a complex and continually changing blend of proteins, fats and sugars, helps protect babies against bacterial infections. In the past, scientists have concentrated their search for the source of its antibacterial properties on the proteins it contains.

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This page provides information, because you are grown ups and have a right to accurate information on this subject.

All too often the breastfeeding debate is framed as if it is just about women choosing to breastfeed. In fact, society does not support and enable women to breastfeed. Women need skilled help, knowledge and a supportive environment to be enabled to breastfeed. Frequently all of that is missing - no wonder they stop much earlier than they intended!

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Why breastmilk and formula are not the same

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Why breastmilk and formula are not the same

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There are some people out there that argue that there is no difference between breastmilk and formulas now that so many "improvements" in formula have occurred. At the biochemical level, formula is not the same as breastmilk, not even close. If you take a look at a can of formula and the list of ingredients, it is patently obvious that breastmilk contains at least 20 times more "ingredients" than formula. Breastmilk contains live cells, stem cells, white cells, immune factors and antibodies which cannot be added formula and that's just the beginning. In every other situation people would readily admit that powdered milk which is then re-constituted with hot water is not the same as fresh milk.
Formula and breastmilk are not at all the same, not even close.
Formula company advertising has tried to convince parents for years that their formulas are the same are the same as breastmilk. Photo 1 shows an ad, probably from the late 1890s or early 1900s, which states, in French "Artificial Milk Feeding", using the word normally used for "breastfeeding" (allaitement). Sneaky no?

And what else does it say? "le seul lait stérilisé identique à celui de la femme" : The only sterilized milk identical to a woman's milk!!!!

So by the beginning to the 20th century, formula was being advertized as just like breastmilk. This has always been essential to formula company advertising because otherwise it would be difficult to convince people to use formula not only in situations where it is medically indicated but also massively and unnecessarily as it is used now. Formula being "just like breastmilk" has even become a way to compete among different formula brands using words like "closer to breastmilk than ever".
What does the next photo tell us?
It states that "our formula" has been around since your great great great grandmother's time and then goes on to list all the improvements since that time. But this ad was printed in the 1990s before:

1. DHA (docosahexaenoic acid), and arachidonic acid (ARA) - compounds which have always been in breastmilk, which have not been added to formulas until recently and which now that they have been added have been found not to have the same effect as when they are in breastmilk. Because just adding stuff to formula doesn't mean it works in the same way as the ingredient works in breastmilk.

2. The protein content of formulas was reduced and even at this time formulas still contain too much protein.

3. Before nucleotides were added to formula (they made a big deal out of this too, though the importance of nucleotides in formulas has yet to be shown to do much of anything at all).

4. Before oligosaccharides, the famous prebiotics, that formula companies have made such a big deal about in the last decade. Oligosaccharides has always been in breastmilk

5. Before probiotics which mothers are buying by the handful. Breastmilk always contained probiotics.

6. Before most "special formulas" were made for things like spitting up and "allergy".

Think about what this means. It means that formulas that were touted as "just like breastmilk" in the 1890s as well as 1990s was "improved" by all sorts of changes since then. It means that if these changes were so important to babies' health, then what about all the babies who received "unimproved formulas" all the way back to your great great great grandmother's time? These formulas were inadequate, even harmful.

And what about all those hundreds of other compounds in breastmilk which have not been added and which will never be added? And those compounds yet to be discovered. Breastmilk is a very complex, living fluid and we are just beginning to understand how complex as we discover new ingredients.
Let's start off by saying that a mother's milk is unique, depending on that mother and that baby
Yes, it is true, every mother makes milk which is different than any other mother. That is because like all physiological fluids (blood, for example) milk varies from person to person. As an example, the amount of sodium in your blood may vary quite widely, normally, by as much as 15%, depending on how thirsty you are, how much sodium was in your lunch and other factors as well. That's just one example.

We know also that colostrum, the first milk, is very different to the later milk. Very different. Yet formula companies and many doctors tell us that formula is a good milk for babies to drink during the first few days.

Aside from the much heralded nucleotides, formulas contain no antibodies. But antibodies are only one of many immune factors that are present in breastmilk that are not present in formulas. Breastmilk contains lactoferrin that is so important to immunity that the formulas are jumping on the lactoferrin bandwagon to discover how to include it in their products. And breastmilk also contains these immune factors: lysozyme (and enzyme that attacks bacteria and kills them by destroying their cell wall), mucins, lactadherin, bifidus factor and many others. And probably many others are yet to be discovered. These immune factors do not just sit there, they work together, in a beautiful cooperation, like the instruments in a symphony orchestra, to protect the baby according to which bacteria, viruses or funguses the baby may be exposed to. Even if the immune factors could be added to formulas, they would not have this "cooperation" as they cannot react to infection, because it's the mother, through her breastmilk who produces these immune factors in response to infection. Breastmilk is a living, dynamic fluid.

Breastmilk has alpha lactalbumin, which in the presence of fats in the body, is changed to HAMLET (human alpha lactalbumin made lethal to tumour cells), no relation to the Prince of Denmark, which exercises broad anti-tumor activity against many different type of cancer and lymphomas

And breastmilk varies from morning to evening, from day to day, from week to week. Because of this, it will never be duplicated by any formulas.

Furthermore, breastmilk is full of anti-inflammatory factors, which decrease inflammation. Inflammation, on its own, can cause tissue damage and inflammation occurs in the presence of the battle of immune factors against bacteria or viruses. Because of the huge numbers of "good" bacteria in the intestines, breastmilk prevents this inflammation which normally would occur when immune factors fight microbes, saving tissue damage of the gut, and probably one of the reasons breastfeeding premature babies are less likely to get a serious, potentially life-threatening condition called necrotizing enterocolitis.

There are dozens, if not hundreds of immune factors and other important components in breastmilk that are not present in formulas. Just to mention two more; one, an important recently discovered immune factor: milk fat globule membranes. Oh, this is hot and the formula companies are working feverishly to include milk fat globule membranes into their milk. If they ever manage, they will tell us how important this immune factor is, hoping we will forget that all the other formulas before the new one didn't have milk fat globule membranes. And the other? Stem cells, the mind boggles thinking how stem cells in breastmilk could be used to help in clinical medicine.

But see my article in Scientific American from 1995 . The article explains how breastfeeding protects babies against infection and why it is important to keep babies breastfeeding when the mother has an infection, including the common infection I get emails about all the time, methicillin resistant Staphylococcus aureus (MRSA). Yes, the sick mother protects her baby if she continues breastfeeding.

Also hot these days is the microbiome, all the bacteria that are part of you. Formula fed babies and breastfed babies have different bacteria in their intestines and elsewhere. And what difference does it make? The microbiome may determine the child's:

Development including neurological and cognitive development

Immune function

Protection against various pathogens

Digestive function

Stress levels

And who knows what else? We are just beginning to plumb the secrets about the difference your microbiome makes

As one article suggests

"We are only beginning to appreciate the potential health benefits that could be accrued from this venture across diagnostic, preventative and treatment realms. We look forward with great anticipation to this transformed appreciation of how our microbial wealth during early life primes for health in adulthood."
Are there things in formula that should not be there?
Of course, here is a quote from an article about aluminum in formulas. Shelle-Ann M Burrell, Christopher Exley. There is (still) too much aluminium in infant formulas BMC Pediatrics 2010; 10:63. These authors are not crazed breastfeeding radicals. In their article, they write "Infant formulas are integral to the nutritional requirements of preterm and term infants". Well, I disagree with infant formulas being integral to the nutritional requirements of preterm and term infants. Breastfeeding is integral, yes, but not formula. But then they go on to say "While it has been known for decades that infant formulas are contaminated with significant amounts of aluminium there is little evidence that manufacturers consider this to be a health issue. Aluminium is non-essential and is linked to human disease. There is evidence of both immediate and delayed toxicity in infants, and especially preterm infants, exposed to aluminium and it is our contention that there is still too much aluminium in infant formulas."

For those who are fond of exotic foods, infant formulas have been found on occasion to contain:

Rat hair

Beetle parts and beetle larvae

Pieces of glass

Melamine-due to adulteration of milk by greedy people

Do humans make mistakes?
Of course they do. And over the years there have been dozens of recalls of formula due to mistakes made in the manufacture of formula. Here is just one example:
So? Formula just like breastmilk?
What an incredible statement. Anyone who says such a thing is either completely ignorant of the biochemistry of breastmilk and formula and doesn't know what they are talking about or is plain saying nonsense for political reasons. And if formulas and breastmilk are that different, then they have very different effects on the baby and the mother. Just pretending it ain't so doesn't make it so.

And these differences do not make a difference for the baby or the mother? Seriously? Here is the truth: You don't take the normal, physiological and have to prove that it is better than the artificial. Formula feeding is an intervention, and in medical terms, you have to prove an intervention safe before it can be recommended as routine us, as in infant feeding. In fact, most women these days "cannot breastfeed" because they are undermined in their ability to do so. Hospital routines around labour and birth, separation of mothers and babies, early introduction of bottles and poor advice from health professionals results in most mothers who "cannot breastfeed". If they had normal births, and good help from the beginning, most such mothers would be very successful breastfeeding.

And one more thing, last but certainly not least. The act of breastfeeding is different from bottle feeding. Breastfeeding is a close intimate, physical and emotional relationship between two people in love.

Need breastfeeding help? Make an appointment at our clinic.

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Why are breastmilk and formula not the same?

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There are some people out there that argue that there is no difference between breastmilk and formulas now that so many "improvements" in formula have occurred. At the biochemical level, formula is not the same as breastmilk, not even close.

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In this study breastfeeding women slept 2.6 hours longer than those who bottle fed. Other studies have had similar findings.

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The significance of breastfeeding on sleep patterns during the first 48 hours postpartum for first time mothers. - PubMed - NCBI

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This 30 study showed a strong link between breastfeeding and a reduction in diabetes risk for women. They controlled for all the possible confunding factors.

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Question Is the protective association between lactation duration and progression to diabetes supported by a biochemical evidence basis?

Findings Among young white and black women in this observational 30-year study, increasing lactation duration was associated with a strong, graded 25% to 47% relative reduction in the incidence of diabetes even after accounting for prepregnancy biochemical measures, clinical and demographic risk factors, gestational diabetes, lifestyle behaviors, and weight gain that prior studies did not address.

Meaning This study provides evidence to support the hypothesis that lactation may lower risk of diabetes in women; these findings open new avenues into mechanisms leading to glucose intolerance.

Importance Lactation duration has shown weak protective associations with incident diabetes (3%-15% lower incidence per year of lactation) in older women based solely on self-report of diabetes, studies initiated beyond the reproductive period are vulnerable to unmeasured confounding or reverse causation from antecedent biochemical risk status, perinatal outcomes, and behaviors across the childbearing years.

Objective To evaluate the association between lactation and progression to diabetes using biochemical testing both before and after pregnancy and accounting for prepregnancy cardiometabolic measures, gestational diabetes (GD), and lifestyle behaviors.

Design, Setting, and Participants For this US multicenter, community-based 30-year prospective cohort study, there were 1238 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study of young black and white women ages 18 to 30 years without diabetes at baseline (1985-1986) who had 1 or more live births after baseline, reported lactation duration, and were screened for diabetes up to 7 times during 30 years after baseline (1986-2016).

Exposures Time-dependent lactation duration categories (none, >0 to 6 months, >6 to <12 months, and ≥12 months) across all births since baseline through 30 years.

Main Outcomes and Measures Diabetes incidence rates per 1000 person-years and adjusted relative hazards (RH) with corresponding 95% CIs, as well as proportional hazards regression models adjusted for biochemical, sociodemographic, and reproductive risk factors, as well as family history of diabetes, lifestyle, and weight change during follow-up.

Overall 1238 women were included in this analysis (mean [SD] age, 24.2 [3.7] years; 615 black women). There were 182 incident diabetes cases during 27 598 person-years for an overall incidence rate of 6.6 cases per 1000 person-years (95% CI, 5.6-7.6); and rates for women with GD and without GD were 18.0 (95% CI, 13.3-22.8) and 5.1 (95% CI, 4.2-6.0), respectively ( Results P for difference < .001). Lactation duration showed a strong, graded inverse association with diabetes incidence: adjusted RH for more than 0 to 6 months, 0.75 (95% CI, 0.51-1.09); more than 6 months to less than 12 months, 0.52 (95% CI, 0.31-0.87), and 12 months or more 0.53 (0.29-0.98) vs none (0 days) ( P for trend = .01). There was no evidence of effect modification by race, GD, or parity.

Conclusions and Relevance This study provides longitudinal biochemical evidence that lactation duration is independently associated with lower incidence of diabetes. Further investigation is required to elucidate mechanisms that may explain this relationship.

One prospective study of women with GD found that increasing lactation intensity and duration were associated with 34% to 57% lower 2-year incidence of diabetes ( P for trend = .01) from annual oral glucose tolerance tests. This is the only study to account for reverse causation and confounding from prepregnancy obesity, gestational metabolism, perinatal outcomes, sociodemographics, and postdelivery lifestyle behaviors.

To overcome the limitations of previous studies among mostly older women, we prospectively evaluated progression to diabetes among young black and white women during the 30-year Coronary Artery Risk Development Study in Young Adults (CARDIA) study ( NCT00005130). CARDIA conducted multiple assessments of glucose tolerance and other risk factors up to 7 times from prepregnancy to postweaning across the childbearing years. The prospective biochemical assessments enhance validity given that randomization to either breast or formula feeding is not desirable or feasible. We hypothesized that lactation duration is associated strongly with lower incidence of diabetes in women through midlife.

The US multicenter CARDIA study examines the trends and correlates of cardiovascular disease risk in young black and white men and women. The CARDIA study enrolled 5115 adults aged 18 to 30 years from 1985 to 1986 (2787 women; 52% black and 48% white) using community-based sampling from 4 geographic areas in the United States: Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California. The study design, recruitment, methodology, and characteristics are described elsewhere. Retention was 81%, 79%, 74%, 72%, 72% and 71% of the surviving cohort at 7, 10, 15, 20, 25, and 30 years since baseline, respectively. Institutional review boards at each participating study center (University of Alabama at Birmingham, Northwestern University, University of Minnesota, and Kaiser Permanente Northern California) approved the study. Written informed consent was obtained from participants for all study procedures.

Of 2787 women enrolled, we excluded 41 with diabetes, 24 with a hysterectomy or bilateral oophorectomy, and 5 who were pregnant or lactating at baseline. We also excluded 2 women who developed diabetes before their first postbaseline birth, 154 without any follow-up, and 1196 without postbaseline births (eFigure 1 in the Supplement). Of 1365 women without diabetes who attended 1 or more follow-up examinations, 127 (9.3%) had missing lactation duration data. The analysis included 1238 women (n = 615 black [50.0%]) without diabetes before pregnancy who delivered 2302 live born infants after baseline. Women excluded were less educated, had higher body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), and were more likely of black race.

We defined incident diabetes as self-report of diabetes with medication treatment or elevated fasting or 2-hour postload serum glucose from the 75 g oral glucose tolerance tests and/or glycated hemoglobin consistent (fasting glucose measured at examinations in years 0, 7, 10, 15, 20, 25, or 30; oral glucose tolerance tests in years 15, 20, 25, or 30; and glycated hemoglobin in years 20, 25, or 30) based on the American Diabetes Association diagnostic criteria for diabetes: fasting glucose, 126 mg/dL or greater; 2-hour glucose, 200 mg/dL or greater; and/or glycated hemoglobin, 6.5% or greater (48 mmol/mol).

Time-Dependent Lactation Duration

Women reported lactation duration at year 7 for all previous birth(s) and for each birth at subsequent examinations. For a "yes" that they had breastfed the child, women selected 1 of these categories: less than 6 weeks, 6 to 11 weeks, 3 to 6 months, or 6 months or more. To calculate duration, we assigned the midpoint of each lactation category to each birth: 21 days for less than 6 weeks; 66 days for 6 to 11 weeks; 135 days for 3 to 6 months; and 210 days as the upper limit for 6 months or more (except women currently lactating, who were assigned a maximum of 650 days). Then, we summed lactation duration (days) across all births. Time-dependent lactation categories were updated at each examination year as births occurred. Women were assigned into relevant categories: none (n = 322 [26.0%]); more than 0 to 6 months (n = 418 [33.8%]); more than 6 months to less than 12 months (n = 268 [21.6%]); and 12 months or more (n = 230 [18.6%]) across examinations through the end of follow-up.

We assessed differences in baseline and follow-up characteristics among lactation categories and by incident diabetes using χ ² statistics for categorical variables and using analysis of variance for continuous variables. Median and interquartile ranges were reported for alcohol intake, HOMA-IR, weight change, and physical activity score for skewed distributions, with differences across lactation categories and by incident diabetes assessed with the Kruskal-Wallis test; P values were obtained from 2-sided tests (significance, <.05). All analyses were performed using SAS version 9.3 (SAS Institute, Inc).

We identified incident diabetes cases between consecutive examinations (0-7, >7 to 10, >10 to 15, >15 to 20, >20 to 25, >25 to 30 years), and estimated incidence rates and 95% CIs for diabetes among lactation categories by dividing the number of incident cases by the person-time across preceding intervals. Person-time is contributed by each individual for the entire time interval within the lactation category. Women may contribute person-time to multiple lactation categories moving across time until the end of follow-up (ie, last examination year 7 to year 30 or onset of incident diabetes). Because diabetes onset was only determined at CARDIA examinations, the exact failure time for a woman without diabetes at a particular examination and onset of diabetes at the subsequent examination is unknown. We calculated point and interval estimates of relative hazards ratio (RH) and 95% CI for incidence of diabetes among lactation duration categories accounting for interval-censored data using the Prentice and Gloeckler proportional hazards regression model. Adjusted models included covariables: examination years (time), race, family history of diabetes, baseline age, fasting glucose, BMI and waist circumference, time-dependent GD, parity and physical activity, and dietary quality score. Trend P values were generated from models of continuous time-dependent lactation duration. We evaluated potential confounders based on a priori hypotheses for selected baseline (BMI, fasting blood glucose and lipids, HOMA-IR, blood pressure, sociodemographics), and follow-up (smoking, dietary quality, physical activity, hypertension, medication use, and pregnancy outcomes) covariates. We evaluated median weight change as a time-dependent dichotomous covariate. Covariates were not included if they were not associated with incident diabetes independent of other model covariates or did not alter 1 or more coefficients for lactation by at least 10% after addition of covariates. We formally tested effect modification of the lactation-diabetes association by race, baseline BMI, GD status, and parity by introduction of cross-product terms ( P value significance, <.10).

