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1.3 Relative risks

A little statistics...

Relative risk (RR) is a ratio of the probability of a disease, in this case, occuring in the experimental group (ie artificially-fed) versus the control (breastfed) group. The equation to work it out is: RR = Probability in experimental group divided by Probability in control group.

For example: If the probability of an infant contracting diarrhoea in the first month of life is 1% when breastfed, but 14% if artificially-fed then the RR=14. An artificially-fed infant has 14 times the risk of getting diarrhoea in the first month of life compared to the risk for a breastfed infant.


Clinical Note:

To obtain true and fair scientifically-relevant results in research studies, the researcher must compare the variable being studied to the norm. For example: compare state of disease in adults who smoke (variable), to state of disease in adults who do not smoke (the norm). Results are then written up as a change from the norm - ie 'incidence of lung cancer is increased in those who smoke by X.'

Breastfeeding is normal and breastfed babies enjoy a NORMAL state of health. Studies of infant health are notoriously reported incorrectly, making statements that equate to 'Breastfed babies are healthier' whereas correct scientific language should read 'Artificially-fed babies are sicker'.

Whenever you discuss feeding outcomes with your colleagues or with parents, ensure you are speaking factually using breastmilk and breastfeeding as the norm.

Acute diseases attributable to artificial feeding

Diarrhea, otitis media and pneumonia


The relative risk of developing diseases throughout life for artificially-fed as compared to human milk-fed infants.1
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.2

Necrotising Enterocolitis

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.3 The mortality rate (15%-25%) for affected infants has not changed appreciably in 30 years.

Septicemia and Meningitis

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:4

Postnatal Age Breastmilk Fed Artificial Milk Fed
first 10 days 5% 10%
11 - 24 days 9% 20%
25 - 38 days 0% 15%

Non-communicable diseases attributable to artificial feeding

Type 1 Diabetes Mellitus (Insulin-dependent diabetes)

Type 1 diabetes is an auto-immune disease determined by a combination of genetic and environmental factors.

  • general population risk of developing Type 1 diabetes = 0.4%
  • when a first-degree relative is affected = 6%

Environmental factors provide the trigger that causes a child to develop diabetes.

There are several hypotheses as to what these environmental factors are:

  • early exposure to cow's milk protein
  • introduction to solid food before 3 months
  • not having all the protective benefits of breastmilk

Meta-analyses of the published research found a strong link between early introduction of artificial milks and the development of Type 1 diabetes:

  • exposure to cow's milk in the first 3 months 5 6 7
  • weaning before 3 months 8
  • no-breastfeeding, while breastfeeding for more than 12 months was protective 9
  • being artificially fed at the time solid foods are commenced 10

The cycle of diabetic risk

Mothers who have type 1 diabetes are more likely to artificially feed their infants.11 Cesarian 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.12

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 artifical infant milk) which triggers the infant to later develop diabetes.

Would mothers put their baby at risk if they knew this?
What can you do at your workplace to help break this cycle?

Type 2 Diabetes and Metabolic Syndrome

The mechanism is not entirely understood, however, studies report that formula-fed infants have higher basal and post-prandial concentrations of insulin and neurotensin. 13 14
Being formula-fed in infancy is associated with later development of type 2 diabetes and/or metabolic syndrome. 15 16 17

Celiac Disease

Some developed countries are reporting an 'epidemic' of celiac disease in children less than 2 years of age. 18
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.19,20

Experiencing infectious diseases early in life increases the risk for later celiac disease.18 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

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.

Breastmilk contains an appetite regulator, leptin. Artifically-fed infants have half the normal serum leptin. 21 Low serum leptin directly predicts high BMI in childhood.22

Artificial feeding is significantly correlated with obesity in childhood and adulthood. 23 24 25 26

Closely associated with childhood obesity:

  • early weaning to artificial infant formula
  • introduction of artificial infant formula before 6 months of age while breastfeeding
  • introduction of solid foods at or before 4 months27

Childhood Cancer

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: 28 29

  • acute lymphoblastic leukemia (leukaemia) 30
  • lymphomas - Hodgkin's and non-Hodgkin's31
  • neuroblastomas
  • rhabdomyosarcoma32

Inflammatory Bowel Diseases

  • Ulcerative colitis
  • Crohn's disease

The causes of these conditions are multifactorial. However, being artificially fed in infancy is directly related. 33 34

Allergic Responses

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. 35 Feeding soy-based artificial baby milk, compared to standard cow's milk-based artifical baby milk does not reduce the risk. 36

The recommendation for atopy and asthma prevention still focuses on avoidance of tobacco smoke exposure and food allergens during the first 4 months of life, and to breastfeed the infant.37

Workbook Activity 1.5

Complete Activity 1.5 in your workbook.

