If a new vaccine became available that could prevent one million or more child deaths a year, and that was moreover cheap, safe, administered orally, and required no cold chain, it would become an immediate public health imperative.
Breastfeeding can do all of this and more, but it requires its own 'warm chain' of support &endash; that is, skilled care for mothers to build their confidence and show them what to do, and protection from harmful practices. If this warm chain has been lost from the culture or is faulty, then it must be made good by health services.
In this course, we will learn how the Baby-Friendly Hospital Initiative ("BFHI") and the 10 Steps to Successful Breastfeeding ("10 Steps") improve outcomes for infants and their mothers as well as the skills and policies necessary to implement the 10 Steps in both hospital and community settings.
The Global Strategy on Infant and Young Child Feeding (2003) outlines four key goals for infant feeding:
Before we dive into the framework and how to implement it, it's important to understand just why investing in promoting, protecting and supporting breastfeeding is so critical. Around the world, most mothers state that they intend to breastfeed their infants and, in many countries, "ever breastfed" rates are very high.
Wondering how your country compares to others? The Global Breastfeeding Scorecard provides a global snapshot of breastfeeding practices and policies in countries globally.
However, globally, just 43% of babies are breastfed within an hour of birth, with wide variations by country.
What is clear is that intention leads to initiation and initiation is necessary to achieve exclusive breastfeeding (or any at all!). Infants who are exclusively breastfed in hospital are more likely to be still breastfeeding at six months. We help parents one family at a time and, at a population level, the more infants who meet each recommendation, the more are able to meet the next step.
Human milk is the only substance specifically designed for the development and nutrition of the human infant.
Lactation is one of the key characteristics of all mammals, regardless of their other characteristics. In fact, lactation is so fundamental, it predates even the evolution of fur and may have begun in some forms before mammals as we now define them even existed.
Breastfeeding is more than a practice; it is foundational to who we are as a species and it has evolved over hundreds of thousands of years to maximize the survival and well-being of humankind. When we introduce iatrogenic barriers to the normal unfolding of birth and lactation, we risk interrupting adaptations that have developed over the course of billions of births to protect and nurture humans all over the world.
Over the past 100 years or so, science has offered new insights into how this evolutionary adaptation, which allows human infants to survive a comparatively "premature" birth and to thrive in vastly disparate climates all over the globe.
Let's learn more…
Human milk does not come with a nutritional label - and sometimes that's to its detriment. Marketers of human milk substitutes and other ultra-processed foods long ago discovered that nutrient and health claims, particularly those that indicate novelty or exclusivity, are highly effective at influencing consumers.
In this section, we will review the nutritional component of human milk, where it is constant across populations and where it varies.
Exclusive breastfeeding for the first 6 months of life provides all the nutrients and water that an infant needs to grow and develop. After 6 months, other nutritionally adequate and safe foods should be added to the infant's diet, with breastfeeding continuing to 2 years of age or beyond.
The composition of human milk is relatively constant with minimal fluctuations caused by maternal diet, even when the mother's food intake is inadequate (eg famine). Unlike the nutrition received by the fetus through the placenta, the nutrition received by breastfed infants is not dependent on the status of maternal metabolism.
Protein, fat and carbohydrates are what we call "macro-nutrients" - substances that are required daily and in relatively large quantities for the normal growth and functioning of the human body. Not all proteins, fats and carbohydrates are created equal - those found in human milk are uniquely suited to the needs of the human infant.
Human milk contains approximately 9g/L of protein, decreasing as lactation progresses. This is less than measured protein in cow's milk, however it is of higher biological value and perfect for a human infant.
There are hundreds of proteins in human milk, of which many do not have a primarily nutritional value, but rather serve other functions such as:
The high concentration of whey proteins and the soft, flocculent curds formed by human milk casein is the reason why breastfed babies do not get constipated. If a mother is concerned her baby might be constipated it is important to investigate the cause, because this is NOT normal for the (exclusively) breastfed baby.