Of 1238 women (n = 615 black [50.0%] and n = 623 white [50.0%]) without diabetes before pregnancies who delivered 1 or more singleton births (n = 2302) after baseline, 155 (12.5%) reported GD status for postbaseline births within a mean (SD) follow-up time of 24.7 (6.6) years. There were 182 incident cases of diabetes (median age, 47 years) in 27 598 person-years for an overall incidence rate of 6.6 cases per 1000 person-years (95% CI, 5.6-7.6), with 132 cases (73.0%) in 13 369 person-years for black women, and 50 cases in 14 229 person-years for white women. Diabetes incidence per 1000 person-years was higher in black women (9.9; 95% CI, 8.2-11.6), than white women (3.5; 95% CI, 2.5-4.5) ( P for differences <.001). Diabetes incidence per 1000 person-years was alsohigher for women with GD than women without GD (non-GD) groups: 18.0 (95% CI, 13.3-22.8) and 5.1 (95% CI, 4.2-6.0), respectively ( P for difference <.001) ( Figure; Table 1). For GD and non-GD groups, lactation duration was inversely associated with diabetes incidence, with lowest incidences for lactation more than 12 months (all P for trend = .02). Eighty-six percent of incident cases of diabetes occurred from 15 to 30 years postbaseline, whereas 93% of the postbaseline births occurred prior to 15 years postbaseline.

At baseline, women who later developed diabetes ( Table 2) were more likely to be black, multiparous, reach menarche earlier, and had higher BMI, waist circumference, fasting glucose and triglycerides, HOMA-IR and blood pressure, and lower high-density lipoprotein cholesterol, physical activity, and diet quality scores. At follow-up, women who later developed diabetes had higher parity, weight gain and decrements in physical activity, shorter lactation duration, and lower diet quality, and a higher percentage were unmarried, treated for hyperlipidemia and hypertension, developed GD, gestational hypertension or metabolic syndrome, and had a family history of diabetes ( Table 3).

Baseline characteristics were similar across the lactation categories (eTable 1 in the Supplement). All biochemical parameters fell within normal ranges, reflecting their young age (18-30 years) and good health, but the absolute differences across lactation categories were small. However, at baseline, women who never lactated (none) tended to be slightly younger, nulliparous, black race, or smokers; had slightly lower mean plasma high-density lipoprotein cholesterol, dietary fiber intake, physical activity, and dietary quality; and slightly higher dietary fat intake, BMI, waist circumference, low-density lipoprotein cholesterol, and HOMA-IR. During follow-up (eTable 2 in the Supplement), the no lactation group (none) had lower education and diet quality, higher prevalence of the metabolic syndrome; treatment for hypertension, and a family history of diabetes; and greater weight gain. Mean weight change during follow-up among lactation categories was similar among women with or without incident diabetes ( P for interaction = .99) (eFigure 2 in the Supplement).

In multivariate models stratified by GD status, graded inverse lower RH of incident diabetes with time-dependent lactation categories were slightly stronger among GD than non-GD groups (data not shown). In multivariate models stratified by race, these graded inverse associations were similar among black women and white women (data not shown) but did not reach statistical significance. Adjusted RHs for incident diabetes in models with continuous months of lactation were similar by race (eTable 3 in the Supplement) and by GD status but reached statistical significance for women with GD (data not shown). There was no evidence of effect modification by race, baseline BMI, GD, or parity ( P values >.16; Figure). Based on these analyses, we combined race and GD groups into a single Cox proportional hazards model ( Table 4). In unadjusted models, increasing time-dependent categories of lactation duration were strongly associated with lower incidence of diabetes ( P for trend <.001; Table 4). Addition of a priori confounders (race, prepregnancy BMI, waist circumference, fasting blood glucose or HOMA-IR, age, time-dependent parity and GD status, family history of diabetes) moderately attenuated associations, but they remained statistically significant ( P for trend = .01; Table 4). Addition of lifestyle behaviors during follow-up (ie, quartiles of dietary quality score and time-dependent physical activity) had minimal impact on RHs. Addition of time-dependent weight change strengthened these graded protective associations with estimates of 25% to 47% lower relative risk of incident diabetes (fully adjusted RHs range from 0.75 to 0.53; P for trend = .01). Other characteristics (eg, medical conditions, fasting lipids, antilipid lowering or hypertensive medication use, pregnancy complications) did not materially affect the estimates. A sensitivity analysis of 848 women who were nulliparous at baseline showed even stronger relative risk reductions in incident diabetes associated with increasing lactation duration that remained statistically significant (eTable 3 in the Supplement). The fully adjusted RHs range from 0.66 to 0.44 for lactation duration from more than 0 through 6 months to 12 months or more ( P for trend = .02).

For the full sample of 1238 women, models with continuous months of lactation yielded consistent lower RHs of incident diabetes in unadjusted and adjusted race-stratified models and combined models (eTable 4 in the Supplement). Finally, unadjusted and adjusted RHs (95% CIs) of incident diabetes for covariates, race, family history of diabetes, and prepregnancy BMI, showed attenuation in fully adjusted models but stable RHs for GD status (eFigure 3 in the Supplement).

Our findings in young black and white women are consistent with studies in high-risk women with GD that rescreened women systematically for diabetes after pregnancy. Among 1010 women with recent GD, lactation intensity and duration were associated with a strong, graded 36% to 57% lower 2-year incidence of diabetes after accounting for gestational metabolic status, prepregnancy obesity, perinatal outcomes, and lifestyle behaviors. This strong graded, protective association is strikingly similar in magnitude to our 30-year follow-up risk reduction in healthy CARDIA women (ie, 2-fold higher risk with no lactation). Among 264 women with GD, lactation for 3 months or longer was associated with 45% lower 15-year incidence of diabetes, but this study validity is reduced by unmeasured confounding from perinatal outcomes, lifestyle behaviors, or weight changes that were not evaluated.

Self-report of disease status may be reasonable to investigate breast cancer and heart disease that have long latency periods, but progressive deterioration in glucose intolerance is optimally detected via regular biochemical screening. Moreover, GD history, a major risk factor for type 2 diabetes in young women, and other perinatal outcomes were not evaluated in the prospective studies of lactation. For example, parity has been directly associated with diabetes, but prospective studies that accounted for prepregnancy metabolic risk and GD status, or that excluded women with a history of GD, showed null associations.

Black women have both higher diabetes prevalence and lower breastfeeding initiation and duration than white women. Type 2 diabetes affects 1.9% of US women of childbearing age (20-39 years) with a 6-fold higher prevalence in black (4.7%) than white women (0.8%). In CARDIA, diabetes incidence was 3-fold higher for black compared with white women, as expected from national estimates. Although 41.0% of black women vs 11.0% of white women had never breastfed a child, the protective association between lactation duration and diabetes risk did not differ by race. This consistency across race groups provides strong evidence that lactation may protect against diabetes via biological mechanisms rather than cultural or social factors. Moreover, CARDIA is a community-based cohort of healthy young adults recruited from suburban and urban centers enhancing its generalizability.

Obesity before pregnancy and insulin treatment of GD have been associated with delayed lactogenesis. It has been hypothesized that heightened insulin resistance may interfere with timely lactogenesis after delivery. However, overweight or obese women are also more likely to experience medical complications and adverse perinatal outcomes that can disrupt early breastfeeding initiation. Heavier women have been found to report more limited access to breastfeeding education and support or may hold unrealistic expectations about weight loss that negatively affect breastfeeding duration. In our study, the strong protective association between lactation and incident diabetes remained even after accounting for prepregnancy metabolic status, obesity, and perinatal outcomes, and the associations became stronger in a sensitivity analysis limited to women who were nulliparous at baseline.

Strengths and Limitations

The study strengths include the biracial cohort, longitudinal serial biochemical assessments from before to after pregnancies and postweaning, standardized diabetes screening almost every 5 years for 30 years (retention, 71%), and control for prepregnancy cardiometabolic risk, lifestyle behaviors, and GD history to minimize reverse causation. All previous prospective studies enrolled women many years to decades after pregnancies and did not conduct any assessments during the childbearing period.

Limitations include the variable timing of assessments in relation to pregnancies and self-report of pregnancy complications. However, GD and other perinatal outcomes were accurately reported. We relied on self-report of lactation and recall post-delivery (within ≤4 years for 88% of births), which may be a limitation, but studies indicate that women are able to accurately recall duration up to 20 years later. Because lactation duration was obtained for a maximum of 6 months for each birth, we could not determine absolute duration. However, CARDIA reflects contemporary breastfeeding practices with 78% of births occurring between 1985 and 1995, when only 20% of US women breastfed at 6 months. Thus, our lactation categories closely approximate actual duration. Women who lactated longer may have had better health habits that determined lower risk of diabetes. However, metabolic status before pregnancy was similar among lactation categories, and we controlled for time-varying weight change and lifestyle behaviors within race groups to address these differences, but they had little impact. The similar protective associations among black and white women, despite differences in obesity, based on our stratified analyses of lactation support the associations. Although this study is not a randomized trial, our study evaluated reverse causation and potential confounding by characteristics antecedent to lactation and diabetes onset, especially biochemical measures before lactation that have not been available in previous studies.

Our findings may have implications for social policies to extend paid maternity leave to achieve higher intensity and longer duration of breastfeeding. Second, increased allocation of health care resources to increase breastfeeding rates through the first year postdelivery may be offset by lower health care costs associated with prevention of chronic disease in women. It is also imperative to improve breastfeeding practices to interrupt the transgenerational transmission of obesity-related diseases. Lactation is a natural biological process with the enormous potential to provide long-term benefits to maternal health, but has been underappreciated as a potential key strategy for early primary prevention of metabolic diseases in women across the childbearing years and beyond.

Corresponding Author: Erica P. Gunderson, PhD, MPH, MS, Division of Research, Cardiovascular and Metabolic Conditions Section, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612 ( erica.gunderson@kp.org).

Accepted for Publication: November 20, 2017.

Published Online: January 16, 2018. doi: 10.1001/jamainternmed.2017.7978

Author Contributions: Dr Gunderson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Gunderson, Lewis, Gross, Jacobs.

Acquisition, analysis, or interpretation of data: Gunderson, Lewis, Lin, Sorel, Sidney, Jacobs, Shikany, Quesenberry.

Drafting of the manuscript: Gunderson.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Jacobs, Quesenberry.

Obtained funding: Gunderson, Lewis, Sidney.

Administrative, technical, or material support: Lewis, Sorel, Shikany.

Study supervision: Gunderson.

Conflict of Interest Disclosures: Dr Gunderson receives funding from Janssen Pharmaceuticals, Inc, and Dr Quesenberry has received research funding from Takeda, Merck & Company Inc, Sanofi-Aventis, Lilly, Genentech, Valeant, and Pfizer. No other conflicts are reported.

Funding/Support: This study and the analyses herin were supported by the National Institute of Diabetes, Digestive, and Kidney Diseases (grants R01 DK106201, R01 DK090047, and K01 DK059944 to Dr Gunderson, who acted as the primary investigator). The Coronary Artery Risk Development in Young Adults Study (CARDIA) is conducted and supported by the National Heart, Lung, and Blood Institute (NHLBI) in collaboration with the University of Alabama at Birmingham (HHSN268201300025C and HHSN268201300026C), Northwestern University (HHSN268201300027C), University of Minnesota (HHSN268201300028C), Kaiser Foundation Research Institute, Northern California (HHSN268201300029C), and Johns Hopkins University School of Medicine (HHSN268200900041C). CARDIA is also partially supported by the Intramural Research Program of the National Institute on Aging (NIA) and an intra-agency agreement between NIA and NHLBI (AG0005).

Role of the Funder/Sponsor: The funder/sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the participants of the CARDIA study for their long-term commitment and important contributions to the study.

Additional Information: This manuscript has been reviewed by CARDIA for scientific content. The CARDIA study was registered in the ClinicalTrials.gov registry with the number NCT00005130. The original protocol for the study is published in the Journal of Clinical Epidemiology (1988;41[11]:1105-1116). CARDIA has strictly adhered to the standards of Health Level Seven (HL7), a standard for exchanging information between medical applications, and other standards models, especially the Logical Observation Identifiers Names and Codes (LOINC) coding system for the electronic exchange of laboratory test results and other observations. All CARDIA datasets conform to the Standards for Privacy of Individually Identifiable Health Information rule of HIPAA (Health Insurance Portability and Accountability Act of 1996), and data points are codified within the coding strategies outlined by the NHLBI ( http://www.aspe.hhs.gov/sp/nhii/Standards.html). The Coordinating Center (CC) maintains a central archive for public use from a newly designed public website ( http://www.cardia.dopm.uab.edu) that provides descriptive information about CARDIA; a searchable and updated publication list; study-wide policies, including ancillary study policies; information to encourage outside investigators to become involved in the study publication process; field center and CC contact information; list of examination components, manuals of operation, protocols, forms and questionnaires; information on access to limited access datasets (LADs) ( https://biolincc.nhlbi.nih.gov/home/); and other information as deemed appropriate by the CARDIA Steering Committee and NHLBI. In addition, the CC has a single SharePoint (Microsoft Corp) web system to which current, as well as legacy, datasets are posted, with anonymized datasets accessible to approved investigators. These include the core examimation data, follow-up, end points, genetic, and anonymized (LAD) datasets, as well as derived variables and definitions, and a tracking log of when new or revised datasets are posted (since year-25 examination). We keep copies of the final datasets in standard formats that can be used with multiple statistical programs (SAS [SAS Institute Inc], STATA [StataCorp], SPSS [IBM Analytics]). All datasets have complete data documentation including data dictionaries, SAS codes, and basic descriptive statistics. In keeping with CARDIA's goal of sharing data with qualified investigators, the anonymized (data repository) datasets are made available to the NHLBI according to guidelines specifically structured to protect the confidentiality of the study participants. The NHLBI then provides the datasets to qualified investigators according to standard policies. This process is described on the public webpage. During the contract period, data repository datasets are provided to NHLBI 3 years after the completion of each examination or follow-up cycle, or 2 years after the baseline, follow-up, genetic, ancillary study, or other dataset is finalized within the study for analysis for use in publication, whichever comes first as per NHLBI guidelines (NHLBI Policy for Data Sharing from Clinical Trials and Epidemiological Studies: http://www.nhlbi.nih.gov/funding/datasharing.htm). Instructions for requesting these data repository datasets can be found at https://biolincc.nhlbi.nih.gov/home/. The CARDIA Study is a community-based prospective cohort study and did not involve any patient relationships between the investigators and the participants in the study. Patients were not involved in the study design, conduct, or recruitment, or the development of outcomes for the study. We acknowledge the commitment and contributions of the study participants. The results from the study assessments were mailed to individual participants. Our findings from this study may be accessed by participants via the CARDIA Study website: http://www.cardia.dopm.uab.edu/

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Lactation Duration and Incident Diabetes in Young Women

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Question Is the protective association between lactation duration and progression to diabetes supported by a biochemical evidence basis? Findings Among young white and black women in this observational 30-year study, increasing lactation duration was associated with a strong, graded 25% to 47% relative reduction in the incidence of diabetes even after accounting for prepregnancy biochemical measures, clinical and demographic risk factors, gestational diabetes, lifestyle behaviors, and weight gain that prior studies did not address.

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Review by the World Health Organisation 2016

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Review by the World Health Organisation 2016

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Acta Paediatrica - Volume 104, Issue Supplement S467 - Impact of Breastfeeding on Maternal and Child Health - Wiley Online Library

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© Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd

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Some people find this a difficult way of talking about the difference in health outcomes between breastfeeding and formula feeding, but breastfeeding is the biological norm; so scientifically it is correct to talk about the risks of not breastfeeding.

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Abstract

Health outcomes in developed countries differ substantially for mothers and infants who formula feed compared with those who breastfeed. For infants, not being breastfed is associated with an increased incidence of infectious morbidity, as well as elevated risks of childhood obesity, type 1 and type 2 diabetes, leukemia, and sudden infant death syndrome. For mothers, failure to breastfeed is associated with an increased incidence of premenopausal breast cancer, ovarian cancer, retained gestational weight gain, type 2 diabetes, myocardial infarction, and the metabolic syndrome. Obstetricians are uniquely positioned to counsel mothers about the health impact of breastfeeding and to ensure that mothers and infants receive appropriate, evidence-based care, starting at birth.

Key words: Breastfeeding, Antenatal care, Infant health outcomes, Lactation

Health outcomes differ substantially for mothers and infants who formula feed compared with those who breastfeed, even in developed countries such as the United States. A recent meta-analysis by the Agency for Healthcare Research and Quality reviewed this evidence in detail1:

For infants, not being breastfed is associated with an increased incidence of infectious morbidity, including otitis media, gastroenteritis, and pneumonia, as well as elevated risks of childhood obesity, type 1 and type 2 diabetes, leukemia, and sudden infant death syndrome (SIDS).

Among premature infants, not receiving breast milk is associated with an increased risk of necrotizing enterocolitis (NEC).

For mothers, failure to breastfeed is associated with an increased incidence of premenopausal breast cancer, ovarian cancer, retained gestational weight gain, type 2 diabetes, and the metabolic syndrome.

These findings suggest that infant feeding is an important modifiable risk factor for disease for both mothers and infants. The American College of Obstetricians and Gynecologists (ACOG) therefore recommends 6 months of exclusive breastfeeding for all infants.2 The American Academy of Pediatrics (AAP)3 and the American Academy of Family Physicians (AAFP)4 similarly recommend exclusive breastfeeding for the first 6 months of life, continuing at least through the infant's first birthday, and as long thereafter as is mutually desired. The World Health Organization (WHO) recommends at least 2 years of breastfeeding for all infants.

In the United States, breastfeeding durations fall far short of these guidelines.5 In 2005, 74.2% of US infants were breastfed at least once after delivery, but only 31.5% were exclusively breastfed at age 3 months, and just 11.9% were exclusively breastfed at age 6 months. These rates show considerable regional variation, with the highest rates in the Pacific Northwest and the lowest rates in the Southeast. Although some of this variation reflects cultural differences, recent data suggest that variations in hospital practices account for a considerable proportion of disparities in breastfeeding duration.6 This suggests that improvements in the quality of antenatal and perinatal support for breastfeeding could have a substantial impact on the health of mothers and infants.

This article reviews the health risks of not breastfeeding, for infants and for mothers, as well as the obstetrician's role in counseling women regarding infant feeding and ensuring an optimal start for breastfeeding at birth.

The Risks of Formula Feeding Versus the Benefits of Breastfeeding

Public health campaigns and medical literature have traditionally described the "benefits of breastfeeding," comparing health outcomes among breastfed infants against a reference group of formula-fed infants. Although mathematically synonymous with reporting the "risk of not breastfeeding," this approach implicitly defines formula feeding as the norm. As several authors have noted,7⁻9 this subtle distinction impacts public perceptions of infant feeding. If "breast is best," then formula is implicitly "good" or "normal." This distinction was underscored by national survey data showing that, in 2003, whereas 74.3% of US residents disagreed with the statement: "Infant formula is as good as breast milk," just 24.4% agreed with the statement: "Feeding a baby formula instead of breast milk increases the chance the baby will get sick."10

These distinctions appear to influence parents' feeding decisions. In 2002, the Ad Council conducted focus groups to develop the National Breastfeeding Awareness Campaign, targeted at reproductive-aged women who would not normally breastfeed. They found that women who were advised about the "benefits of breastfeeding" viewed lactation as a "bonus," like a multivitamin, that was helpful but not essential for infant health. Women responded differently when the same data were presented as the "risk of not breastfeeding," and they were far more likely to say that they would breastfeed their infants. Given these findings, this review will present differences in health outcomes as risks of formula feeding, using breastfeeding mother-infant dyads as the referent group.

