1.2 What information to give
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![]() Key Points - Case Study AJoanne, aged 32, a regular patient, comes to see you when she is 12 weeks pregnant with her first baby. She has just returned from a trip around Australia and her pregnancy was confirmed by a doctor in the town they were in at the time. She has copies of her baseline blood tests with her and all are normal. Would you discuss breastfeeding at this visit?
What information would you give?
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What information would you give?
Ask whether she has thought about how she will feed her baby, and her views about breastfeeding. Most women say they will "breastfeed if they can" or think they should breastfeed but feel uncertain and anxious. They may see breastfeeding as a superior product, with formula feeding being seen as an adequate and valid alternative method of infant feeding1 with little understanding of the differences between the two.
Disadvantages of Breast Milk Substitutes
When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding:
(Please click on any point for further details.)
- are more expensive for the family and the community2
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are usually less convenient
- preparation and storage of alternative feeding products
- being caught out without sufficient formula
- needing to find places and ways of keeping formula sterile and utensils clean when travelling
- risk contamination during
- lack the same hormonal responses in the mother
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lack the same levels of nutritional components
- ie. essential amino acids and types of proteins, fatty acids and other nutritional components tailored to suit the developing human infant.9 (See Case 3 for further information)
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lack immunological components that provide protection from a number of diseases and adverse outcomes in infants and their mothers10,11 such as ...
- infection (otitis media, gastrointestinal infection, lower respiratory tract infections)
- allergy (atopic dermatitis, asthma)
- chronic disease (Type 1 and Type 2 diabetes, childhood leukaemia, SIDS, coeliac disease)
- necrotising enterocolitis (NEC)
- poorer cognitive development
- maternal type 2 diabetes
- maternal breast and ovarian cancer
- maternal rheumatoid arthritis
- All these effects are evident in developed as well as developing countries. Two extensive reviews10,11 published in 2007 evaluated the methodological rigour of studies comparing the effect of breastfeeding and formula feeding on a number of outcomes. These reviews and other studies published since their data were collected are able to quantify the risk for formula fed infants and their mothers.
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increase the likelihood of acute otitis media
- Formula fed infants are twice as likely to develop acute otitis media as infants exclusively breastfed for 3-6 months (OR 2)10 and are more likely to suffer from recurrent otitis media12. Additionally, infants breastfed for 4-6 months are nearly twice as likely (OR 1.95) to develop otitis media by the time they are two years old as infants breastfed for more than 6 months13.
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increase the likelihood of gastrointestinal infection
- The adjusted odds ratio of formula fed infants developing non-specific gastrointestinal infection is approximately 2.7.10,14 In recent published research from the United Kingdom14 exclusive breastfeeding could have prevented 53% of hospital admissions for gastrointestinal illness each month in the first eight months of life. The risk of hospital admission doubles for each month after weaning.
- increase the likelihood of lower respiratory tract infections (LRTI)
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increase the likelihood of atopic dermatitis
- For children under school age the odds ratio for those formula fed, compared to those exclusively breastfed for 3 months, developing atopic dermatitis was 1.47. This was even more evident for children from atopic families (OR 1.72)10. However, the effect does not appear to persist into later childhood or adulthood15.
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increase the likelihood of asthma
- Although studies appear to give conflicting reports and are difficult to evaluate, formula feeding appears to increase the incidence of wheezing within the first four years of life (OR 1.43) especially for those with a family history of atopy (OR 1.66)10,16. Similar to the findings with atopic dermatitis, it is unlikely that the effect persists into adolescence and adulthood10,16.
- increase the likelihood of Type 1 diabetes
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increase the likelihood of Type 2 diabetes
- Similarly, formula fed infants are more likely to develop Type 2 diabetes than those breastfed (OR 1.64).18
- increase the likelihood of childhood leukaemia
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increase the likelihood of obesity
- There appears to be a small increase in obesity and overweight in children and adults who were not breastfed as infants (OR 1.32 1.07). This effect seems to be dose related ie the effect increases with increasing duration of breastfeeding11 with one study finding a reduction of 4% in the risk of overweight for each month of breastfeeding.21
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increase the likelihood of SIDS
- A meta-analysis of studies using a precise definition of SIDS and adjusting for known confounders found that formula fed infants were more likely to die of SIDS than infants who had been breastfed at all (OR 1.56)10.