Intelligence

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 38 was able to demonstrate an intellectual deficit caused by artificial infant formula feeding, there have been numerous research papers confirming those findings. 39 40

Assessment of children at 6.5 years of age reveals:

  • exclusive artificial feeding, or early introduction of artificial infant formula, contributes significantly to 41

    • reduced total IQ
    • reduced verbal IQ
    • reduced performance IQ

Think about it

If you search the medical and scientific journals using search terms such as IQ, visual development, motor development, verbal skills, etc and link them to feeding method in the first 12 months of life you'll receive literally thousands of hits. The effect of first food on the development of the brain has been intensely studied.

While the previously discussed acute and chronic conditions affect a percentage of children, development of the immature brain affects EVERY child. ie EVERY child fed on artificial infant formula will have their IQ reduced from their potential.

Do parents know this? If they did would they choose this option for their child lightly?

Some infants have to be fed artificially, and therefore it is of critical importance that the researchers continue their search so that these children are not further disadvantaged. The formula manufacturers quickly add the latest finding into their formulas; however, to date, no additiive has prevented this damage to the IQ of the artificially-fed infant.

Sudden Infant Death Syndrome (SIDS)

Over the past 30 years deaths from SIDS has been significantly reduced by sleeping infants on their backs on a safe sleep surface and avoidance of cigarette smoke. Researchers have now been able to demonstrate that artificial feeding causes SIDS. 42

Artificial feeding at one month of age was associated with double the risk for SIDS. 43 The majority of babies older than one month who died of SIDS were fed artifical formula. 44 45 46

A meta analysis of 23 SIDS studies revealed 19 studies which found artifical feeding increased SIDS. The combined analysis indicated that artificially-fed infants were twice as likely to die from SIDS. 44

'Breastfeeding' is being recommended by major SIDS Prevention councils around the World.47

Maternal Health

The health benefits of breastfeeding are not limited to the infant. The breastfeeding mother also receives significant protective effects with all the following being significantly more common in women who artificially feed their infants:
  • breast cancer
  • premenopausal ovarian cancer
  • Type 2 diabetes mellitus
  • hypertension
  • myocardial infarction
  • anemia

SUMMARY

Artificial feeding is detrimental to infant health because it:

  1. does not provide optimal nutrition; increasing the risk of non-communicable diseases

  2. does not provide the many special, unique protective factors, both antibody and non-antibody, found in human milk; increasing the risk of acute and chronic infectious diseases

  3. exposes the infant to bacterial pathogens in other food sources

Think about it:

Most new parents do not know of the research that clearly demonstrates these poor health and developmental outcomes from artificial feeding. As a health professional do you feel it is fair to withhold this information from parents who generally just want to do the best thing for their children?

Who do you think is being protected when this information is not shared with parents?
Who stands to lose by withholding this information?
Who stands to gain by withholding this information?


But we shouldn't make mothers feel guilty!

Click on the icon above to read an article about making mothers feel guilty.

What would you say?

Well, have you thought about what you would say now if a mother said to you,
"Is breastfeeding really worth all the effort it takes?"

In Module 3 you'll learn that discussing specific effects of breastfeeding and artificial infant formula feeding is required of you. However, the next module will help you to see how you can discuss this topic (and many others) giving

What should I remember?

  • the absence of breastmilk properties is the first contributing factor to disease processes
  • the exposure to artificial substances such as artificial infant milk has a strong association with acute and chronic illness
  • the acute conditions which are associated with infant formula feeding
  • the chronic conditions which are associated with infant formula feeding
  • there is a positive correlation between artificial infant formula feeding rates and the incidence of infant mortality and morbidity in every country in the World

Self-test Quiz

Assessment Quiz

When you are happy that you've understood all the information in this topic you will be ready to complete the Module 1 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 1.