Infant Feeding and Child Health Outcomes

Infectious Morbidity

Compared with breastfed infants, formula-fed infants face higher risks of infectious morbidity in the first year of life. These differences in health outcomes can be explained, in part, by specific and innate immune factors present in human milk.11 Plasma cells in the mother's bronchial tree and intestine migrate to the mammary epithelium and produce IgA antibodies specific to antigens in the motherinfant dyad's immediate surroundings, providing specific protection against pathogens in the mother's environment.12 In addition, innate immune factors in milk provide protection against infection. Oligosaccharides prevent attachment of common respiratory pathogens, such as Haemophilus influenzae and Streptococcus pneumoniae, to respiratory epithelium, and glycoproteins prevent binding of intestinal pathogens such as Vibrio cholerae, Escherichia coli, and rotavirus.13

Glycosaminoglycans in milk prevent binding of HIV gp120 to the CD4 receptor, reducing risk of transmission, and human milk lipids contribute to innate immunity, with activity against Giardia lamblia, H influenzae, group B streptococci, S epidermidis, respiratory syncytial virus (RSV), and herpes simplex virus type 1 (HSV-1).14

Otitis Media

Approximately 44% of infants will have at least 1 episode of otitis media in the first year of life, and the risk among formula-fed infants is doubled (95% confidence interval [CI], 1.4-2.8) compared with infants who are exclusively breastfed for more than 3 months.1 Human milk oligosaccharides and antibodies to common respiratory pathogens in the infant's environment are thought to provide protection from infection.

Lower Respiratory Tract Infection

In a meta-analysis of 7 cohort studies of healthy term infants in affluent regions, Bachrach and associates15 found that infants who were not breastfed faced a 3.6-fold increased risk (95% CI, 1.9-7.1) of hospitalization for lower respiratory tract infection in the first year of life, compared with infants who were exclusively breastfed for more than 4 months. These studies included adjustment for parental smoking and socioeconomic status. The majority of respiratory hospitalizations for infants result from infection with RSV. Lipids in human milk appear to have antiviral activity against RSV.

Obesity and Metabolic Disease

Epidemiologic studies suggest that children who are formula fed in infancy are more likely to become obese or develop type 2 diabetes.1,19,20 In meta-analyses, children formula fed in infancy were 1.1 (95% CI, 1.0-1.1)21 to 1.3 (95% CI, 1.2-1.5)22 times as likely to become obese as children who had ever been breastfed. Being formula fed in infancy is also associated with a 1.6-fold risk (95% CI, 1.2-2.3) of type 2 diabetes, compared with being breastfed.1,19,23 Some studies have also suggested an increase in risk for cardiovascular disease, including higher blood pressure19,24,25 and less favorable lipid profiles,26 but the literature is mixed. Researchers have proposed several mechanisms to explain these associations, including differences in composition of human milk versus formula, feeding practices, associated lifestyle factors, and self-regulation of intake by the infant. 27 Moreover, human milk contains adipokines, which may play a role in regulating energy intake and long-term obesity risk.28 Several authors have postulated that long-chain polyunsaturated fatty acids in breast milk may affect blood pressure and insulin resistance in later life.19 Nevertheless, observational data must be interpreted with caution because of potential confounding by other lifestyle behaviors in families with long durations of breastfeeding versus formula feeding.

Neurodevelopment

Multiple authors have examined associations between infant feeding and cognitive development, with mixed results.29⁻31 Several studies reported modestly lower IQ scores in formulafed children compared with breastfed children, whereas others reported no association between infant feeding and intelligence. Observational data should be interpreted with caution due to confounding by socioeconomic status and maternal intelligence. Nevertheless, data from 2 randomized controlled trials provides evidence of developmental differences with shorter durations of breastfeeding. Dewey and associates32 randomized mothers in Honduras to introduction of complementary foods at 4 months versus continued exclusive breastfeeding until 6 months postpartum. Infants in the complementary food group crawled later than those that were exclusively breastfed from 4 to 6 months ( P = .007). Among normal birth weight infants, those who were randomized to complementary foods before 6 months were less likely to be walking at 12 months (39 vs 60%; P = .02). Kramer and colleagues33 similarly found differences in neurodevelopment with shorter breastfeeding in the PROBIT study. At age 6.5 years, verbal IQ scores were 7.5 points lower (95% CI, −0.8 to −14.3) among children in the usual care group than among children in the breastfeeding support group. Kramer's results suggest that hospital policies that support breastfeeding can impact neurodevelopment at school age.

These studies were conducted prior to use of formula supplemented with long-chain polyunsaturated fatty acids (LCPUFA), which had been added to infant formula with the goal of improving neurocognitive outcomes. However, a recent Cochrane meta-analysis concluded that most well-conducted randomized trials showed no benefit of LCPUFA versus control formula on visual acuity or neurodevelopment among term infants.34 These findings make it unlikely that LCPUFA-supplemented formula would reduce the differences in outcomes between children in intervention and control groups in these studies.

SIDS

Case-control studies suggest that formula feeding is associated with a 1.6-(95% CI, 1.2-2.3)1 to 2.1-fold (95% CI, 1.7-2.7)35 increased odds of SIDS compared with breastfeeding. These associations persisted after adjustment for sleeping position, maternal smoking, and socioeconomic status. In reviewing the evidence, the American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome concluded that factors associated with breastfeeding, but not breastfeeding per se, were associated with a lower incidence of SIDS.36

Infant Mortality

After adjusting for maternal age, education, smoking status, infant race, gender, birth weight, congenital malformation, birth order, plurality, and Women, Infants and Children Nutrition Program status, formula feeding is associated with a 1.3-fold (95% CI, 1.1-1.5) higher risk of infant mortality in the United States compared with ever breastfeeding.37 In a subgroup analysis, the association was limited to SIDS and injury-related death.

Role of Exclusive Breastfeeding in Infant Health Outcomes

Early feeding plays a central role in development and maturation of the infant immune system. Compared with human milk-fed infants, formulafed infants have higher pH stools and greater colonization with pathogenic bacteria, including E coli, Clostridium difficile, and Bacteroides fragilis.38 Bioactive factors in human milk appear to facilitate the more favorable gut colonization in breastfed infants. These oligosaccharides, cytokines, and immunoglobulins regulate gut colonization and development of gut-associated lymphoid tissue and govern differentiation of T cells that play a role in host defense and tolerance.39 Formula-fed infants also have a smaller thymus than breastfed infants.40 These differences in immune system differentiation may underlie the higher incidence of allergic disease observed in formula-fed children. Not breastfeeding may also affect disease risk through exposure to foreign antigens in formula.

Type 1 Diabetes

Epidemiologic studies have reported an association between exposure to cow's milk antigen and development of type 1 diabetes, although results have been mixed.43 Less than 3 months of breastfeeding has been associated with a 1.2- (95% CI, 1.1-1.4)44 to 1.4-fold (95% CI, 1.2-1.5)45 increased risk of developing type 1 diabetes compared with more than 3 months of breastfeeding. There is some evidence that differential recall between cases and controls may have biased results.44 A randomized, controlled trial is currently underway to test whether cow's milk formula increases development of islet-cell antibodies. Infants at high risk of type 1 diabetes have been randomized to supplementation with hydrolysated formula versus cow's milk formula. In a pilot study,46 exposure to cow's milk-based formula was associated with higher prevalence of islet cell auto-antibodies, providing tentative evidence for a causal association between cow's milk exposure and type 1 diabetes.

Childhood Cancer

Several studies have examined associations between formula feeding and childhood leukemia based on the hypothesis that immunoreactive factors in breast milk may prevent viral infections implicated in the leukemia pathogenesis.47 Two meta-analyses1,48 found a 1.3-fold higher risk of acute lymphoblastic leukemia (95% CI, 1.1-1.4) among formula-fed children compared with children who were breastfed less than 6 months. Kwan and colleagues48 also found a 1.2-fold higher risk of acute myeloid leukemia (95% CI, 1.0-1.4) among formula-fed infants compared with infants breastfed more than 6 months.

Infant Feeding and Maternal Health Outcomes

Not breastfeeding or weaning prematurely is associated with health risks for mothers as well as for infants. Epidemiologic data suggest that women who do not breastfeed face higher risk of breast cancer and ovarian cancer, as well as obesity, type 2 diabetes, metabolic syndrome, and cardiovascular disease. As in the pediatric literature, most evidence arises from observational studies, which are subject to confounding by other health behaviors. For maternal health outcomes, associations are generally reported according to lifetime duration across all pregnancies, rather than duration of feeding for each pregnancy.

Lactation and Malignancy

Lactation suppresses ovulation, leading to lactation amenorrhea. In addition, lactogenesis leads to terminal differentiation of breast tissue with potential long-term effects on malignant transformation. These effects may mediate associations between breastfeeding and breast and ovarian cancer.

Breast Cancer

Some studies have suggested that breastfeeding reduces breast cancer risk, but evidence has been mixed. Observational studies relating lactation and breast cancer among postmenopausal women have largely failed to identify an association.49,50 Reports from case-control studies suggest a modest inverse association between breastfeeding and premenopausal breast cancer risk, but findings have been inconsistent and limited by potential recall bias.51,52 Longitudinal studies have similarly produced conflicting results.49,53⁻55 A meta-analysis of 47 studies found that each year of breastfeeding was associated with a 4.3% (95% CI, 2.9-5.8) reduction in risk of invasive breast cancer.56 In the Nurses' Health Study II, the association was stronger among women with a first-degree relative with breast cancer.57 In this group, never breastfeeding was associated with a 2.4-fold increase (95% CI, 1.3-4.5) in incidence of premenopausal breast cancer, compared with ever having breastfed.

Ovarian Cancer

In case-control studies,1 never breastfeeding is associated with a 1.3-fold higher (95% CI, 1.1-1.5) risk of ovarian cancer, compared with ever having breastfed. Danforth and colleagues58 prospectively examined risk of ovarian cancer in the Nurses' Heath Studies and found that women who had never breastfed faced a 1.5-fold risk (95% CI, 1.0-2.2) of ovarian cancer, compared with women who breastfed for greater than 18 months. These associations may be mediated by antibodies to MUC-1 antigen, which are thought to develop during mastitis.59

Lactation and Maternal Metabolism

Breastfeeding poses a substantial metabolic burden on mothers, requiring 500 kcal per day to supply milk for an exclusively breastfed infant. This metabolic load may help mobilize weight gained during pregnancy. In addition, breastfeeding is associated with more favorable glucose levels, lipid metabolism, and blood pressure. Epidemiologic studies suggest that these differences may persist after weaning with significant longterm benefits for mothers.60

Dewey and associates61 compared weight loss during the first year postpartum between 2 groups of women: those breastfeeding less than 3 months and those continuing for more than 1 year. Women who were intentionally dieting to lose weight were excluded from the study. Women in the prolonged breastfeeding group lost 4.4 lbs more than women who weaned at 3 months, and this difference in weight persisted at 2 years postpartum ( P < .05). Other studies have found mixed results,1 suggesting that differences in caloric intake and physical activity may play a greater role in postpartum weight change than breastfeeding.

A randomized, controlled trial in Honduras provides evidence that breastfeeding can mobilize calories for weight loss.32 Women exclusively breastfeeding were randomized at 4 months postpartum to introduce complementary foods for their infants or continue to breastfeed exclusively. At 6 months, exclusively breastfeeding mothers had lost 600 g more than those in the complementary feeding group ( P < .05), suggesting that more intense lactation mobilizes additional adipose stores.

Differences in metabolism between breastfeeding and formula-feeding women appear to persist into later life. Several authors have found a higher risk of diabetes and the metabolic syndrome among women who have never breastfed compared with those who breastfed for a prolonged period. In the Nurses' Health Studies, the risk of type 2 diabetes in the 15 years since their last birth was 1.7-fold higher (95% CI, 1.3-2.3) among parous women who never breastfed compared with those who breastfed for a lifetime total of 2 years or more.62 Never having breastfed was also linked with a 1.3-fold (95% CI, 1.1-1.6) risk of myocardial infarction compared with lifetime breastfeeding for 2 years or more in the Nurses' Health Study.63 Ram and colleagues64 assessed the prevalence of metabolic syndrome in a cohort of middle-aged women and found a 1.3-fold higher risk (95% CI, 1.0-1.6) among parous women who had never breastfed, compared with those who had ever breastfed. Similarly, in the Women's Health Initiative, Schwarz and colleagues65 found a 10% to 20% higher risk of diabetes, hyperlipidemia, and cardiovascular disease among parous women who had never breastfed compared with those who breastfed for 13 to 23 months ( P for trend < .001 for all outcomes).

The Obstetrician's Role in Promoting and Supporting Breastfeeding

Multiple studies provide evidence that formula feeding is associated with increased risks for infants and mothers compared with breastfeeding. By supporting breastfeeding as the normative way to feed an infant, the obstetrician-gynecologist can play a powerful role in improving health outcomes across 2 generations.

Counseling During Antenatal Care

When counseling patients about breastfeeding, studies suggest asking open-ended questions such as: "What have you heard about breastfeeding?" followed by acknowledging the mother's concerns and targeting education to her specific needs. For the mother who elects to bottle feed, this approach allows for an open discussion of risks and benefits and ensures informed consent for the feeding decision. Such an approach is more effective than asking a closed-ended question such as: "Are you going to breast- or bottle-feed?"68

Physician office participation in formula marketing programs is also a major predictor of breastfeeding outcomes. Howard and colleagues69 conducted a randomized, controlled trial of promotional materials at the first prenatal visit. Mothers received either a formula company-sponsored information pack on infant feeding or a noncommercial pack of equal value. Among mothers who were uncertain about their plans to breastfeed, those who received the formula marketing packet were 1.7 (95% CI, 1.2-2.6) times more likely to wean than those who received the noncommercial information. This randomized trial provides compelling evidence that obstetric care providers should not participate in formula marketing programs.

Physiology of Breastfeeding

Lactation begins with secretory differentiation of breast tissue during pregnancy.70 Hormonal changes in estrogen, prolactin, progesterone, and IGF-1 cause differentiation of the mammary epithelium in preparation for milk production. Alveoli form by the end of the first trimester of pregnancy. Placental prolactin, placental growth hormone, and human placental lactogen support mammary differentiation and milk formation. Progesterone produced by the placenta prevents synthesis of mature milk until after birth. Secretory activation occurs as progesterone levels fall and milk production increases from 50 mL/d at birth to approximate 500 mL/d in the first 2 to 3 days after delivery. As production increases, mammary secretions change from colostrum, a clear fluid rich in secretory IgA and lactoferrin, to mature milk, which contains lactose, lipids, and proteins.

Successful establishment of lactation requires removal of progesterone and estrogen with delivery of the placenta, followed by a cycle of milk let down, successful latch, and removal of milk. Obstetricians can facilitate this process of "let down, latch, and moving milk" by encouraging immediate skin-to-skin contact after birth, followed by feeding on demand and "rooming in," keeping the mother and infant together during the postpartum stay. Of note, in a small observational study, Keefe73 found that mothers who kept infants in their rooms at night slept as much as those who send their infants to the nursery.

Hospital Practices and Breastfeeding Success

Data from randomized studies show that maternity care practices have a substantial impact on breastfeeding success and infant health outcomes. In the PROBIT trial,17 intervention hospitals implemented the BFHI. This set of evidence-based guidelines was developed by the WHO to increase initiation and duration of breastfeeding.74 Kramer and colleagues33 found that the intervention increased duration of exclusive and total breastfeed through the first year of life and resulted in improved health outcomes ranging from gastroenteritis to school-age verbal IQ.

The BFHI has been widely implemented around the world, reaching more than 15,000 maternity hospitals in 134 countries. However, in the United States, fewer than 100 hospitals are certified as Baby Friendly. A recent study by the Centers for Disease Control and Prevention6 surveyed 2687 maternity centers to measure implementation of BFHI guidelines. The mean score was 63 out of 100 possible points. The authors found that routine practices in many maternity hospitals are not supportive of breastfeeding. For example, 65% of hospitals reported that staff advise mothers to limit duration of suckling at each feeding, and 70% distribute formula company marketing packs to breastfeeding mothers, despite evidence that both practices reduce breastfeeding success.

Obstetricians can help close this quality gap by supporting efforts to eliminate outdated practices and providing evidence-based support for breastfeeding. For example, a Cochrane review of randomized trials demonstrated that infants placed skin-to-skin at delivery breastfeed 42 days longer than infants who are swaddled in the first hour of life.75 The obstetrician can directly impact this practice by placing the healthy infant on the mother's chest at delivery and encouraging hospital staff to perform the initial assessment while the infant is with the mother, as recommended by the AAP ( Table 1 ).

Table 1

American Academy of Pediatrics Section on Breastfeeding Recommendations for Skin-to-Skin Care at Delivery3

Healthy infants should be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished.

The alert, healthy newborn infant is capable of latching on to a breast without specific assistance within the first hour after birth. Dry the infant, assign Apgar scores, and perform the initial physical assessment while the infant is with the mother. The mother is an optimal heat source for the infant. Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed. Infants affected by maternal medications may require assistance for effective latch-on. Except under unusual circumstances, the newborn infant should remain with the mother throughout the recovery period.

The Obstetrician's Role in Supporting Breastfeeding

During Antenatal Care

* Do not participate in formula marketing programs.

* Ask the patient, "What have you heard about breastfeeding?" Respond to her concerns and educate her about medical recommendations for 6 months of exclusive breastfeeding.

* Provide anticipatory guidance about early initiation of breastfeeding, skin-to-skin care, feeding on demand, and rooming in.

* For women with a history of breast reduction surgery or a difficult feeding experience with a prior child, refer to a lactation consultant for an antenatal consult.

Intrapartum

* Provide anticipatory guidance about establishment of breastfeeding.

* For women undergoing cesarean deliveries, encourage skin-to-skin contact in the recovery room to facilitate establishment of breastfeeding.

* Educate labor floor staff about the importance of skin-to-skin contact.

During the Postpartum Hospitalization

* Ask "How is breastfeeding going?" Respond to specific concerns and emphasize recommendations for exclusive breastfeeding for the first 6 months.

* Encourage rooming in and feeding on demand.

* Ensure involvement of a lactation consultant if there is pain during feeding beyond the initial latch.

* Collaborate with pediatric providers regarding maternal medications that may be of concern during breastfeeding. Use LactMed as a reference for evidence-based reviews of medication safety.

* Provide referrals to breastfeeding resources in the community.

At the Postpartum Visit

* Ask "How is breastfeeding going?" Respond to specific concerns and emphasize recommendations for exclusive breastfeeding for the first 6 months.

* Provide guidance on expression of milk for return to school or work.

* Offer to sign a letter to her employer regarding the importance of accommodations to allow continued breastfeeding. (Sample available at http://www.womenshealth.gov/breastfeeding/programs/business-case/outreach-marketing-resources.pdf.)