The three main proteins in human milk are whey, casein and mucins. Whey makes up the bulk of proteins during early lactation (~80%), with casein accounting for most of the rest. Mucins are found in the membranes that surround fat globules in milk and are challenging to isolate for this reason; their primary function is immunological.
The high concentration of whey proteins are digested quickly and easily in the infant's stomach. Whey proteins include lactoalbumin and lactoferrin, both of which have immunological functions and lactoferrin is the source of the highly bioavailable iron in human milk. Casein has a mainly nutritive function, providing minerals and essential amino acids to the infant.
Several observational studies have shown an association between a high protein intake (>15 energy %) early in life and an increased risk of developing obesity and thereby non-communicable diseases (NCDs) later in life.
It is also plausible that an important reason for the slower growth in breast-fed infants is the lower content of protein human milk, but other qualities of human milk could also play a role.
A high intake of protein, especially dairy protein [in infant formula], stimulates the growth factors insulin-like growth factor (IGF-I) and insulin, and it has been suggested that the lower risk of NCDs in breast-fed infants is mediated through a regulation of IGF-I.
Lactose is the principal carbohydrate in all mammalian milk. Lactose is the most stable component of mature human milk, with little variation. Lactose is synthesized in the breast and broken down by the enzyme lactase in the baby's small intestine. The enzyme lactase breaks lactose into glucose and galactose, ready for absorption into the bloodstream.
The role of lactose:
Lactose is not the only carbohydrate found in human milk. Like the many proteins described in the last section, carbohydrates in human milk serve functions other than providing energy. Oligosaccharides make up approximately 20% of the total carbohydrate in human milk and, to date, more than 150 types have been fully identified. While the volume of carbohydrate is stable, the types of oligosaccharides found in human milk vary widely from one lactating parent to another.
At a concentration of 70g/L, human milk has the highest concentration of lactose of all the mammalian milks. Have you ever wondered why? Could it be because the human brain has the MOST growth of all mammal species to accomplish over the next two years and lactose contains elements essential to brain growth?
Consider what effects a lactose-free artificial infant formula could have on the infant fed on it. Discuss this with your colleagues.
Milk lipids are the most variable constituent of human milk, changing from feeding to feeding with variations by gestational age as well as at the population level in some studied groups. Fats globules in human milk are highly digestible, carrying with them the enzymes needed for digestion.
Properties of milk lipids:
This variability from feeding to feeding is directly related to the amount of milk held in the breast at that time. Milk removed when the breast is fullest has a low concentration of fat. Fat concentration increases in a linear fashion as more and more milk is removed.
Illustrated is a series of samples from an expression collected in 1mL fractions. The fat is seen as small clumps of white towards the top of each tube.
The samples are, in order from left to right, a fore-milk sample (hand-expressed), a stimulation sample (the first milk removed by the breast pump), 7 samples collected during the expression, and a final sample hand-expressed after pumping. The initial sample is 5.6% cream (fat) and the final is 18.3% cream (fat).
In this example, this represents a change in degree of breast fullness from 0.55 (about half full) to 0.0 (well-drained).
The proportion of fatty acids synthesized in the mammary gland is strongly influenced by diet. Maternal diet does not affect the total amount of fat in human milk. However, the types of fat in the mother's diet influence the composition of fatty acids in her human milk.
Cholesterol is found in fairly stable quantities in human milk (10-20mg/dL), regardless of dietary manipulation. Amongst other important tissues it is involved in laying down the myelin sheath which covers the axons of nerve cells in the rapidly growing brain and spinal cord. Multiple sclerosis, a problem of myelinisation, is much more prevalent in countries where breastfeeding is less common.
As with proteins and carbohydrates, there is also variation in the type of lipids found in human milk. These variations are more tightly linked to maternal dietary intake than with carbohydrates and proteins.