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increase the likelihood of coeliac disease
- Being breastfed at the time of the introduction of gluten reduced the incidence of coeliac disease by 52%. Additionally, reducing lengths of breastfeeding increase the risk of the infant developing coeliac disease22.
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increase the likelihood of NEC
- The absolute risk difference for developing NEC between premature infants receiving breast milk or formula is 5%. However, any advantage is still clinically important in these fragile infants10.
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increase the rate of infant mortality
- The odds ratio of a formula fed infant dying in the first 12 months in the USA compared to an infant who was ever breastfed is 1.2723. This equates to approximately 720 post-neonatal deaths in the USA each year.
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affect cognitive development
- Even when many confounding variables have been accounted for, children who had been breastfed as infants have intelligence scores approximately 4.9 points higher than children who had been formula fed11. A 2006 paper24 and subsequent review10 suggest that this difference is a function of maternal intelligence rather than a function of breast milk or breastfeeding. However, another study, adjusting for maternal cognitive ability and other confounders found a difference of 5.6 and 6.3 points in two different populations. They also found that the association between breastfeeding and cognitive development was modified by a gene involved in fatty-acid metabolism.25
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increase the likelihood of maternal Type 2 diabetes
- In women without gestational diabetes a shorter duration of breastfeeding (or no breastfeeding) was related to an increased risk of developing Type 2 diabetes26.
- increase the likelihood of breast and ovarian cancer
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increase the likelihood of other diseases where there is some data
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septicaemia and meningitis, urinary tract infection27
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Odds ratio of disease incidence with breast or formula-feeding
Notes
- # Wiessinger D (2004) Watch your language
- # Cattaneo A et al. (2006) Infant feeding and cost of health care: a cohort study
- # Smith JP et al. (2002) Hospital system costs of artificial infant feeding: estimates for the Australian Capital Territory
- # Weimer J (2001) The Economic Benefits of Breastfeeding: A Review and Analysis
- # Walker M (1993) A fresh look at the risks of artificial infant feeding
- # Giovannini M et al. (2008) Enterobacter sakazakii: an emerging problem in paediatric nutrition.
- # Kennell JH et al. (1998) Bonding: Recent observations that alter perinatal care
- # Klaus MH (1998) Mother and infant: Early emotional ties
- # Lawson M (2007) Contemporary aspects of infant feeding
- # Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries
- # Horta B et al. (2007) Evidence on the long-term effects of breastfeeding
- # Lubianca Neto JF et al. (2006) Systematic literature review of modifiable risk factors for recurrent acute otitis media in childhood
- # Chantry CJ et al. (2006) Full breastfeeding duration and associated decrease in respiratory tract infection in US children
- # Quigley MA et al. (2007) Breastfeeding and hospitalization for diarrheal and respiratory infection in the United Kingdom Millennium Cohort Study
- # Pesonen M et al. (2006) Prolonged exclusive breastfeeding is associated with increased atopic dermatitis: a prospective follow-up study of unselected healthy newborns from birth to age 20 years
- # Greer FR et al. (2008) Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas
- # Rosenbauer J et al. (2007) Early nutrition and risk of Type 1 diabetes mellitus - a nationwide case-control study in preschool children.
- # Owen CG et al. ( 2006) Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence
- # Kwan ML et al. (2004) Breastfeeding and the risk of childhood leukemia: a meta-analysis
- # Ortega-Garcia JA et al. (2008) Full breastfeeding and paediatric cancer
- # Harder T et al. (2005) Duration of breastfeeding and risk of overweight: a meta-analysis
- # Akobeng AK et al. (2006) Effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies
- # Chen A et al. (2004) Breastfeeding and the risk of postnatal death in the United States
- # Der G et al. (2006) Effect of breast feeding on intelligence in children: prospective study, sibling pairs analysis, and meta-analysis
- # Caspi A et al. (2007) Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism
- # Stuebe AM et al. (2005) Duration of lactation and incidence of type 2 diabetes
- # Hanson LA (2004) Protective effects of breastfeeding against urinary tract infection