* Work with lactation consultants in your community to manage pain, low milk supply, or other breastfeeding concerns.

At Annual Well-Woman Visits

* Assess whether patients are currently breastfeeding.

* Be aware that the World Health Organization recommends a minimum of 2 years of breastfeeding for each infant.

Conclusions

Formula feeding is associated with adverse health outcomes for both mothers and infants, ranging from infectious morbidity to chronic disease. Given the compelling evidence for differences in health outcomes, breastfeeding should be acknowledged as the biologic norm for infant feeding. Physician counseling, office, and hospital practices should be aligned to ensure that the breastfeeding mother-infant dyad has the best chance for a long, successful breastfeeding experience.

Research suggests that breastfeeding is a key modifiable risk factor for disease for both mothers and infants. Current guidelines recommend exclusive breastfeeding for a minimum of 6 months up to the first 2 years of life, although breastfeeding in the United States falls far short of these recommendations. Data suggest that variations in hospital practices account for disparities in breastfeeding duration. Improvements in the quality of antenatal and perinatal support could have a substantial impact on mother and infant health.

There are specific and innate immune factors present in human milk that provide specific protection against pathogens in the mother's environment. In addition, immune factors in milk provide protection against infections such as H influenzae, S pneumoniae, V cholerae, E coli, and rotavirus.

Not breastfeeding is associated with health risks for both mothers and infants. Epidemiologic data suggest that women who do not breastfeed face higher risk of breast and ovarian cancer, obesity, type 2 diabetes, metabolic syndrome, and cardiovascular disease.

Patient perception of clinician opinion is directly associated with breastfeeding duration. A Massachusetts study found that just 8% of physicians believed their advice on breastfeeding practices was important, but more than one-third of mothers reported that their provider's advice on this subject was important.

The Baby Friendly Hospital Initiative has been widely implemented throughout the world, reaching more than 15,000 maternity hospitals in 134 countries, although routine practices in many maternity hospitals are not supportive of breastfeeding. Obstetricians who counsel on breastfeeding can help eliminate outdated practices and provide evidence-based support on behalf of breastfeeding.

References

2. American College of Obstetrics and Gynecology, authors. Special Report from ACOG. Breastfeeding: maternal and infant aspects. ACOG Clinical Review. 2007;12(suppl):1S-16S. [ Google Scholar]

19. Horta BL, Bahl R, Martinés JC, et al. Evidence on the long-term effects of breastfeeding: systematic review and meta-analyses. Geneva: World Health Organization; 2007. pp. 1-57. [ Google Scholar]

Articles from Reviews in Obstetrics and Gynecology are provided here courtesy of MedReviews, LLC

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The Risks of Not Breastfeeding for Mothers and Infants

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Health outcomes in developed countries differ substantially for mothers and infants who formula feed compared with those who breastfeed. For infants, not being breastfed is associated with an increased incidence of infectious morbidity, as well as elevated risks of childhood obesity, type 1 and type 2 diabetes, leukemia, and sudden infant death syndrome.

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2013 - in depth look at the evidence

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By Kathleen Mitchell-Askar, Pregnancy & Birth and Feeding Editor for The Attached Family
A study published in the April 2010 issue of The Journal of Pediatrics by The Western Australian Pregnancy Cohort (Raine) Study suggests that breastfeeding may have a positive effect on children's and adolescents' mental health. A paper that appeared in the Journal of Child Psychology and Psychiatry listed children's mental health as one of the six priority areas in need of attention to improve the health and development of children and adolescents across the globe. At a time when 10 to 20% of children worldwide suffer from emotional or behavioral problems, a possible solution as simple as breastfeeding is one that could prove both attainable and powerful.

For more than 50 years, breastfed babies have been shown to hold developmental and cognitive advantages over non-breastfed children. Some studies have even shown that breastfed infants are better able to cope with adverse stimuli with more control, and children who were breastfed as infants exhibited greater resilience against the stress and anxiety associated with parental separation and divorce. These previously published studies are limited, however, by their small, often nonrandom, samples.

The Australian study derives its strength from its large sample size, longitudinal nature, and excellent response fractions. From 1989 to 1992, the Western Australian Pregnancy Cohort enrolled 2,900 pregnant women during their second trimesters who went on to deliver at the major obstetric hospital in Perth. Researchers gathered data on both parents' familial, social, economic, and demographic backgrounds, along with their medical and obstetric histories, and updated the data during the 34th gestational week. The newborns (both singletons and twins) were initially examined by a midwife or pediatrician at two days postpartum, and 2,868 live births were included in the study. These children were followed until age 14.

The study focused on the parent-report Child Behaviour Checklist (CBCL) as the outcome variable at the five-, eight-, ten-, and 14-year follow-ups. The two-year-old children were evaluated with a similar questionnaire, modified with appropriate sleep questions and other subtle differences relative to the age group. Parents completed the 118-item CBCL, which measures behavioral psychopathology in children according to eight syndrome constructs:

Withdrawn

Anxious/depressed

Somatic complaints

Social problems

Attention problems

Thought problems

Delinquent behavior

Aggressive behavior.

Withdrawn; anxious/depressed; and somatic complaints were grouped and scored as "internalizing problems." Delinquent and aggressive behaviors were treated as "externalizing problems." The results from the CBCL were converted into age/sex-appropriate scores. The higher the score, the more problematic the child's mental health.

A little over half of all mothers in the study (52%) breastfed for six months or longer, and 11% never breastfed at all. Nineteen percent of the children were breastfed for less than three months, 19% for three to six months, 28% for six to 12 months, and 24% for 12 months or more. The study investigated the effects of exclusive breastfeeding but found it did not change the conclusions drawn from the data with "any" breastfeeding (breastfeeding with the addition of solid food).

The study's findings point to a boon for breastfed children: The longer a baby fed at the breast, the lower the child's score on the CBCL, and the trend continued through adolescence. The differences between breastfed and non-breastfed children were most distinct in the total and externalizing scores. Even after researchers controlled for such confounding factors as maternal age at birth, maternal education, maternal smoking, family structure (whether the biological father lived with the family), life stress events, and maternal postnatal depression - all of which have been linked with higher rates of mental health problems - shorter breastfeeding duration was "consistently associated with increased risks for mental health problems of clinical significance through childhood and into adolescence," the study concludes.

Despite the promising findings on the effects of breastfeeding on mental health, whether the positive correlation was due to breastmilk itself or the maternal-child bond cultivated at the breast was unclear. It is known that the fatty acids and other bioactive components in breastmilk positively contribute to child development and health. The hormone leptin, also found in breastmilk, may reduce stress in infants through its effects on the hippocampus, hypothalamus, pituitary gland, and adrenal gland.

Breastfeeding mothers have also been shown to touch their babies and gaze into their eyes more often. Such stimulation has not been linked with better mental health in human studies yet, but the Australian researchers cite a study on rat pups, and those that received a greater amount of maternal contact were better able to cope with stress as adults.

According to the study, "Breastfeeding may also be an indicator of a secure attachment status, which is known to have a positive influence on the child's psychological development into adulthood."

Even though breastmilk is the healthiest first food for a child, if a mother cannot or chooses not to breastfeed, it is possible that the attachment between parent and child affects the child's mental health more profoundly than does the food itself. By practicing Attachment Parenting, holding the baby close while bottle-feeding, and increasing the amount of touch through babywearing, the mother of a non-breastfed baby could give her child mental-health benefits similar to those enjoyed by a breastfed baby. Parents who give proper attention to their children and remain present with them, whether breastfeeding or not, will make their child feel cherished and have a positive effect on his or her self-esteem.

But, as the Western Australian Pregnancy Cohort (Raine) Study shows, "breastfeeding for a longer duration appears to have significant benefits for the onward mental health of the child into adolescence...Therefore, interventions aimed at increasing breastfeeding duration could be of long-term benefit for child and adolescent mental health."

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The Link between Breastfeeding and Mental Health

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By Kathleen Mitchell-Askar , Pregnancy & Birth and Feeding Editor for The Attached Family A study published in the April 2010 issue of The Journal of Pediatrics by The Western Australian Pregnancy Cohort (Raine) Study suggests that breastfeeding may have a positive effect on children's and adolescents' mental health.

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Easy read article with good links

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My son kicks off the covers and rouses from his slumber with a start. It's 2am and he's having a bad dream.

When hugs fail to soothe his soul, I honour his request as he tugs at my pajama top, allowing him to nurse and find the comfort he seeks. Relaxation and relief are immediate.

Flooded with feelings of gratitude for this maternal superpower, I'm astonished that our journey has taken us this far.

We've been breastfeeding for four and a half years.

As the weight of his little body melts into my arms, I'm transported back in time to the early days of motherhood; sitting upright in bed with a nursing pillow around my waist, lamp on, snack handy and feeling mesmerized by the newborn spirit that nestled himself quickly into my heart.

As a new mother, I remember being asked how long I anticipated breastfeeding for by curious family members: the truth was that I had no idea, but I'd confidently reply with 'two years', qualifying my unconventional response by saying that the World Health Organization recommends it. But, on my son's second birthday we were far from done.

And so, one more day turned into one more week. Weeks morphed into months and months merged into years.

Every day I am able to nourish my son in this way feels like a blessing, an exceptional encore perhaps, we're both cheering for more. We nurse at dawn and dusk; a natural gateway between our mellow slumber and the electric energy of our days.

Claim your FREE Guide: FIVE THINGS I WISH I HAD KNOWN BEFORE I STARTED BREASTEEDING

Occasionally my son nurses to ease a bump and bruise, both physical and emotional, and when he does, it's spiritual gold dust for me too. A few moments of meditation, where the world stops and it's just my son and I. A few moments of slowness that gives me the space to contemplate the speed and direction of our lives.

A few moments to reset and catch my breath in our unnecessarily busy world.

Like most of us, I'm parenting without a village in the most literal of senses. It's beyond difficult, but in many ways, it's liberating. The flip side of little support is a greater sense of freedom to make my own choices.

But, I have heard comments and I'm not immune to them; "If he has teeth he's too old to nurse! If she can ask for milk she's too old to breastfeed! Isn't it about time she gave her breasts back to her husband?! That mother is psychologically damaging her child."

Our western culture considers breastfeeding beyond babyhood to be abnormal and, in many ways, consciously or not, sabotages the practice. Whether and for how long a woman chooses to breastfeed is a personal decision and one that should be met with support, not judgement.

This post is not intended to be divisive, but rather to share my unexpected experience and inform mothers (and those who care for them) so that we all feel empowered to make our own choices. I firmly believe that 'informed is best' and only a mother knows how to make the right choice for her and her family.

So here are a handful of reasons science proves breastfeeding beyond babyhood is beyond normal.

1. BECAUSE HUMANS ARE DESIGNED TO NURSE BEYOND BABYHOOD

Dr. Katherine A. Dettwyler, anthropologist and breastfeeding advocate, suggests that evolution dictates that our children expect to breastfeed for three to seven years. Katherine cites numerous anthropological studies, to determine what a 'normal' weaning age may be:

Quadrupling of birth weight: Research shows weaning occurs after birth weight is quadrupled in large mammals. For humans, this occurs at around 27-30 months.
Adult bodyweight: Other studies suggest primates wean when they reach one-third of adult bodyweight. For humans, this means weaning at four to seven years.

Length of pregnancy: Chimpanzees and gorillas nurse more than six times the length of gestation. Drawing a comparison from our closest cousins suggests that humans would nurse for 4.5 years, or six times gestational length.

Dental eruption: Many primates nurse until the first permanent molars erupt. In humans, this occurs at around 5.5 to 6.0 years.

2. BECAUSE BREASTMILK DOESN'T HAVE AN EXPIRY DATE

Recent research by Vicki Greene, a biosciences student at South Devon College in the UK, went viral when she shared images of nine petri dishes containing the bacteria M. luteus, to which she had added human breastmilk from a mom of a 15-month-old and from the mom of a 3-year-old.

The results were incredible.

In the center of the petri dish, where the breast milk was placed, the bacteria was completely killed off. Research continues, with similar results having been seen for E. coli and MRSA.

Similarly exciting results were reported in a groundbreaking 2010 study that showed breastmilk contains a substance known as HAMLET which has been shown to kill forty different types of cancer cells.

Supporting this are results from a 2015 investigation published in JAMA which analyzed 18 studies related to leukemia and breastfeeding. Researchers found that breastfeeding a child for six months or longer was associated with a 19% lower risk for childhood leukemia. Encouragingly, their analyses also revealed that children who were ever breastfed had an 11% lower risk for childhood leukemia.

The composition of breastmilk does change over time but it does so in order to match the evolving needs of a child. The notion that breastmilk has no nutritional value or protective function beyond a certain age is false. A study published in the journal Pediatrics, reported that the fat and energy contents in milk from moms who have been nursing for more than one year were "significantly increased" compared to milk from moms breastfeeding younger babies. Some immune factors also increase in concentration during the second year of breastfeeding.

According to KellyMom.com, 448mL of breastmilk provides toddlers with 29% of energy requirements, 43% of protein requirements, 36% of calcium requirements and 94% of vitamin B12 requirements.

3. BECAUSE IT FUELS EMOTIONAL AND INTELLECTUAL INTELLIGENCE

Extensive research shows that children who breastfeed the longest have higher rates of cognitive achievement (IQ scores, grades in school), with a positive relationship being seen between longer breastfeeding duration and social development. Elizabeth Baldwin, in Extended Breastfeeding and the Law says that, 'Meeting a child's dependency needs is the key to helping that child achieve independence. And children outgrow these needs according to their own unique timetable.'

When we attempt to push children into premature independence they feel less secure in that independence than those who have achieved it at their own pace. Building a solid foundation for our kids at a young age by meeting their dependency requirements will set them up to be more grounded, independent teenagers and adults.

4. BECAUSE IT NOURISHES A MOTHER'S HEALTH

Recent research has shown that extended breastfeeding was related to a 30% reduction in the risk of premenopausal breast cancer. But, there are even more health benefits including:

* Delaying the return of fertility by suppressing ovulation helping to achieve natural child spacing
* Reduce the risk of ovarian, uterine, and endometrial cancer
* Protect against osteoporosis
* Reduce the risk of rheumatoid arthritis, cardiovascular disease and post-natal depression

5. BECAUSE BREASTFEEDING PROTECTS KIDS, NO MATTER THEIR AGE

The World Health Organization suggests that "a modest increase in breastfeeding rates could prevent up to 10% of all deaths of children under five: Breastfeeding plays an essential and sometimes underestimated role in the treatment and prevention of childhood illness."

Breastmilk is a unique substance that can't be replicated, protecting babies and children against disease regardless of their age.

In the second-year postpartum breastmilk contains significantly higher concentrations of lactoferrin, lysozyme and immunoglobulin A than milk from new mothers. Antibodies to infectious disease remains high throughout lactation and when a nursing child is affected by an illness the number of white blood cells in the mother's milk spikes in response. The mechanism behind this response is thought to involve the mother's body reacting to backwash from her baby's mouth through breastfeeding.

It is also well known that breastfed babies and children more likely to experience lower rates of asthma and allergies. It is thought that the short-chain fatty acids found in breast milk are uniquely able to line an infants' gut as well as power the cells in the colon, leading to a more robust immune system.

GO AHEAD AND BREASTFEED BEYOND BABYHOOD

Before becoming a mother I didn't think I'd breastfeed at all, but when we surrender to motherhood it has a way of shattering our preconceived ideals and disempowering cultural norms. If there is one thing that I have learned on this journey, it is that fitting in is overrated. Authenticity and following our instincts is the key to true belonging.

Breastfeeding is a maternal superpower; why we would give it up prematurely is simply beyond me.

An excellent post, Why Mothers Nurse Their Children into Toddlerhood, sums up my feelings on nursing beyond babyhood perfectly, "No matter how much effort has gone into the selling of distance between mother and child - distance achieved by mother substitutes, like playpens and pacifiers, and by child substitutes, like hobbies and pets - mothers, it seems, cannot be changed. We still are happiest when we can hold our children close."

When we hold our children close something magical happens.

If nursing beyond babyhood is the right choice for you then I encourage you to follow your heart. Find strength in the knowledge that although we may be trailblazers by modern standards, women have been nursing their children beyond babyhood throughout human history. The science is in: breastfeeding beyond babyhood is NORMAL.

Claim your FREE Guide: FIVE THINGS I WISH I HAD KNOWN BEFORE I STARTED BREASTEEDING
* Post updated on December 5th, 2017

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The Science Is In: Breastfeeding Beyond Babyhood is Normal - Raised Good

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My son kicks off the covers and rouses from his slumber with a start. It's 2am and he's having a bad dream. When hugs fail to soothe his soul, I honour his request as he tugs at my pajama top, allowing him to nurse and find the comfort he seeks.

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Why don't more women breastfeed in the UK?

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Why don't more women breastfeed in the UK?

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This open letter to the UK Government was published in 2016 and signed by every medical and charitable body concerned with infant health. It highlights that the crisis in breastfeeding in the Uk is, in fact a crisis in support for women to enable them to breastfeed for as long as they want.

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On Tuesday 9 February, health visitors, midwives, paediatricians, GPs, lactation consultants, breastfeeding counsellors, peer supporters, university researchers, professional organisations and charities signed a letter calling for action by the UK Government and National Assemblies of Scotland, Wales and Northern Ireland to support mothers to breastfeed.
Open Letter Press release
The letter has been signed by (among others):-

Royal College of Paediatrics and Child Health, Royal College of General Practitioners, Institute of Health Visiting, Community Practitioners' and Health Visitors' Association, Independent Midwives UK, Midwives Information & Resource Service (MIDIRS), ARM, Lactation Consultants of Great Britain, National Infant Feeding Network, NCT, The Breastfeeding Network, Association of Breastfeeding Mothers, La Leche League GB, Leicester Mammas CIC, The Local Infant Feeding Information Board, United Kingdom Association for Milk Banking, Best Beginnings, First Steps Nutrition Trust, Baby Feeding Law Group, Baby Milk Action/IBFAN-UK, World Breastfeeding Trends Initiative UK, and by university researchers at the University of Dundee, University of Central Lancashire, University of Brighton, Swansea University, and Ealing Hospital, London North West Healthcare NHS Trust.

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Open Letter on the crisis in UK breastfeeding

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On Tuesday 9 February, health visitors, midwives, paediatricians, GPs, lactation consultants, breastfeeding counsellors, peer supporters, university researchers, professional organisations and charities signed a letter calling for action by the UK Government and National Assemblies of Scotland, Wales and Northern Ireland to support mothers to breastfeed.

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Breast milk and formula are not the same

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Breast milk and formula are not the same

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sA detailed exploration of the differences.