While water is not a nutrient, it is a major component of human milk and is important to note as parents may be concerned that their infant is at risk of dehydration during warmer periods.
Additional water is not necessary for the exclusively or predominantly breastfed child even at high temperatures. Offering water as a drink may displace the calories and nutrients in human milk in the child's diet and, in large quantities, can disrupt the child's electrolyte balance. In addition, where safe water supply and washing facilities are not consistently available, water may become a source of illness.
Human milk is understood by most to be the best food for an infant, but as we can see above, it's function is also immunological. These functions are particularly important in the early hours, weeks and months of life as the infant adapts to the specific environment into which they have been born and build their ability to mount a protective immune response to pathogens.
From a teaching perspective, these functions of human milk are also critical as they cannot be replaced by any available commercial product and the consequences of these early experiences may be lifelong.
Let's review:
Immunoglobulins are present in human milk. The special structure secretory IgA (sIgA) is the main immunoglobulin. Concentration in colostrum is particularly high to provide immediate protection for the infant entering a world of microbes.
Check
In the last section, we reviewed the unique characteristics of human milk for human infants and how they contribute to normal growth and development. In this section, we will look at how breastfeeding impacts health and the costs of not breastfeeding.
A 2016 analysis published in the Lancet estimated that more than 820,000 lives could be saved each year by meeting breastfeeding recommendations globally, with a savings of US$300B annually. In 2019, a global tool estimated that there are 595 379 childhood deaths annually from diarrhoea and pneumonia alone and an overall global cost of US$341B.
Let's take a closer look…
The relative risk of developing diseases throughout life for artificially-fed as compared to human milk-fed infants.
0 - 1 month | 1 - 12 months | 1 - 6 years | |
---|---|---|---|
Diarrhea | 14 | 4 - 10 | |
Otitis media | 8.6 | 3.3 - 4.3 | |
Respiratory illness | 3.3 - 4.3 | ||
Urinary Tract Infection | Significant increase in UTI amongst artificially-fed infants in Sweden; this protection for the breastfed infant persisted after weaning |
Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in the NICU, with often devastating consequences.The key risk factors leading to NEC are prematurity, formula feeding, intestinal ischemia, and bacterial colonization. The mortality rate (15%-25%) for affected infants has not changed appreciably in 30 years.
Neonatal septicemia and meningitis is associated with severe morbidity and high mortality rates. Artificially fed infants in neonatal intensive care units, and artificially fed infants in developing countries, are most at risk.
A comparison of risk of sepsis in babies in neonatal intensive care units:
Postnatal Age | Breastmilk Fed | Artificial Milk Fed |
---|---|---|
first 10 days | 5% | 10% |
11 - 24 days | 9% | 20% |
25 - 38 days | 0% | 15% |
Donor human milk is a critical resource when a child cannot receive human milk from their own parent. According the 2018 BFHI Implementation Guidance, donor human milk should be prioritized when supplementation is necessary beyond what the parent can provide and 80% of vulnerable and low-birth weight birth weight infants should receive donor human milk, when supplementation is required. How is donor milk collected and distributed in your facility? Are there sources of donor milk for parents outside the hospital in the community?
Type 1 diabetes is an auto-immune disease determined by a combination of genetic and environmental factors.
Environmental factors provide the trigger that causes a child to develop diabetes.
There are several hypotheses as to what these environmental factors are:
Meta-analyses of the published research found a strong link between early introduction of artificial milks and the development of Type 1 diabetes:
Mothers who have type 1 diabetes are more likely to artificially feed their infants. Cesarean section birth, prematurity and unstable condition of baby at birth are among the reasons given for this occurrence. Breastfeeding duration is likely to be shorter amongst this group of mothers with breastfeeding <4 weeks being associated with overweight at age 2 years.
Can you see how the risk of type 1 diabetes can spiral through the generations? The birth and post-birth circumstances and management of the diabetic mother can lead to an intervention (ie. infant being not-breastfed/early exposure to cow's milk protein in artificial infant milk) which triggers the infant to later develop diabetes.