Notes

  1. # Heinz (2001-02) Heinz Sight: Infant Nutrition Newsletter
  2. # Marild S et al. (2004) Protective effect of breastfeeding against urinary tract infection
  3. # Yeo SL (2006) NICU update: state of the science of NEC.
  4. # el-Mohandes AE et al. (1997) Use of human milk in the intensive care nursery decreases the incidence of nosocomial sepsis
  5. # Patelarou E et al. (2012) Current evidence on the associations of breastfeeding, infant formula, and cow\'s milk introduction with type 1 diabetes mellitus: a systematic review.
  6. # Kostraba JN et al. (1993) Early exposure to cow's milk and solid foods in infancy, genetic predisposition, and risk of IDDM.
  7. # Gerstein HC (1994) Cow's milk exposure and type 1 diabetes mellitus. A critical overview of the clinical literature.
  8. # Perez-Bravo E et al. (1996) Genetic predisposition and environmental factors leading to the development of insulin-dependent diabetes mellitus in Chilean children
  9. # Malcova H et al. (2006) Absence of breast-feeding is associated with the risk of type 1 diabetes: a case-control study in a population with rapidly increasing incidence
  10. # Frederiksen B et al. (2013) Infant Exposures and Development of Type 1 Diabetes Mellitus: The Diabetes Autoimmunity Study in the Young (DAISY).
  11. # Hummel S et al. (2007) Breastfeeding habits in families with Type 1 diabetes
  12. # Hummel S et al. (2008) [Breastfeeding in women with gestational diabetes]
  13. # Lucas A et al. (1980) Breast vs Bottle: endocrine responses are different with formula feeding
  14. # Salmenperä L et al. (1988) Effects of feeding regimen on blood glucose levels and plasma concentrations of pancreatic hormones and gut regulatory peptides at 9 months of age: comparison between infants fed with milk formula and infants exclusively breast-fed from birth.
  15. # Plagemann A et al. (2012) Early postnatal life as a critical time window for determination of long-term metabolic health.
  16. # Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries
  17. # Horta BL et al. (2007) Evidence on the long term efects of breastfeeding:systematic review and meta-analyses
  18. # Myléus A et al. (2012) Early infections are associated with increased risk for celiac disease: an incident case-referent study.
  19. # Ivarsson A et al. (2013) Prevalence of childhood celiac disease and changes in infant feeding.
  20. # Akobeng AK et al. (2006) Effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies
  21. # Savino F et al. (2004) Breast-fed infants have higher leptin values than formula-fed infants in the first four months of life
  22. # Savino F et al. (2013) High serum leptin levels in infancy can potentially predict obesity in childhood, especially in formula fed infants.
  23. # Baker JL et al. (2004) Maternal prepregnant body mass index, duration of breastfeeding, and timing of complementary food introduction are associated with infant weight gain.
  24. # Kalies H et al. (2005) The effect of breastfeeding on weight gain in infants: results of a birth cohort study
  25. # Li C et al. (2005) Additive interactions of maternal prepregnancy BMI and breast-feeding on childhood overweight
  26. # Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries.
  27. # Pearce J et al. (2013) Timing of the introduction of complementary feeding and risk of childhood obesity: a systematic review.
  28. # Shu XO et al. (1999) Breast-feeding and risk of childhood acute leukemia
  29. # Martin RM et al. (2005) Breast-feeding and childhood cancer: A systematic review with metaanalysis
  30. # Crouch S et al. (2012) Infectious illness in children subsequently diagnosed with acute lymphoblastic leukemia: modeling the trends from birth to diagnosis.
  31. # Rudant J et al. (2011) Childhood Hodgkin\'s lymphoma, non-Hodgkin\'s lymphoma and factors related to the immune system: the Escale Study (SFCE).
  32. # Lupo PJ et al. (2013) Allergies, atopy, immune-related factors and childhood rhabdomyosarcoma: A report from the children\'s oncology group.
  33. # Frolkis A et al. (2013) Environment and the inflammatory bowel diseases.
  34. # Hansen TS et al. (2011) Environmental factors in inflammatory bowel disease: a case-control study based on a Danish inception cohort.
  35. # Friedman NJ et al. (2005) The role of breast-feeding in the development of allergies and asthma
  36. # Ram FS et al. (2002) Cow's milk protein avoidance and development of childhood wheeze in children with a family history of atopy.
  37. # Lau S (2013) What is new in the prevention of atopy and asthma?
  38. # Lucas A et al. (1992) Breast milk and subsequent intelligence quotient in children born preterm
  39. # Jedrychowski W et al. (2012) Effect of exclusive breastfeeding on the development of children\'s cognitive function in the Krakow prospective birth cohort study.
  40. # Brion MJ et al. (2011) What are the causal effects of breastfeeding on IQ, obesity and blood pressure? Evidence from comparing high-income with middle-income cohorts.
  41. # Gustafsson PA et al. (2004) Breastfeeding, very long polyunsaturated fatty acids (PUFA) and IQ at 6 1/2 years of age.
  42. # Hauck FR et al. (2011) Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis.
  43. # Vennemann MM et al. (2009) Does breastfeeding reduce the risk of sudden infant death syndrome?
  44. # McVea KL et al. (2000) The role of breastfeeding in sudden infant death syndrome
  45. # Alm B et al. (2002) Breastfeeding and the sudden infant death syndrome in Scandinavia, 1992-95
  46. # Horne RS et al. (2004) Comparison of evoked arousability in breast and formula fed infants.
  47. # Young J et al. (2012) Responding to evidence: breastfeed baby if you can--the sixth public health recommendation to reduce the risk of sudden and unexpected death in infancy.