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There are some people out there that argue that there is no difference between breastmilk and formulas now that so many "improvements" in formula have occurred. At the biochemical level, formula is not the same as breastmilk, not even close. If you take a look at a can of formula and the list of ingredients, it is patently obvious that breastmilk contains at least 20 times more "ingredients" than formula. Breastmilk contains live cells, stem cells, white cells, immune factors and antibodies which cannot be added formula and that's just the beginning. In every other situation people would readily admit that powdered milk which is then re-constituted with hot water is not the same as fresh milk.
Formula and breastmilk are not at all the same, not even close.
Formula company advertising has tried to convince parents for years that their formulas are the same are the same as breastmilk. Photo 1 shows an ad, probably from the late 1890s or early 1900s, which states, in French "Artificial Milk Feeding", using the word normally used for "breastfeeding" (allaitement). Sneaky no?

And what else does it say? "le seul lait stérilisé identique à celui de la femme" : The only sterilized milk identical to a woman's milk!!!!

So by the beginning to the 20th century, formula was being advertized as just like breastmilk. This has always been essential to formula company advertising because otherwise it would be difficult to convince people to use formula not only in situations where it is medically indicated but also massively and unnecessarily as it is used now. Formula being "just like breastmilk" has even become a way to compete among different formula brands using words like "closer to breastmilk than ever".
What does the next photo tell us?
It states that "our formula" has been around since your great great great grandmother's time and then goes on to list all the improvements since that time. But this ad was printed in the 1990s before:

1. DHA (docosahexaenoic acid), and arachidonic acid (ARA) - compounds which have always been in breastmilk, which have not been added to formulas until recently and which now that they have been added have been found not to have the same effect as when they are in breastmilk. Because just adding stuff to formula doesn't mean it works in the same way as the ingredient works in breastmilk.

2. The protein content of formulas was reduced and even at this time formulas still contain too much protein.

3. Before nucleotides were added to formula (they made a big deal out of this too, though the importance of nucleotides in formulas has yet to be shown to do much of anything at all).

4. Before oligosaccharides, the famous prebiotics, that formula companies have made such a big deal about in the last decade. Oligosaccharides has always been in breastmilk

5. Before probiotics which mothers are buying by the handful. Breastmilk always contained probiotics.

6. Before most "special formulas" were made for things like spitting up and "allergy".

Think about what this means. It means that formulas that were touted as "just like breastmilk" in the 1890s as well as 1990s was "improved" by all sorts of changes since then. It means that if these changes were so important to babies' health, then what about all the babies who received "unimproved formulas" all the way back to your great great great grandmother's time? These formulas were inadequate, even harmful.

And what about all those hundreds of other compounds in breastmilk which have not been added and which will never be added? And those compounds yet to be discovered. Breastmilk is a very complex, living fluid and we are just beginning to understand how complex as we discover new ingredients.
Let's start off by saying that a mother's milk is unique, depending on that mother and that baby
Yes, it is true, every mother makes milk which is different than any other mother. That is because like all physiological fluids (blood, for example) milk varies from person to person. As an example, the amount of sodium in your blood may vary quite widely, normally, by as much as 15%, depending on how thirsty you are, how much sodium was in your lunch and other factors as well. That's just one example.

We know also that colostrum, the first milk, is very different to the later milk. Very different. Yet formula companies and many doctors tell us that formula is a good milk for babies to drink during the first few days.

Aside from the much heralded nucleotides, formulas contain no antibodies. But antibodies are only one of many immune factors that are present in breastmilk that are not present in formulas. Breastmilk contains lactoferrin that is so important to immunity that the formulas are jumping on the lactoferrin bandwagon to discover how to include it in their products. And breastmilk also contains these immune factors: lysozyme (and enzyme that attacks bacteria and kills them by destroying their cell wall), mucins, lactadherin, bifidus factor and many others. And probably many others are yet to be discovered. These immune factors do not just sit there, they work together, in a beautiful cooperation, like the instruments in a symphony orchestra, to protect the baby according to which bacteria, viruses or funguses the baby may be exposed to. Even if the immune factors could be added to formulas, they would not have this "cooperation" as they cannot react to infection, because it's the mother, through her breastmilk who produces these immune factors in response to infection. Breastmilk is a living, dynamic fluid.

Breastmilk has alpha lactalbumin, which in the presence of fats in the body, is changed to HAMLET (human alpha lactalbumin made lethal to tumour cells), no relation to the Prince of Denmark, which exercises broad anti-tumor activity against many different type of cancer and lymphomas

And breastmilk varies from morning to evening, from day to day, from week to week. Because of this, it will never be duplicated by any formulas.

Furthermore, breastmilk is full of anti-inflammatory factors, which decrease inflammation. Inflammation, on its own, can cause tissue damage and inflammation occurs in the presence of the battle of immune factors against bacteria or viruses. Because of the huge numbers of "good" bacteria in the intestines, breastmilk prevents this inflammation which normally would occur when immune factors fight microbes, saving tissue damage of the gut, and probably one of the reasons breastfeeding premature babies are less likely to get a serious, potentially life-threatening condition called necrotizing enterocolitis.

There are dozens, if not hundreds of immune factors and other important components in breastmilk that are not present in formulas. Just to mention two more; one, an important recently discovered immune factor: milk fat globule membranes. Oh, this is hot and the formula companies are working feverishly to include milk fat globule membranes into their milk. If they ever manage, they will tell us how important this immune factor is, hoping we will forget that all the other formulas before the new one didn't have milk fat globule membranes. And the other? Stem cells, the mind boggles thinking how stem cells in breastmilk could be used to help in clinical medicine.

But see my article in Scientific American from 1995 . The article explains how breastfeeding protects babies against infection and why it is important to keep babies breastfeeding when the mother has an infection, including the common infection I get emails about all the time, methicillin resistant Staphylococcus aureus (MRSA). Yes, the sick mother protects her baby if she continues breastfeeding.

Also hot these days is the microbiome, all the bacteria that are part of you. Formula fed babies and breastfed babies have different bacteria in their intestines and elsewhere. And what difference does it make? The microbiome may determine the child's:

Development including neurological and cognitive development

Immune function

Protection against various pathogens

Digestive function

Stress levels

And who knows what else? We are just beginning to plumb the secrets about the difference your microbiome makes

As one article suggests

"We are only beginning to appreciate the potential health benefits that could be accrued from this venture across diagnostic, preventative and treatment realms. We look forward with great anticipation to this transformed appreciation of how our microbial wealth during early life primes for health in adulthood."
Are there things in formula that should not be there?
Of course, here is a quote from an article about aluminum in formulas. Shelle-Ann M Burrell, Christopher Exley. There is (still) too much aluminium in infant formulas BMC Pediatrics 2010; 10:63. These authors are not crazed breastfeeding radicals. In their article, they write "Infant formulas are integral to the nutritional requirements of preterm and term infants". Well, I disagree with infant formulas being integral to the nutritional requirements of preterm and term infants. Breastfeeding is integral, yes, but not formula. But then they go on to say "While it has been known for decades that infant formulas are contaminated with significant amounts of aluminium there is little evidence that manufacturers consider this to be a health issue. Aluminium is non-essential and is linked to human disease. There is evidence of both immediate and delayed toxicity in infants, and especially preterm infants, exposed to aluminium and it is our contention that there is still too much aluminium in infant formulas."

For those who are fond of exotic foods, infant formulas have been found on occasion to contain:

Rat hair

Beetle parts and beetle larvae

Pieces of glass

Melamine-due to adulteration of milk by greedy people

Do humans make mistakes?
Of course they do. And over the years there have been dozens of recalls of formula due to mistakes made in the manufacture of formula. Here is just one example:
So? Formula just like breastmilk?
What an incredible statement. Anyone who says such a thing is either completely ignorant of the biochemistry of breastmilk and formula and doesn't know what they are talking about or is plain saying nonsense for political reasons. And if formulas and breastmilk are that different, then they have very different effects on the baby and the mother. Just pretending it ain't so doesn't make it so.

And these differences do not make a difference for the baby or the mother? Seriously? Here is the truth: You don't take the normal, physiological and have to prove that it is better than the artificial. Formula feeding is an intervention, and in medical terms, you have to prove an intervention safe before it can be recommended as routine us, as in infant feeding. In fact, most women these days "cannot breastfeed" because they are undermined in their ability to do so. Hospital routines around labour and birth, separation of mothers and babies, early introduction of bottles and poor advice from health professionals results in most mothers who "cannot breastfeed". If they had normal births, and good help from the beginning, most such mothers would be very successful breastfeeding.

And one more thing, last but certainly not least. The act of breastfeeding is different from bottle feeding. Breastfeeding is a close intimate, physical and emotional relationship between two people in love.

Need breastfeeding help? Make an appointment at our clinic.

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Why are breastmilk and formula not the same?

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There are some people out there that argue that there is no difference between breastmilk and formulas now that so many "improvements" in formula have occurred. At the biochemical level, formula is not the same as breastmilk, not even close.

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How often does breastfeeding really fail?

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How often does breastfeeding really fail?

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Article exploring the facts and the myths.

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Pamela Morrison, IBCLC, West Sussex, UK

Imagine that the world had invented a new 'dream product' to feed and immunize everyone born on Earth. Imagine also that it was available everywhere, required no storage or delivery-and helped mothers to plan their families and reduce the risk of cancer ... Then imagine that the world refused to use it ... This scenario is not, alas, a fiction. The 'dream product' is human breast milk, available to us all at birth, and yet we are not using it. UNICEF, 1991.

When friends and well-wishers asked me how I was going to feed my first baby, I always answered, "I'll try to breastfeed." Against all odds, my babies grew and thrived on exclusive breastfeeding, including the surprise twins who arrived five years to the day after the birth of our first son.

If I can...

Why did I believe that I might not be able to breastfeed?

Research suggests that mothers with less confidence are likely to give up breastfeeding early [1]. " Not enough milk" is the most common reason that new mothers give for stopping breastfeeding [2] and the following kind of ego-sapping information is typical of the information new parents receive:

" Although experts believe breast milk is the best nutritional choice for infants, breastfeeding may not be possible for all women. For many, the decision to breastfeed or formula feed is based on their comfort level, lifestyle, and specific medical situations. For mothers who are unable to breastfeed or who decide not to, infant formula is a healthy alternative. Formula provides babies with the nutrients they need to grow and thrive [3]."

The cost of not breastfeeding

With today's research demonstrating the higher risks of mortality, allergy, illness, and later non-communicable diseases associated with the use of breast milk substitutes, [4] it is unacceptable that only 1% of British babies today are exclusively breastfed for the first six months as per global recommendations. There is an economic cost too to such a high rate of breastfeeding failure. If 90% of US families could comply with medical recommendations to breastfeed their babies exclusively for six months, the United States would save $13 billion per year and prevent an excess 911 deaths [5].

A US 2013 cost analysis of maternal disease associated with sub-optimal breastfeeding found that if 90% of mothers were able to breastfeed for at least one year after each birth, compared to current breastfeeding rates, this would result in savings of $17.4 billion resulting from premature death, and $733.7 million in direct and $126.1 million in indirect morbidity costs associated with breast cancer, premenopausal ovarian cancer, hypertension, type 2 diabetes mellitus, and myocardial infarction [6].

In the UK, UNICEF commissioned a report, published in 2012 [7], to examine how raising breastfeeding rates could save money through improving health outcomes. It was found that moderate increases in breastfeeding could save tens of thousands of hospital admissions and GP consultations for just five common childhood infections, and ultimately translate to a cost saving for the National Health Service of £40 million.

In January 2016 The Lancet Breastfeeding Series Global Launch reported on the most extensive piece of research into the effects of breastfeeding ever undertaken. Increasing breastfeeding worldwide could prevent over 800000 child deaths and 20000 deaths from breast cancer every year. Failing to breastfeed costs the global economy around US$302 billion every year [7a].

James Akre, in his book, The Problem with Breastfeeding: a personal reflection [8] maintains that all mothers love their babies and want the best for them, but it is whole communities who breastfeed, and the homily, "It takes a village to feed a child" remains true wherever we live. Akre postulates that if Irish women (who have the lowest breastfeeding initiation rates in the world [9], at 45%) lived in Sweden where breastfeeding rates are high, most of them would also breastfeed.

What is normal?

In global terms, breastfeeding is normal, whereas because only 8% of the world's babies are born in countries where bottle-feeding is the cultural norm [10] some might describe bottle-feeding as a "traditional harmful practice of the minority," as set out in the Innocenti Declaration [11]. In resource-poor settings new mothers are not seen to have a choice about how to feed their babies, since not to breastfeed would place the infant's health and survival in jeopardy. Certain cultural beliefs and taboos also ensure that breastfeeding will continue to be practised. Breastfeeding, often portrayed with reverence, is not only a duty and a privilege, but also a sign of sexual fidelity. By giving birth and having children, a woman's status in society is elevated. By breastfeeding her babies, a woman demonstrates to her husband, family, and friends that she is a good wife and mother.

5% of all mothers?

So how often does breastfeeding really fail?

In the sophisticated, emancipated societies of the global west and north, it has been suggested that 5% of mothers are unable to produce enough breast milk to nourish their babies at the breast. Well-respected authors who have anecdotally referred to the 5% figure include Dana Rafael [12] in 1955 and Marianne Neifert [13] in 1983, but a search of the literature fails to reveal any primary research to document or validate it. Betty Crase, a La Leche League Leader and former director of the LLLI's Center for Breastfeeding Information, exhaustively traced the 5% figure back to a remark in an opening presentation given by JC Spence, MD, FRCP, at the Annual Meeting of the British Medical Association in Plymouth, in 1938 [14]. What Betty discovered was that since then everyone was just quoting everyone else who had used the figure. Researchers or authors in the 1980s or 1990s for example simply quoted Neifert. Betty concluded that whenever a specific number is quoted, it gives the impression that there is research behind the number. In this case, there was no research, just a remark in a speech by a physician at a prestigious medical meeting. The 5% had taken on a life of its own [15].

In reality, the physiology of lactogenesis (the production of breast milk) is much more reassuring. During early pregnancy, hormones including progesterone, produced by the placenta, which is fetal tissue, cause proliferation of the milk producing cells within a mother's breasts. Thus the baby is responsible for generating his own future source of nutrition after birth, and the breasts are ready to produce milk any time after the 16 th week of pregnancy.

Before birth, progesterone acts as a brake on milk production. Afterwards it is the abrupt withdrawal of progesterone following delivery of the placenta that causes the breasts to start producing copious quantities of milk.

Use it or lose it

Between day four and day nine postpartum, the breasts will produce 400-750ml of breast milk per day, regardless of whether the mother has decided to breastfeed or not. It is the frequent and thorough drainage of milk from the breasts that maintains continued breast milk synthesis. This is the most critical time in a mother's lactation journey. If not removed, special milk proteins signal the cells to make less milk. Ongoing over-fullness (called engorgement) can dramatically reduce continued breast milk production within just four days. This is Nature's way of ensuring that there is no waste. Use it or lose it is the principle new mothers need to be aware of.

If the baby is sleepy, or cannot latch and breastfeed effectively, or if the breasts become overfull for any reason whatever, mothers need prompt skilled assistance to express the excess milk enabling future milk production to be preserved. If a baby is too premature or too sick to breastfeed, then the mother can be taught how to provide her expressed milk to him until he matures.

In my practice as an International Board Certified Lactation Consultant, after ruling out known causes of delayed lactogenesis such as underactive thyroid, postpartum hemorrhage, or retained placental fragments, and after applying the very best lactation management techniques, I have documented that only one in a thousand (0.1%) of new mothers simply do not produce any breast milk at all. For the mother who wanted to breastfeed, this is a heart-breaking disappointment. Fortunately it is very, very rare.

Much more commonly the mother receives outdated information and inadequate help and ends up believing that-like so many of her friends who had similar negative experiences-she was unable to breastfeed.

The decision whether to breastfeed

In sophisticated societies where infant formula is both easily accessible and socially acceptable, where the value of mother's milk is trivialized, and where there is clean water and expert medical care to treat the greater number of infections that a bottle-fed baby can be expected to suffer, mothers who are struggling to breastfeed may receive strong pressure from family, their peers, or even from less well-informed healthcare providers to switch to bottle-feeding. Often such mothers become very defensive as, rather than confront failure or accept that they themselves were failed by a poor support network, they attempt to rationalize a decision not to breastfeed.

An increasing number of articles, social support networking sites, blogs, books, and videos affirming mothers' choice to formula-feed attest to the bitterness, disappointment, and strength of feeling generated by the failure to succeed at breastfeeding [16], [17], [18], [19], [20].

Anger is sometimes directed at breastfeeding advocates, who may be labeled "Fanatics," "Lactivists," "Nipple Nazis," or "Breastapo." Consequently there is often considerable stigma attached to breastfeeding promotion, coupled with a very real fear of engendering maternal guilt. Many breastfeeding counselors are at pains to rationalize formula-feeding by defending women's right to bodily integrity.

A mother may absolutely believe that, when breastfeeding is difficult, her own emotional wellbeing is more important than her baby's health:

" When the entire focus is on what's 'best for baby,' we devalue mothers and their physical and emotional well-being. I was happier, more relaxed and less stressed when I switched to formula feeding my oldest son. That is important to acknowledge, even if I get flak for it. I was happier. And that was absolutely the best thing for my babies" [21].
"All 'fearless' formula feeding means to me is that you feel you have made the best choice for your family, for your baby, for you. Fearless doesn't necessarily mean regret-less, guilt-less, anger-less, resentful-less. It just means you're not scared of your choice, because you know it is safe, and you know it was right" [22].
The World Health Organization maintains that "The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother's milk be considered unsuitable for her infant [23]-in the majority of health conditions affecting either the mother or the baby, breastfeeding should continue. The acceptable medical reasons why a baby should not receive breast milk, are very few, as follows [24]:

Acceptable medical conditions in infants:

Galactosemia

Maple Syrup Urine disease

Phenylketonuria

Acceptable medical conditions in mothers:

HIV infection where the mother has not received antiretroviral treatment and where formula-feeding is deemed to be safe

Severe illness, e.g. sepsis

Herpes simplex virus type-1 on the breasts pending treatment

Medication with sedating psychotherapeutic drugs, anti-epileptic drugs & opioids, radioactive iodine-131, topical iodine, cytotoxic chemotherapy."

As someone who works to resolve breastfeeding difficulties, I know better than most that when breastfeeding has been mismanaged, supplements to mother's milk can be lifesaving in protecting a baby's nutritional status. If donor or banked breast milk cannot be obtained, formula may be necessary in the short term while the mother works to increase her breast milk supply. Rarely, the baby may need supplementation for many months. But most of the time it is possible to pinpoint the cause, and identify the cascade of events that led to breastfeeding failure and to employ strategies and techniques which will increase breast milk production to slowly resolve the problem. Sometimes even though nursing directly is not possible breast milk-feeding using another method of delivery can be successfully achieved for weeks, months, or even years.

Choice and capacity

It is important to distinguish the difference between choice and capacity: to be clear that, given enough up-to-date information and skilled assistance when they need it, 99.9% of new mothers will provide enough milk for their babies. At the same time it is vital to afford sensitive care to the tiny number of individual mothers who are physically unable to breastfeed. When there is secondary breast milk insufficiency due to poor breastfeeding management, mothers who partially breastfeed can provide:

ALL of the emotional benefits by encouraging comfort sucking whenever the infant wants, and by feeding breast milk and supplements at the breast, through the use of a supplemental nursing system.