The mechanism is not entirely understood, however, studies report that formula-fed infants have higher basal and postprandial concentrations of insulin and neurotensin.
Being formula-fed in infancy is associated with later development of type 2 diabetes and/or metabolic syndrome.
Some developed countries are reporting an 'epidemic' of celiac disease in children less than 2 years of age. Celiac disease is an autoimmune enteropathy. Genetic susceptibility and dietary exposure to gluten are necessary for it to occur.
Artificial feeding increases the incidence 4-fold, as well as causing an earlier onset.
Being breastfed during the introduction of gluten-containing foods has a significant protective effect.
Experiencing infectious diseases early in life increases the risk for later celiac disease. As already noted, artificially fed infants experience significantly more early-life infections.
The current recommendation to prevent the development of celiac disease is for children to be breastfed exclusively for 6 months and for breastfeeding to continue while, and for several months after, gluten is introduced into the diet.
Obesity is a serious condition that leads to chronic diseases such as heart disease, diabetes, hypertension, some cancers and an earlier death. Prevention of obesity starts at birth and is greatly influenced by the feeding method chosen.
Human milk contains an appetite regulator, leptin. Artificially-fed infants have half the normal serum leptin. Low serum leptin directly predicts high BMI in childhood.
Artificial feeding is significantly correlated with obesity in childhood and adulthood.
Closely associated with childhood obesity:
Fortunately childhood cancers are rare; unfortunately the child who was artificially-fed is at increased risk.
Being artificially fed is linked to development of the following cancers:
The causes of these conditions are multifactorial. However, being artificially fed in infancy is directly related.
Cow's milk is the most common single allergen affecting infants. The proteins in cow's milk are the allergen, NOT lactose. Standard infant formulas are made from cow's milk.
Asthma, eczema, urticaria, rhinitis, failure-to-thrive, colic, chronic respiratory disease, gastro-oesophageal reflux and gastro-intestinal disease are all examples of conditions caused by an allergy or intolerance to cow's milk protein.
Compared to breastfed infants, artificially-fed infants have a significantly higher incidence of all forms of atopy. Feeding soy-based artificial baby milk, compared to standard cow's milk-based artificial baby milk does not reduce the risk.
The brain of the newborn infant continues to develop rapidly after full term birth, doubling in size by one year of age. The brain growth in the preterm infant is even more rapid and therefore has an even greater potential to be harmed by inappropriate nutrition.
Since Lucas in 1992 was able to demonstrate an intellectual deficit caused by artificial infant formula feeding, there have been numerous research papers confirming those findings.
Assessment of children at 6.5 years of age reveals:
exclusive artificial feeding, or early introduction of artificial infant formula, contributes significantly to
While the mean difference in IQ may appear to be small at the individual level, the cost of children not meeting their full cognitive potential has devastating consequences for families in poverty and for entire nations. Of the US$341B annual cost in Alive and Thrive's global tool, more than 80% was attributable to cognitive losses.
Lactation is a normal reproductive phase following pregnancy and where it is interrupted, we can naturally expect adverse health outcomes. There are few activities that a person can undertake for such a limited time that will have as many positive outcomes for their health over their lifespan:
Do you think that most parents know that breastfeeding protects their health? What strategies might we use to ensure that breastfeeding is listed as a protective factor in health promotion campaigns?
While most of our section here has focussed on health outcomes, the cost of not breastfeeding is not only calculated at the population level. Families who must artificially feed their infants face direct costs related to infant formula and related supplies as well as the costs of increased illness, such as doctor's visits and time off work.
Do you know how much it costs to buy infant formula for 6-12 months in your community?
Infant formula also exacts a heavy environmental price, with estimates that each non-breastfed infant contributes 95kg-153kg CO2 equivalent in the first six months of life.