ALL of the immunological protection. When the volume of breast milk is low, as in colostrum or weaning milk, the antibodies are concentrated in colostrum or weaning milk [25], [26].

PARTIAL nutrition. When the breast milk supply is low, supplements may be required to make up the nutritional deficit, but the partially breastfed baby still receives human milk enzymes, hormones, fatty acids, proteins, and sugars which cannot be obtained from any other source, and even 50 ml of breast milk each day is of huge benefit to the baby.

Whose rights?

It is difficult to find a woman's right to formula-feed set out in any of the Human Rights literature. On the contrary, the United Nations Convention on the Rights of the Child, the most comprehensive statement of children's rights ever produced, [27], [28] recognizes that every child has the right to enjoyment of the highest attainable standard of health, with the best interests of the child at the forefront of all actions and policies affecting their development, health, and survival. In particular, all segments of society are to be informed of the advantages of breastfeeding.

What's needed?

I conclude that breastfeeding is a learned behavior.

Young girls and new mothers need to receive:

the clear message that breastfeeding is worthwhile because the value of their milk to their babies is irreplaceable,

sufficient help and information to ensure that breastfeeding is successful, meaning that the baby thrives, and

national policies that support working mothers' rights to breastfeed.

It should be seen as a national scandal that a health care system can fail to equip its health care providers with the skills and expertise to motivate and assist mothers to initiate and maintain breastfeeding.

There is also a responsibility for mothers themselves to seek help when they run into difficulties. A Google search of "Breastfeeding Help" reveals 55 million hits in less than half a second. Expert assistance is available at the touch of a button including, in England, the number for a breastfeeding helpline with links to four breastfeeding support organizations, e.g. La Leche League, and over 400 International Board Certified Lactation Consultants.

Ultimately, being able to keep your baby well fed, happy, and healthy at the breast is one of life's greatest gifts. I am so lucky that I had the help I needed to breastfeed my singleton, and then my twins. I cannot imagine the loss if I had not enjoyed this wonderful experience.

References

[3] Kids Health, accessed November 22, 2015.

[5] Bartick, M. & Reinhold, A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics 2010;125(5):e1048-56 doi: 10.1542/peds.2009-1616. Epub 2010 Apr 5.

[6] Bartick, M., Stuebe, A., Schwarz E., Luongo, C., Reinhold, A,, Foster, E. Cost analysis of maternal disease associated with suboptimal breastfeeding, Obstetrics & Gynecology 2013;122(1):111-119, doi:10.1097/AOG.0b013e318297a047.

[7] Renfrew, M. et al. Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK UNICEF UK October 2012.

[8] Akre, J. The Problem with Breastfeeding: a personal reflection, Hale Publishing 2006.

And see: WHO , Akre J, editor: Infant Feeding, the Physiological Basis, Bulletin of the World Health Organization, 1989 Supplement to Vol 67.

[9] The Journal.ie National Breastfeeding Week: Irish breastfeeding rates below European neighbours, Oct 1, 2012.

[10] UNICEF 2003. Statistical Tables: Economic and Social Statistics on the Countries and Territories of the World with Particular Reference to Children's Wellbeing, calculated births in industrialised nations as percentage of world births, figures for 2003.

[11] UNICEF 1990, Innocenti Declaration.

[12] Rafael, D. The Tender Gift: Breastfeeding, Knopf Doubleday Publishing Group, September 12, 1955.

[13] Neville, M. & Niefert, M. Lactation: Physiology, Nutrition and Breast-Feeding, Plenum Press 1983.

[15] Marian Tompson, LLLI Founder, Personal Communication with Betty Crase shared with the author on October 29, 2012.

[17] Barston, S. Bottled Up: How the Way We Feed Babies Has Come to Define Motherhood, and Why It Shouldn't, University of California Press, October 2012.

[19] Wallace, K. Similac commercial is a hit. Judgy moms and dads face off in hit ad. January 28, 2015, CNN.

[20] Fearless Formula Feeder Facebook page.

[21] Kristina Wright. 8 Reasons to Formula Feed Your Baby, July 10, 2015.

[22] Fearless Formula Feeder Facebook page meme, accessed November 23, 2015.

[23] WHO 2003 Global Strategy for Infant and Young Child Feeding, clause 18, page 10.

[24] WHO 2009, Acceptable medical reasons for use of breast milk substitutes.

[25] Goldman, A., Garza, C. et al. Immunologic factors in human milk during the second year of lactation. Act Paediatr. Scand. 1983, 72, 461-2.

[26] Pietersen, B. et al. Quantitative determination of immunoglobulins, lysozyme and certain electrolytes in breastmilk during the entire period of lactation during a 24-hour period and in milk from the individual mammary gland. Act Paediatr. Scand. 1975, 64, 709-717.

[27] UN (1989) Convention of the Rights of the Child. Adopted and opened for signature, ratification and accession by General Assembly resolution 44/25 of 20 November 1989; entry into force 2 September 1990, in accordance with article 49.
[28] UN Convention on the Rights of the Child, General comment No. 15 (2013) on the right of the child to the enjoyment of the highest attainable standard of health (art. 24)* April 2013.
Pamela Morrison is the mother of three adult sons, including twins, who were all breastfed. She became a La Leche League Leader in Zimbabwe and then certified as the first IBCLC in the country where she practiced until 2003. Now living in England, Pamela enjoys working to assist mothers who wish to maximize their milk supply in challenging circumstances, for example those wishing to induce lactation or to relactate for adopted, surrogate, sick babies, or those whose babies experience inadequate weight gain or failure to thrive.

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How Often Does Breastfeeding Really Fail?

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Pamela Morrison, IBCLC, West Sussex, UK Photo: Janet Fotheringham Imagine that the world had invented a new 'dream product' to feed and immunize everyone born on Earth. Imagine also that it was available everywhere, required no storage or delivery-and helped mothers to plan their families and reduce the risk of cancer ...

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The Foods for Health Institute, at the University of California, Davis, has the appearance of a Tuscan villa, its terra-cotta-walled buildings overlooking a large vineyard and a garden that bursts with summer vegetables. It is led by a chemist named Bruce German, and if there were a world title in extolling the virtues of milk he would surely hold it. At our first meeting, he spent half an hour monologuing on the subject, bouncing on an exercise ball and kneading a tattered shred of bubble wrap as he spoke. Milk, he said, is a perfect source of nutrition, a superfood that is actually worthy of the label. This isn't a common view. The number of scientific publications about milk is tiny, compared with the number devoted to other bodily fluids-blood, saliva, even urine. The dairy industry has spent a fortune on extracting more and more milk from cows, but very little on understanding just what this white liquid is or how it works. Medical-funding agencies have generally dismissed it as irrelevant, German said, because "it doesn't have anything to do with the diseases of middle-aged white men." And nutritionists have looked at it as a simple cocktail of fats and sugars, one that can be easily duplicated and replaced by formulas. "People said it's just a bag of chemicals," German told me. "It's anything but that."

Milk is a mammalian innovation, common to platypuses and pangolins, humans and hippos, its ingredients varying according to what each species needs. Human milk is a particular marvel. Every mammal mother produces complex sugars called oligosaccharides, but human mothers, for some reason, churn out an exceptional variety: so far, scientists have identified more than two hundred human milk oligosaccharides, or H.M.O.s. They are the third-most plentiful ingredient in human milk, after lactose and fats, and their structure ought to make them a rich source of energy for growing babies-but babies cannot digest them. When German first learned this, he was gobsmacked. Why would a mother expend so much energy manufacturing these complicated chemicals if they were apparently useless to her child? Why hasn't natural selection put its foot down on such a wasteful practice? Here's a clue: H.M.O.s pass through the stomach and the small intestine unharmed, landing in the large intestine, where most of our bacteria live. What if they aren't food for babies at all? What if they are food for microbes?

This idea dates back to the early twentieth century, when two very different groups of scientists made discoveries that, unbeknownst to them, were closely connected. In one camp, pediatricians found that microbes called Bifidobacteria ("Bifs," to their friends) were more common in the stools of breast-fed infants than bottle-fed ones. They argued that human milk must contain some substance that nourished the bacteria-something that later scientists called the bifidus factor. Meanwhile, chemists had discovered that human milk contains carbohydrates that cow milk does not, and were gradually whittling this enigmatic mixture down to its individual components, including several oligosaccharides. The parallel tracks met in 1954, thanks to a partnership between Richard Kuhn (chemist, Austrian, Nobel laureate) and Paul Gyorgy (pediatrician, Hungarian-born American, breast-milk advocate). Together they confirmed that the mysterious bifidus factor and the milk oligosaccharides were one and the same-and that they nourished gut microbes.

By the nineteen-nineties, scientists knew that there were more than a hundred H.M.O.s in milk, but they had characterized only a few. No one knew what most of them looked like or which species of bacteria they fed. The common wisdom was that they nourished all Bifs equally, but German wasn't satisfied. He wanted to know exactly who the diners were and what dishes they were ordering. To do that, he took a cue from history and assembled a diverse team of chemists, microbiologists, and food scientists. Together they identified all the H.M.O.s, pulled them out of the milk, and fed them to bacteria. And, to the researchers' chagrin, nothing grew.

The problem soon became clear: H.M.O.s are not an all-purpose food for Bifs. In 2006, the team found that the sugars selectively nourish one subspecies, Bifidobacterium longum infantis. As long as you provide B. infantis with H.M.O.s, it will outcompete any other gut bacterium. A closely related subspecies, B. longum longum, grows weakly on the same sugars, and the ironically named B. lactis, a common fixture of probiotic yogurts, doesn't grow at all. Another probiotic mainstay, B. bifidum, does slightly better, but is a fussy, messy eater. It breaks down a few H.M.O.s and takes in the pieces it likes. By contrast, B. infantis devours every last crumb using a cluster of thirty genes-a comprehensive cutlery set for eating H.M.O.s. No other Bif has this genetic cluster; it is unique to B. infantis. Human milk has evolved to nourish the microbe, and it, in turn, has evolved into a consummate H.M.O.vore. Unsurprisingly, it is often the dominant microbe in the guts of breast-fed infants.

B. infantis earns its keep. As it digests H.M.O.s, it releases short-chain fatty acids, which feed an infant's gut cells. Through direct contact, B. infantis also encourages gut cells to make adhesive proteins that seal the gaps between them, keeping microbes out of the bloodstream, and anti-inflammatory molecules that calibrate the immune system. These changes only happen when B. infantis feeds on H.M.O.s; if it gets lactose instead, it survives but doesn't engage in any repartee with the baby's cells. In other words, the microbe's full beneficial potential is unlocked only when it feeds on breast milk. Likewise, for a child to reap the full benefits that milk can provide, she must have B. infantis in her gut. For that reason, David Mills, a microbiologist who works with German, actually sees B. infantis as part of milk, albeit a part that is not made in the breast.

It is unclear why human breast milk stands out among that of other mammals. It has five times as many types of H.M.O.s as cow's milk, and several hundred times the quantity. Even chimp milk is impoverished compared with ours. Mills suggests a couple of possible explanations for this difference. One involves our brains, which are famously large for a primate of our size, and which grow incredibly quickly during our first year of life. This fast growth partly depends on a nutrient called sialic acid, which also happens to be one of the chemicals that B. infantis releases while it eats H.M.O.s. It is possible that, by keeping this bacterium well fed, mothers can raise brainier babies. This might explain why, among monkeys and apes, social species have more milk oligosaccharides than solitary ones, and a greater range of them to boot. Living in larger groups requires remembering more social ties, managing more friendships, and manipulating more rivals. Many scientists believe that these demands drove the evolution of primate intelligence; perhaps they also fuelled the diversity of H.M.O.s.

An alternative idea involves diseases. In a group setting, pathogens can easily bounce from one host to another, so animals need better ways of protecting themselves. H.M.O.s provide one such defense. When a pathogen infects our guts, it almost always begins by latching onto glycans-sugar molecules-on the surfaces of our intestinal cells. But H.M.O.s bear a striking resemblance to these glycans, so pathogens sometimes stick to them instead. They act as decoys, drawing fire away from a baby's own cells. They can block a roll call of gut villains, including Salmonella; Listeria; Vibrio cholerae, the culprit behind cholera; Campylobacter jejuni, the most common cause of bacterial diarrhea; Entamoeba histolytica, a voracious amoeba that causes dysentery and kills a hundred thousand people every year; and many virulent strains of E. coli. H.M.O.s may even be able to obstruct H.I.V., which might explain why more than half of infants who suckle from infected mothers don't get infected, despite drinking virus-loaded milk for months. Every time scientists have pitted a pathogen against cultured cells in the presence of H.M.O.s, the cells have come out smiling.

The team at the Foods for Health Institute has set up an impressive milk-processing facility in its mock-Tuscan building. In the main lab, which Mills runs with the food scientist Daniela Barile, there are two huge steel drums in which milk is stored, a pasteurizer that looks like an espresso machine, and a riot of other equipment for filtering the liquid and breaking it down into its components. When I visited, hundreds of empty white buckets were stacked on a nearby rack. "They're normally full," Barile told me. The full buckets are kept in a huge walk-in freezer, which is chilled to an intensely uncomfortable -25.6 degrees Fahrenheit. On a nearby bench, there's a row of Wellies ("When we process, there's milk all over," Barile said), a hammer for chipping ice ("The door's not closing properly"), and, inexplicably, a ham slicer (I didn't ask). We popped our heads inside. White buckets were arrayed on pallets and shelves, containing some six hundred gallons of milk between them. A lot of this was cow's milk, donated by dairies, but a surprising amount came from humans. "Lots of women pump milk and store it, and once their kid weans, they think, Now what do we do with it? People then hear about us and we get donations," Mills said. "We got eighty litres, collected over two years, from someone random at Stanford University, who said, 'I have all this milk. Do you guys want it?' " Yes, they did. They need all the milk they can get.

About twenty miles east of the Institute, at U.C. Davis Children's Hospital, a pediatrician named Mark Underwood is making practical use of the findings of German and his team. Underwood heads the hospital's neonatal intensive-care unit, which can accommodate as many as forty-eight premature babies at a time. The youngest are born at twenty-three weeks; the lightest weigh just over a pound. They are usually delivered through C-sections, put on courses of antibiotics, and stuck in a supremely sanitized environment. Bereft of the usual pioneering microbes, they grow up with a very strange microbiome: low on the usual Bifs and high in opportunistic pathogens that grow in their place. The preemies are the epitome of microbial imbalance, or dysbiosis, and their strange internal communities put them at risk of an often fatal gut condition known as necrotizing enterocolitis. Many doctors have tried to prevent NEC by giving probiotics to premature babies, with some success. But Underwood, after talking to people like German and Mills, thinks that he can do better by infusing the infants with a combination of B. infantis and breast milk. "The food you feed these bugs is as important as the bugs themselves in getting them to grow and colonize a fairly hostile environment," he told me. If the treatment works, breast milk could do for preemies what it does for their full-term brethren, nourishing baby and bacteria, infant and infantis, and preparing them for life ahead.
Copyright © 2016 by Ed Yong. Reprinted by permission of the publisher.

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The Foods for Health Institute, at the University of California, Davis, has the appearance of a Tuscan villa, its terra-cotta-walled buildings overlooking a large vineyard and a garden that bursts with summer vegetables. It is led by a chemist named Bruce German, and if there were a world title in extolling the virtues of milk he would surely hold it.

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How mothers can nurse themselves healthy

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How mothers can nurse themselves healthy

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Breastfeeding reduces women's chances of heart disease in later life.

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E. Bimla Schwarz, a women's health expert and scholar of evidence-based data, sheds new light on the maternal health benefits of breastfeeding. "There is a simple and natural way to spare tens of thousands of women from having heart attacks each year... yet less than 8% of hospitals are fully promoting this approach." - E. Bimla Schwarz

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How mothers can nurse themselves healthy

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E. Bimla Schwarz, a women's health expert and scholar of evidence-based data, sheds new light on the maternal health benefits of breastfeeding. "There is a simple and natural way to spare tens of thousands of women from having heart attacks each year... yet less than 8% of hospitals are fully promoting this approach."

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Endometriosis, the growth of endometrial tissue outside of the uterus, currently affects 10% of U.S. women and has no known cure.

A new study based on data from over 70,000 women followed for 20 years found the duration of total and exclusive breastfeeding were associated with a decreased risk of endometriosis diagnosis.

Breastfeeding lowers the risk of endometriosis through postpartum amenorrhea and other hormonal mechanisms, including suppression of steroid hormones.

These findings support public policies that encourage breastfeeding for infant and maternal health benefits.

The benefits of breastfeeding are nearly always considered from the perspective of the infant, but breastfeeding also has positive effects on the health of the mother. The hormonal changes associated with lactation may lower the risk of developing many chronic diseases, including breast and ovarian cancer. The results of a new study [1] of over 70,000 women suggest that these same hormonal changes may also lower the risk of developing endometriosis.

Endometriosis is a chronic disorder diagnosed in 10% of U.S. women, but the number affected may be even higher as diagnosis requires confirmation by laparoscopy to rule out other gynecological disorders with similar symptoms, which include painful and heavy periods, and infertility [1]. Despite affecting so many women, endometriosis still has no known cure. Identification of risk factors, particularly those that are behavioral like breastfeeding, is essential in reducing the incidence of this debilitating disorder.

Location, Location, Location

The endometrium is the tissue that lines the inside of the uterus. During the first half of the menstrual cycle, the endometrium thickens in anticipation of a fertilized egg. If no egg attaches, the top layer of the endometrium (called the functional layer) is shed as menstrual blood. Endometriosis occurs if endometrium tissue grows outside of the uterus, usually on the ovaries or fallopian tubes [1]. Having no idea that it is not where it is supposed to be, the endometrium tissue continues along, business as usual, responding to the same hormonal cues in the same manner-thickening in anticipation of a fertilized egg and shedding the top layer if one does not implant. As a result, women with endometriosis generally experience more pain during menstruation and a heavier menstrual cycle.

How does tissue that should only reside in the uterus get to the ovaries and fallopian tubes? The leading hypothesis to explain endometriosis is retrograde menstruation, which is the movement of menstrual blood, containing endometrial tissue, into the fallopian tubes, ovaries, and even the pelvic cavity. It is still not well understood, but a small amount of retrograde menstruation may occur as a normal part of each menstrual cycle [1]. Development of endometriosis depends on how much endometrial tissue ends up in the wrong location-more menstrual cycles mean more retrograde menstruation, and thus a greater risk for developing endometriosis [1-4].

Factors that increase the number of periods a women experiences, such as an earlier age at menarche (≤11 years old) and shorter cycle length (≤27 days), are associated with an increased risk of developing endometriosis [2]. On the other hand, factors that decrease the number of periods, including pregnancy and lactation, have the potential to reduce the risk [1,2].

Full Stop

During pregnancy, high levels of circulating estrogen and progesterone suppress the hormones (i.e., follicle stimulating hormone, or FSH, and luteinizing hormone, LH) that trigger ovulation. Moreover, the implantation of a fertilized egg in the endometrium means that tissue stays right where it belongs. The relationship between breastfeeding and ovulation is less clear-cut, however. "You can't get pregnant while you are breastfeeding" may be one of the most common pieces of advice given to new mothers, but it is not entirely accurate advice. Breastfeeding can suppress ovulation, resulting in amenorrhea (lack of menstruation) and temporary infertility. But just how long a mother remains infertile while breastfeeding varies with respect to nursing frequency and intensity, as well as maternal condition.

Infant suckling suppresses the production of FSH and LH, thereby inhibiting ovulation and menstruation. However, the stimulus from infant suckling must be consistent in order to suppress these hormones at levels sufficient to prevent follicular development and subsequent ovulation [5]. Thus, lactational amenorrhea requires frequent nursing (approximately every 3-4 hours), like that associated with the earliest months of lactation (< 6 months) before solid foods are introduced [5].

Lowering the Risks

Based on the relationship between breastfeeding and amenorrhea, a team of researchers from Harvard, UCLA, and Michigan State University hypothesized that, among women who have been pregnant, the duration of breastfeeding would be associated with a lower risk of developing endometriosis [1]. Specifically, they predicted that the strongest protective effects would be associated with the duration of exclusive breastfeeding (i.e., milk is the only source of nutrition) and lactational amenorrhea [1].

Data to test their hypothesis came from the Harvard-based Nurses' Health Study II, one of the largest prospective cohort studies on risk factors for disease in U.S. women. Over 100,000 female nurses were originally enrolled to provide information on diet, lifestyle, and health via questionnaires provided every two years. The current study on breastfeeding and endometriosis included 72,394 women who had reported at least one pregnancy lasting at least 6 months between 1989 and 2011. Of these, 3,296 had endometriosis that was confirmed by laparoscopy [1]. This is the largest study to date to address the relationship between breastfeeding and risk of endometriosis.

When looking at the total duration of breastfeeding across their lifetime, women who breastfed for 36 months or more had a 40% lower risk of an endometriosis diagnosis compared with women that never breastfed. For every additional three months of lifetime breastfeeding, the risk decreased an additional 3% [1].

The results when considering individual pregnancies were similar to those looking at the total duration of breastfeeding; for every additional three months a mother breastfed an individual infant, her risk of endometriosis diagnosis dropped by 8% [1]. The protective effect of exclusive breastfeeding was even more dramatic. For each pregnancy, there was a 14% decreased risk of endometriosis for each 3-month increase in exclusive breastfeeding.

Exclusive breastfeeding has a biologically defined endpoint-as human infants grow, their metabolic needs require provisioning with foods other than breast milk sometime around 6 months of age. Thus, it is extremely important that this study found breastfeeding after solid food introduction still offered a significant protective effect [1]. Moreover, this study identified an inverse linear relationship between breastfeeding duration and risk of endometriosis; rather than plateau out at some point during lactation, risk continued to decrease with each additional three months of nursing.

Taken together, these findings suggest that factors other than postpartum amenorrhea are responsible for the protective effect of breastfeeding on endometriosis. To this end, the study [1] found the duration of postpartum amenorrhea was inversely associated with risk of endometriosis and explained a significant proportion-but not all-of the risk reduction that was associated with total lifetime duration of breastfeeding and exclusive breastfeeding.

Equally important to considering retrograde menstruation is an understanding of the mechanisms that control this tissue's ability to adhere, proliferate, and survive outside of the uterus [1]. Supporting this, a study [6] on rats with surgically induced endometriosis found that although endometrial lesions progressed during pregnancy, no lesions progressed during lactation.

The hormonal profiles of breastfeeding women, even those no longer experiencing amenorrhea, are different from non-nursing (or non-pregnant) women [1,4]. Notably, breastfeeding women have higher circulating levels of oxytocin and prolactin and lower levels of estrogen and progesterone [1,4]. These hormonal changes are believed to offer protective effects on the growth of breast and ovarian cancers and may play a similar role in limiting the growth of endometrial tissue [1,4].

Next Steps

Breastfeeding does not prevent endometriosis. And it is not a cure. But the findings of this prospective cohort study of over 70,000 women suggest it is a significant factor in the development of this disorder and may even play a role in lessening or alleviating symptoms in breastfeeding women with endometriosis [1].

The takeaway from these findings is not to simply tell all women to breastfeed and to do so for as long as possible. The world we live in is not structured in such a way that this is achievable for all women (or even for most women). Policy must follow the science. When study after study continues to demonstrate the health benefits of breastfeeding (for both mother and child), there should be some response in policy to encourage and support breastfeeding across the population (e.g., longer maternity leave, private and hygienic pumping stations at places of work). This type of research should not make those that are unable to breastfeed feel inadequate, but rather it should encourage action to level the playing field so that all mothers can improve their health outcomes.

1. Farland LV, Eliassen AH, Tamimi RM, Spiegelman D, Michels KB, Missmer SA. History of breast feeding and risk of incident endometriosis: prospective cohort study. bmj. 2017 Aug 29;358:j3778.
2. Cramer DW, Missmer SA. 2002. The epidemiology of endometriosis. Annals of the New York Academy of Sciences. 955(1): 11-22.
3. Missmer SA, Hankinson SE, Spiegelman D, Barbieri RL, Malspeis S, Willett WC, Hunter DJ. 2004. Reproductive history and endometriosis among premenopausal women. Obstetrics & Gynecology. 104: 965-74.
4. Heilier J-F, Donnez J, Nackers F, Rousseau RJ, Verougstraete V, Rosenkranz K, Donnez O, Grandjean F, Lison D, Tonglet R. 2007. Environmental and host-assocaited risk factors in endometriosis and deep endometriotic nodules: A matched case-control study. Environmental Research. 103: 121-9.
5. Vekemans M. 1997. Postpartum contraception: the lactational amenorrhea method. The European Journal of Contraception & Reproductive Health Care. 2(2): 105-11.
6. Barragán JC, Brotons J, Ruiz JA, Acién P. 1992. Experimentally induced endometriosis in rats: effect on fertility and the effects of pregnancy and lactation on the ectopic endometrial tissue. Fertility and Sterility. 58(6): 1215-9.

Contributed by
Dr. Lauren Milligan Newmark
Research Associate
Smithsonian Institute

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Breastfeeding Associated with Lower Risk for Endometriosis - International Milk Genomics Consortium

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The benefits of breastfeeding are nearly always considered from the perspective of the infant, but breastfeeding also has positive effects on the health of the mother. The hormonal changes associated with lactation may lower the risk of developing many chronic diseases, including breast and ovarian cancer.

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For teenagers or just for fun!

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OK so this goes against the grain of everything you were told at antenatal classes, every poster dotted around the hospital and quite possibly every health professional you saw during pregnancy. But really, it's true.

Breast is best is actually just a really clever marketing campaign, but not originally from the people you might expect. In fact, it's a brilliant example of a very common marketing technique - and once you are aware of it, you can spot it around you on a daily basis.

Let's take chickens (a leap I know but bear with me) a normal life for a kept chicken is really quite simple. A hen house to keep them safe at night, an area for them to move about, scrat and eat grain, water to drink and you're pretty much done.

Veer away from these basic requirements and as you might expect you have problems. As Hugh Fearnley-Whittingstall has highlighted with his "chicken out" campaign, remove their outdoor wandering/scratting area, coup excessive numbers together - and you get unhealthy, underweight chickens that need large amounts of antibiotics and other drugs to keep them alive (with some companies injecting eggs with antibiotics before the chickens have even hatched!).

These chickens when mature look so bad with their deformed legs and lack of muscle tone, they would never sell; plus they are so scrawny and underweight they wouldn't make enough money for the producers. So a process called "plumping" is undertaken; this is injecting the chicken pieces with salt water, sodium phosphate and "natural flavorings" (don't get me started on that one!) until they look like something you might be prepared to eat. The legal limit is I believe 15% "other stuff" - meaning a piece of "standard" chicken can contain more salt than a large serving of French Fries..

So in short, give a chicken a standard chicken life and you end up with a normal chicken. Treat it in an abnormal way and you end up with a chicken packed with antibiotics, excessive salt levels, flavourings and water.

Let's picture accurate labelling of these products. The first - standard chicken, easy. The second hmmm "substandard battery chicken; includes antibiotics, salt, flavours, reduced protein and increased fat levels".

I'm thinking the second isn't going to be a big hit in store.

Retailing is about pounds kerchinging into the till, not accuracy - and so the marketing bods step in. The normal chicken is elevated to "best" and they give it a cool name like "free range", "organic", "finest" or "taste the difference". Lots of different ways to describe a chicken that has in reality, only had an existence which at least met the basic requirements.

This allows the substandard, modified chicken to neatly slip in behind, taking the label "chicken". Good old standard chicken. Realistically, what is being sold as "standard" is in fact anything but. No mention of the health implications of eating something which is now considered more fat than protein, no mention of the injected substance, or how you are actually paying for this because chicken is often sold by weight. Nope - it's just "chicken".

Supermarkets sell more "standard chickens" than any other type - and not just because of the price tag. In fact, even if the price difference was nominal, sales would still be higher. This is because the vast majority of people believe standard is "OK". Fair enough it might not have quite as much flavour as the "fancy one", but then they didn't home grow the carrots or make the gravy from scratch either. OK does most of us pretty well and this is what the marketing people understand! But let's not forget, in reality it's not standard, it's substandard that is cleverly marketed.

This happens in all areas of retail - tomatoes ripened on the vine, where they are supposed to be and thus actually taste as they should, are "finest". Those picked early and ripened in boxes during transportation leaving them more like tasteless balls of water are "standard". Sausages that have more meat than fillers are "finest" and so on and so forth.

So back to breastfeeding.

Breastmilk is the bog standard, normal substance a human infant is built to consume - there's nothing best or superior about it. A survey a few years ago asked mothers whether they would buy a "value" formula, unbranded and in plain packaging - rather like the blue and white stripey budget tins at the supermarket. Absolutely not was the overwhelming response - the perception was that value branding compromised on quality, whereas standard ranges are "OK". It might not be "best" but it was fine.

"Breast is best" is a slogan straight off the back of a milk tin and when you understand the marketing it's very clear why. With breastmilk substitutes it actually has a double benefit that isn't seen in other areas of retail. By law manufacturers are required to state on the tin that their product isn't as good as breastfeeding - as we saw above, should parents get a sniff of substandard they're off and so yep, it's time to call in those marketing bods again.

Hmmm if we say breastfeeding is best, not only does that allow our product to slip in as "OK", but parents also (unaware of the laws) think we are mightily honest telling them upfront another product is "better" and so trust us; building loyalty and belief in whatever other information we give them. Ultimately sales are safe as we know most people aspire to "OK", not "optimum". Given most mums will end up using a breastmilk substitute, spending around £700 per year, we can afford to spend a fair bit on advertising to really drive this message home.

Next time someone tells you breast is best - let them know, it 's really not at all, it's just normal.

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OK so this goes against the grain of everything you were told at antenatal classes, every poster dotted around the hospital and quite possibly every health professional you saw during pregnancy. But really, it's true. Breast is best is actually just a really clever marketing campaign, but not originally from the people you might expect.

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What is in it, comparative health outcomes etc

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Far from being an easily synthesised mixture of nutrients, breast milk contains a multitude of microbes, stem cells and biological molecules that scientists are still trying to understand. Dr Natalie Shenker MRSB explores what we do and don't know about the white stuff The Biologist 64(3) p10-13
After 70 years of cultural shift in the West towards babies being bottle-fed formula milk rather than breastfed, one of the prevailing views in the general population is that there is no difference biologically between breast milk and formula.

This view is also held by a large number of doctors and healthcare professionals, propagating myths about common breastfeeding issues as being reasons to stop and "just give formula". For example, if a medication is to be prescribed and there is no available information about the transfer of the drug or its metabolites into breast milk, women are often advised to stop breastfeeding to be on the safe side.

This is contrary to the reality that breastfed babies are at lower risk of infections, obesity and haematological malignancies[1]. In preterm and sick babies, breast milk is critically important to prevent infections and necrotising enterocolitis (NEC), a catastrophic gut condition that carries a mortality rate of 40%.

Some states in the US have taken the radical step of banning the use of formula on neonatal intensive care units.

For mothers, the benefits of breastfeeding are well established. It is classified by the World Cancer Research Fund/American Institute for Cancer Research as protective against breast and ovarian cancers[2]. Breastfeeding for even a short amount of time reduces risk by 16-24% for triple negative breast cancer, the most aggressive form of the disease[3,4].

An estimated 18% of ovarian cancers in the UK are linked to women breastfeeding each of their children for fewer than six months.5 According to several meta-analyses, ovarian cancer risk is 24-30% lower in women who have ever breastfed, versus those who have never done so[6].

The risk of both cancers is reduced even further in women with high-risk genetic mutations such as BRCA[1]. Women who breastfeed have lower chances of developing type 2 diabetes later in life[7], obesity[8] and cardiovascular disease, as well as a reduced likelihood of postnatal depression[9].

What is it about maternal milk that can explain this diverse impact on maternal and infant health?

Breast milk contains thousands of different molecules, growth factors, hormones, microorganisms and cells, which work together to provide the human baby with all the tools necessary to grow and develop normally. Many of its components have only recently been discovered - leaving the tantalising possibility that more remain - and the functions of many remain unknown.

Carl Linnaeus, the founder of taxonomy, originally used the word 'Mammalia' ('mamma' is Latin for breast) to describe animals that feed their young with milk. Evolutionary biologists estimate that the ancestor of all mammals lived 310 million years ago and oozed milk from its skin for the young to feed on after hatching from eggs. Over time, these skin glands evolved into nipples as a way to deliver the mother's immune system to newborns to protect them from infections. Food might have been a secondary benefit.

This immune protection covers the vulnerable period of early life when the immature immune system is not well developed - in humans, the immune system is thought to be fully mature only at the age of six. The breast itself is a source of specific immune cells and can, therefore, be seen as an immune organ, although it is never listed as such in medical textbooks. One hypothesis regarding the benefit of breastfeeding to mothers is that the breast also ramps up the mother's own immune system to aid postnatal recovery.
Breast milk contains a multitude of human and non-human cells as well as nutrients, hormones and other immune system-related components.
Human milk has evolved to specifically nourish human babies. Hundreds of bioactive components directly protect them from pathogens found in their environment.

Compared with other species, a higher proportion and diversity of fatty acids support the growth of the human brain (which is particularly large in comparison to that of other mammals), and an extraordinarily diverse microbiome (>800 bacterial strains on average, along with fungi, parasites and viruses) drives the healthy development of infant gut physiology. The composition of the breast milk microbiome changes over months and years, and work is ongoing to understand the impact this has on the developing gut.

Breast milk contains cells - and lots of them. In mature milk (produced approximately six weeks after birth), a single millilitre can contain millions of epithelial lactocytes, stem cells and immune cells.

Colostrum, produced within the first two to three days after birth, provides an energy-rich dose in just a few millilitres per feed, but also includes a dense cellular component made up predominantly of white blood cells. Of these, the most common cells are breast-specific macrophages, which can engulf and absorb harmful microorganisms.

These macrophages also manufacture lactoferrin and lysozyme. The former is an iron-binding protein that helps the baby to absorb and store iron. As well as being important nutritionally, this prevents the growth of harmful microorganisms such as E. coli, Staphylococcus species and yeast ( Candida), which need iron to survive.

Lysozyme is an enzyme that kills bacteria by disrupting their cell walls and also has antiviral effects. Both it and lactoferrin increase in concentration in breast milk over time as babies become mobile and start to explore their environment.

The World Health Organization recommends that babies should be exclusively breastfed until approximately six months of age, with the introduction of complementary foods thereafter and weaning from breastfeeding after the age of two years. This has been widely interpreted as breast milk having no benefits (or even nutritional value) over the six-month cut-off. However, breast milk not only continues to provide increased immune protection to the child, but the calorie value per feed increases as the child grows, and so they need feeding less frequently[1].

Evolutionarily, the age of natural term weaning is likely to range from between two and seven years - hence the term 'milk teeth', which start falling out when children are around six or seven.

Antibodies produced by the mother, which are transferred into milk as well as to cells in breast milk, are highly targeted against infectious agents in her environment.

When a mother ingests or inhales pathogens, lymph nodes in the lungs and small intestine manufacture specially sensitised lymphocytes, which then migrate to the breasts and create tailor-made secretory antibodies against that pathogen.

These mucosal pathogens are a major killer of children below the age of five years, causing more than 14 million deaths annually. Diarrhoeal disease alone kills five million children each year in the developing world; the risk of dying from diarrhoea is reduced by approximately 20-fold in breastfed children.

Breast milk also contains more than 200 types of sugars known as oligosaccharides. Although most oligosaccharides have unknown functions, some help to block bacterial antigens from sticking to the wall of the gastrointestinal tract. This blocking mechanism is particularly effective against Pneumococcus, an extremely 'sticky' bacterium that can cause pneumonia and systemic sepsis. Twenty oligosaccharides in milk can't be digested by humans, but are there instead to feed the 'helpful' bacteria found in breast milk and the infant gut.

These bacteria will help the baby to form its own normal microbiome, to the exclusion of harmful pathogens. Scientists and doctors are starting to understand how the microbiome has a huge role in helping the gut to develop, digest food and support the immune system of the baby as it grows.

Indeed, the microbiome of maternal milk may be critical to helping the immature gut of a very premature baby to seal, preventing colonisation by pathogenic bacteria and reducing the likelihood of the development of NEC.

As new research begins to understand lactation, more surprising findings are emerging. Multipotent stem cells were discovered in breast milk in 2007, having the potential to form an entire functioning breast ductal system that can produce milk. Stem cells are carried into the infant stomach, where they potentially can survive the acidic environment.

Animal studies have shown maternally derived stem cells to be present in the brain and kidneys of infants, creating chimeras between the mothers and their offspring. In humans, we don't know yet whether these cells are simply by-products of the 10-fold increase in ductal stem cell cycling during pregnancy or have a specific function.

Mothers and babies are known to communicate with each other through breastfeeding in multiple ways - hormonally through surges of oxytocin (the 'hug' hormone) that create feelings of wellbeing and relaxation in the mother and stimulate the milk let-down reflex, through skin-to-skin exposure, and directly through components in the milk.

Babies are born without diurnal cortisol rhythms, which develop in the first few months of life. Breastfed babies have five-fold higher levels of cortisol receptors than formula-fed babies, reflecting the transfer of cortisol through milk, although the function of cortisol in this context is unknown - it is likely to be an important mediator of metabolism and establishing normal cortisol functioning, and sleep cycles, in infants.

It has also been shown that early initiation of breastfeeding - that is, within an hour of birth - can have significant long-term effects, and work is ongoing to understand how breastfeed can modulate the infant's genes.

Finally, and most speculatively, ultrasound studies in Australia have shown that infant saliva can be sucked back into the nipple through the vacuum effect created by the mouth. Although only a hypothesis at present, babies may just be sending information into the breast about any infections to which they have been exposed. They may even be ordering what they need in their next meal through microRNAs, tiny genetic messages in their saliva.

Breast milk contains hundreds of bioactive components, including one of the most complex microbiomes in the human body. The normal physiology of how each individual component functions, let alone the complexity of the interactions within human milk and between the mother and child, leaves a broadly under-researched field open for investigation.

With the advent of novel funders internationally, independent of food industry involvement, there is hope that the seeds of a new field of biology - human lactology - are being planted. Our own work at the Hearts Milk Bank, to establish a large bioresource of breast milk samples, will facilitate a wide range of studies into infant and maternal health, a small part of a huge body of work that lies ahead.
This rich fluid may hold many clues about human health during childhood and how illnesses that start in adulthood may be patterned in our earliest days.
Breast v bottle

Public health messaging over the last 20 years has been focused around the catchy phrase 'Breast is Best', now shorthand for the debate over how our children are fed.

However, the UK has among the lowest rates of breastfeeding in the world and although this message has increased breastfeeding initiation rates to over 85%, only 40% of babies are receiving any breast milk at six weeks, and fewer than 20% at six months.

The Lancet Series on Breastfeeding[1] indicated that optimising breastfeeding globally could save more than 800,000 babies each year, and prevent 20,000 maternal deaths from cancer.

Given that most health impacts of breastfeeding for both the mother and child are time-dependent, the fact that only one in 200 women breastfeed for one year in the UK demonstrates the need for greater public education on the science of infant feeding.

Natalie Shenker MRSB is an Oxford-trained doctor with a PhD in breast cancer epigenetic risk markers from Imperial College. She is the co-founder of the Hearts Milk Bank, which aims to remove the NHS postcode lottery for screened donor milk.

References
1) Victora, C. G. et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet 387(10017), 475-490 (2016).
2) World Cancer Research Fund/American Institute for Cancer Research. Continuous Update Project Findings & Reports. Accessed October 2016.
3) Parkin, D. M. et al. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. Summary and conclusions. Br. J. Cancer 105 (S2):S77-S81 (2011).
4) Chowdhury, R. et al. Breastfeeding and maternal health outcomes: a systematic review and meta-analysis. Acta. Paediatr. 104(467), 96-113 (2015).
5) Li, D. P. et al. Breastfeeding and ovarian cancer risk: a systematic review and meta-analysis of 40 epidemiological studies (link is external). Asian. Pac. J. Cancer Prev. 15(12), 4829-4837 (2014).
6) Luan, N. N. et al. Breastfeeding and ovarian cancer risk: a meta-analysis of epidemiologic studies. Am. J .Clin. Nutr. 98(4), 1020-1031 (2013).
7) Aune, D. et al. Breastfeeding and the maternal risk of type 2 diabetes: a systematic review and dose-response meta-analysis of cohort studies. Nutr. Metab. Cardiovasc. Dis. 24, 107-115 (2014).
8) Bobrow, K. L. et al. Persistent effects of women's parity and breastfeeding patterns on their body mass index: results from the Million Women Study. Int. J. Obes. (Lond) 37, 712-717 (2013).
9) Dias C. C. & Figueiredo, B. Breastfeeding and depression: a systematic review of the literature. J. Affect. Disord. 171, 142-154 (2015).

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Far from being an easily synthesised mixture of nutrients, breast milk contains a multitude of microbes, stem cells and biological molecules that scientists are still trying to understand.

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Information aimed at GPs, but nice diagrams!

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A fascinating book with detained information on the health outcomes for breastfeeding and formula. This book explains the concept of relative risk well. It is also a great read if you want to understand why women struggle to breastfeed in the UK and what everyone can do to support them better.

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You may find that your healthcare professionals give you guidance based on a less than thorough understanding of the impact of stopping or limiting breastfeeding

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Covers impact on both maternal and child mental health

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Early life experiences set the stage for physical health in later life. Reducing early toxic stress is key to preventing disease in adults ( Shonkoff, 2016).

Breastfeeding is one important way to decrease early toxic stress. Recent studies have shown that breastfeeding increases babies' physical and mental well-being, and these effects go well beyond the composition of the milk. Maternal responsiveness is key to understanding these long-term effects. When mothers consistently respond to their babies' cues, they set the stage for lifelong resiliency in their offspring. And responsiveness is built into the breastfeeding relationship. We see this reflected in children's mental health.

In one study of 2,900 mother-infant pairs, breastfeeding for one year was associated with better child mental health at every age up to age 14 ( ). Longer duration of breastfeeding was associated with better child mental health at every assessment point.

Maternal depression

Maternal depression has a well-documented negative effect on babies and children. It is harmful because it impairs mothers' ability to be responsive to their babies. Depressed mothers tend to disengage from their babies, and fail to respond to their cues. Babies experience this as highly stressful, and there can be lifelong effects from being raised by a chronically depressed mother or father ( Field, Diego, & Hernandez-Reif, 2009 ; Kendall-Tackett, 2002 , 2010 ; Weissman, 2006 ).

Edward Tronick 's 'Still-Face Mother' experiments are an analog of what happens with maternal depression. You can see the effects of not responding in these compelling videos.

These effects are long lasting. A 20-year follow-up of children of depressed parents compared them with a matched group of adult children whose parents had no psychiatric illness. The adult children of depressed parents had three times the rate of major depression, anxiety disorders, and substance abuse compared to adult children of non-depressed parents.

For many years, feeding method was not included in studies of maternal depression. In fact, for years, professionals who specialized in perinatal mental health believed that breastfeeding was actually a risk factor for postpartum depression. Fortunately, we now have evidence that indicates that exclusively breastfeeding mothers are at lower risk for depression. Indeed, breastfeeding is protective of maternal mental health ( Dennis & McQueen, 2009 ; Groer & Davis, 2006 ; Kendall-Tackett, Cong, & Hale, 2011 ).

Sleep

One reason why breastfeeding lowers depression risk is its impact on sleep. On every parameter of sleep, exclusively breastfeeding mothers fare better than their mixed- or formula-feeding counterparts:

Our study of 6,410 mothers indicated that exclusively breastfeeding mothers were significantly better on every sleep measure compared to their mixed- and formula-feeding counterparts. Surprisingly, there was no significant difference between the mixed- and formula-feeding mothers ( Kendall-Tackett et al., 2011 ). In other words, exclusive breastfeeding is a different physiological experience than mixed feeding. When mothers supplement with formula, they lose the physiological benefit of breastfeeding on their sleep.

Protection and responsivity

One study also found that breastfeeding protects babies when their mothers are depressed. This study compared four groups of mothers: mothers who were either depressed (breast or formula-feeding) or non-depressed (breast or formula-feeding). The measure was the babies' EEG (electroencephalogram) patterns (abnormal patterns were a symptom of depression in the infants). The babies of depressed, breastfeeding mothers had normal EEG patterns compared to the babies of depressed, formula-feeding mothers ( Jones, McFall, & Diego, 2004 ). In other words, breastfeeding protected the babies from the harmful effects of their mothers' depression. The reason for this finding comes down to maternal responsivity. The researchers discovered that the depressed, breastfeeding mothers did not disengage from their babies. They couldn't. The breastfeeding mothers looked at, touched, and made eye contact with their babies more than the mothers who were not breastfeeding. And that was enough to make a difference.

Cycle of violence

Mothers with a history of childhood abuse often feel as though they do not have the tools they need to parent their own children successfully. They may wonder whether they will perpetuate the cycle of violence.

Impaired sleep can be an important trigger to the intergenerational transmission of abuse. Babies of mothers with depression or PTSD are more likely to have sleep difficulties, possibly because of their exposure in utero to their mothers' elevated stress hormones ( Field, Diego, & Hernandez-Reif, 2006 ; Field et al., 2007 ). And a recent study found that for women with PTSD and a history of childhood abuse, infant sleep difficulties and maternal depression impaired mother-infant bonding and increased the risk of intergenerational transmission of trauma ( Hairston et al., 2011 ). But there's a different picture if the mother breastfeeds.

In Strathearn et al's ( 2009 ) 15-year longitudinal study of 7,223 Australian mother-infant pairs, breastfeeding substantially lowered the risk of maternal-perpetrated child maltreatment. Non-breastfeeding mothers were 2.6 times more likely to be physically abusive, and 3.8 times more likely to neglect their children compared to breastfeeding mothers.

The results of our 2013 study may help explain why this is so. In our sample of 6,410 new mothers, 994 women reported previous sexual assault. As predicted, sexual assault had a pervasive, negative effect on mothers' sleep, physical well-being, and mental health. The sexually assaulted mothers' sleep was poor, they were more tired, they were more anxious and angry, and had more depression. But when we added feeding method to our analyses, we found that breastfeeding attenuated the effects of sexual assault and downregulated the stress response. This effect was only for exclusively breastfeeding women ( Kendall-Tackett, Cong, & Hale, 2013 ). Anger, in particular, was lessened and this might explain Strathearn's findings cited above. Also, lower rates of depression improve maternal responsiveness, which is protective.

Attachment and long-term health

We can also examine the impact of security of mother-infant attachment and its effects on long-term health. In an article written shortly before the end of their lives, attachment pioneers Mary Ainsworth and John Bowlby noted that maternal (or caregiver) responsivity was key to creating a secure attachment in infants. Ainsworth developed the primary measure of attachment in infants: The Strange Situation.

The Strange Situation has been used in thousands of studies all over the world. Secure attachment on this measure is a great predictor of child mental and physical health. And responsiveness is key. When babies are not responded to consistently, they develop insecure attachments, and that has long-term implications for health, as a recent 32-year longitudinal study of 163 people found ( Puig, Englund, Simpson, & Collins, 2013 ). Participants in this study were followed from birth to age 32. At 12 to 18 months, they were assessed via the Strange Situation. Those with insecure attachments had significantly more inflammation-based illnesses at age 32 than those who had secure attachments. These findings are likely due to the chronic activation of the inflammatory response system in those with insecure attachments.

In summary, the results from these studies demonstrate that breastfeeding has a much larger role to play in maintaining physical and mental health than we have previously believed.

Because breastfeeding increases maternal responsivity, it makes the day-to-day experience of mothering more tolerable. And it increases the chances that the babies will be securely attached. Breastfeeding is so much more than just a method of feeding. It's a way of caring for a baby that will provide a lifetime's worth of good health because it provides a way for mothers to connect with their babies-even if they did not experience that kind of care themselves.

In short, breastfeeding can make the world a happier and healthier place, one mother and baby at a time. It's not just the milk.

References

Shonkoff, J. P., Boyce, W. T., & McEwen, B. S. (2009). Neuroscience, molecular biology, and the childhood roots of health disparities: building a new framework for health promotion and disease prevention. (21), 2252-2259. doi: 301/21/2252 [pii] 10.1001/jama.2009.754

Shonkoff, J.P. (2016). Capitalizing on Advances in Science to Reduce the Health Consequences of Early Childhood Adversity. JAMA Pediatr, 170(10),1003-1007. doi:10.1001/jamapediatrics.2016.1559

Strathearn, L., Mamun, A. A., Najman, J. M., & O'Callaghan, M. J. (2009). Does breastfeeding protect against substantiated child abuse and neglect? A 15-year cohort study. Pediatrics, 123 (2), 483-493. doi: 123/2/483 [pii] 10.1542/peds.2007-3546
Kathleen Kendall-Tackett, PhD, IBCLC, FAPA
Dr. Kendall-Tackett is a health psychologist and International Board Certified Lactation Consultant, and the owner and Editor-in-Chief of Praeclarus Press , a small press specializing in women's health. She is Editor-in-Chief of two peer-reviewed journals: Clinical Lactation and Psychological Trauma. She is Fellow of the American Psychological Association in Health and Trauma Psychology, Past President of the APA Division of Trauma Psychology, and a member of the Board for the Advancement of Psychology in the Public Interest. Dr. Kendall-Tackett specializes in women's-health research including breastfeeding, depression, trauma, and health psychology, and has won many awards for her work including the 2016 Outstanding Service to the Field of Trauma Psychology from the American Psychological Association's Division 56.

Dr. Kendall-Tackett has authored more than 400 articles or chapters, and is currently completing her 35th book, The Phantom of the Opera: A Social History of the World's Most Popular Musical. Her most recent books include: Depression in New Mothers, 3 rd Edition (2016, Routledge UK, in press), Women's Mental Health Across the Lifespan (2016, Routledge US, in press, with Lesia Ruglass), Psychology of Trauma 101 (2015, Springer, with Lesia Ruglass) and The Science of Mother-Infant Sleep (2014, Praeclarus, with Wendy Middlemiss). Her websites are:
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Now available in Spanish too: Crianza Natural

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Neuroscience Shows Breastfeeding Is Not Just Milk

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Early life experiences set the stage for physical health in later life. Reducing early toxic stress is key to preventing disease in adults ( Shonkoff, 2016). Breastfeeding is one important way to decrease early toxic stress. Recent studies have shown that breastfeeding increases babies' physical and mental well-being, and these effects go well beyond the composition of the milk.

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Article comparing breastfeeding and bottle feeding

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Hard hitting article, not aimed at parents. Doctors do not routinely get training in breastfeeding, so this article is a useful one.

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Psychological effects of breastfeeding on children and mothers

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Psychological effects of breastfeeding on children and mothers

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Psychological effects of breastfeeding on children and mothersPsychologische Effekte des Stillens auf Kinder und Mütter

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Review for the Northern Irish Government 2018

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Review for the Northern Irish Government 2018

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Interesting as it’s up to date and includes evidence of economic benefit at age 50 from having been breastfed.

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Five amzing things we know but don’t understand  about human milk

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Five amzing things we know but don’t understand  about human milk

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A mother's milk, rich in an exquisitely tailored mix of fats, proteins, vitamins and minerals, provides all the nutrition a helpless infant requires - and more. Breast milk is thought to protect against disease, set up a healthy digestive system and even influence a child's behavior. And yet we know a lot less about this important substance than we could, says lactation researcher Katie Hinde of Arizona State University.

In a 2016 talk, Hinde noted that more studies are done on coffee, wine or tomatoes than on human breast milk. (The scholarly database Web of Science identified about 1,200 scientific articles published in 2017 for the search term "breast milk," compared with almost 3,500 for "tomatoes.") "Breast milk," Hinde says, "has not been a research priority."

But the research is picking up. Here are five mysteries about breast milk that scientists are working to understand.

Nursing sick babies

It's well-established that human milk (as well as the fluid known as colostrum that mothers produce the first days after birth) carries protective factors such as antibodies to help a baby stave off infections. But research suggests that immune components in milk might ramp up when babies need them most. A 2013 study found that when mothers and babies both had colds, levels of white blood cells in milk jumped by a factor of 64. But even when just the babies were sick, levels of white blood cells still increased 13 times. "That's quite a big increase," says the study's lead author, Foteini Kakulas (formerly Hassiotou), a cell biologist and lactation researcher at the University of Western Australia.

Research suggests that immune components in milk might ramp up when babies need them most.

A second study found that lactoferrin - an immune molecule that performs a variety of protective functions, such as puncturing the walls of harmful bacteria - was elevated in the weeks before and after an infant was sick. Once again, mothers did not report being sick, though the authors write that there was "almost certainly" underreporting of illness from moms.

How might this work? The most likely explanation is that infant saliva traveling back through the mother's breast ducts carries a status report on the baby's health, says Kakulas. "When baby saliva is transferred back into the breast ... it's very logical that the pathogen that is driving the sickness would be transferred too."

Sleep signals in milk

As new parents know well, babies don't come with built-in sleep schedules. Could breast milk help to set them? Both the sleep hormone, melatonin, and its precursor, tryptophan, are present in human breast milk and both seem to fluctuate on a cycle that might help babies sleep or wake. A 2016 study found that melatonin levels were, on average, nearly five times higher in breast milk produced at night than during the day.

Another report, in 2017, found that levels of the hormones cortisone and cortisol were higher in morning breast milk than in milk produced in the afternoon, evening and night. Both cortisone and cortisol are involved in the body's stress response, and cortisol serves to kick-start our physiology when it's time to wake.

But it still isn't clear whether these signals actually allow a mother's daily rhythm to shape her baby's sleep-wake cycle, says Hinde. Also unclear is what a lack of these chemicals might mean for formula-fed babies, or what may happen to sleep patterns if babies drink milk pumped at another time of day. "We know that babies have the receptors for these hormones in their bodies, that the hormones coming from the mother are binding to receptors in the baby," she says. "But what does it mean if they aren't getting that signal? We don't know."

Eating for the gut microbiome

Breast milk isn't food just for babies - it's food for trillions of microbes that set up camp in their digestive systems, a community dubbed the human gut microbiome. Recent research suggests that breast milk may have evolved to promote the growth of microbes that help keep babies healthy.

Breast milk isn't food just for babies - it's food for trillions of microbes that set up camp in their digestive systems

"The third-largest constituent in breast milk is not there to feed the babies - it's there to feed the microbes," says microbiologist David Mills of the University of California, Davis. He's referring to human milk oligosaccharides, complex chains of sugars found in breast milk. (Mills has established a probiotic company based on his research.) These complex sugars bolster the kinds of intestinal bacteria that can digest the compounds into short-chain fatty acids - ones that babies need to thrive.

It's not yet clear what defines a healthy infant gut microbiome, or how that system changes as babies develop. And scientists disagree on how the microbiome is set up to begin with: Are key microbes delivered to the newborn's uncolonized gut via breast milk, or do they come in from other sources such as amniotic fluid or the mother's skin?

Variations in milk

All breast milk is not created equal: It can vary in levels of proteins, fats, sugars, hormones and other components. But breast milk doesn't just differ from mother to mother. It can also differ when the same mother nurses different babies, and across the span of an infant's development.

It also may shift depending on a baby's sex. Working with rhesus monkeys, Hinde found that that mothers make more milk for female offspring, but milk richer in fat for male offspring. She saw similar sex differences when she pored over the lactation records of more than a million cows.

If these kinds of differences translate to human milk, understanding them could help optimize formula or donor milk for babies who don't have access to their own mother's milk, Hinde says. But scientists have only begun to characterize this variation and the factors that drive it.

A dash of stem cells

In 2007, scientists discovered an unexpected ingredient in human breast milk: stem cells. These cells retain flexibility that most adult cells have lost and can form a broad variety of tissues. In a 2014 study, scientists tracked individual stem cells from the mammaries of nursing mice. They found that the cells crossed the pups' stomach walls into circulation and lodged themselves into developing tissues throughout their bodies. When the baby mice grew up, the mothers' cells were still there and had turned into mature tissues alongside the babies' own cells.

In a lab dish, scientists have grown stem cells extracted from human breast milk and coaxed them to form organ-like blobs that have spherical endings reminiscent of the alveoli that make up the mammary glands. These organoids could even produce milk.

No one yet knows how these cells affect infant development or what happens to babies who don't get them - another mystery to add to the things-we'd-like-to-know list.

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A mother's milk, rich in an exquisitely tailored mix of fats, proteins, vitamins and minerals, provides all the nutrition a helpless infant requires - and more. Breast milk is thought to protect against disease, set up a healthy digestive system and even influence a child's behavior.