1.2 What information to give

Key Points - Case Study A
Joanne, 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?
- Topic 1.1: Discussing breastfeeding
- It is important that doctors discuss infant feeding decisions and breastfeeding with women early in a pregnancy rather than waiting until the third trimester or after the baby is born.
What information would you give?
- Topic 1.2: What information to give
- When discussing infant feeding with mothers it is important to note that alternatives to breastfeeding have many undesirable outcomes.
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. 1 They may see breastfeeding as a superior product, with formula feeding being seen as an adequate and valid alternative method of infant feeding 2 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 community 3
- costs of formula, bottles, teats/artificial nipples, etc and medical costs
- costs to community: negative impact on the health care system by increasing the number of patient visits, 4 hospital admissions 5 and health care costs 6 with up to US$10.5 billion a year saved in the United States if all infants were exclusively breastfed to 6 months. 7
- 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
- lack the same levels of essential amino acids and types of proteins, fatty acids and other nutritional components tailored to suit the developing infant. 16 (See Case 3 for further information)
- lack immunological components that provide protection from a number of diseases and adverse outcomes in infants and their mothers 17 18 19 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 reviews 18 19 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 17 are able to quantify the risk for formula fed infants and their mothers.
- Acute otitis media
- Formula fed infants are twice as likely to develop acute otitis media as infants exclusively breastfed for 3-6 months (OR 2.0) 18 and are more likely to suffer from recurrent otitis media. 20 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 months. 21
- Gastrointestinal infection
- The adjusted odds ratio of formula fed infants developing non-specific gastrointestinal infection is approximately 2.7. 18 22 In an English study, 22 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. It appears that the protective effect of breastfeeding continues after the infant is weaned. 23 24
- Lower respiratory tract infections (LRTI)
- Formula-fed infants are at higher risk of developing lower respiratory tract infections. 25 24 26 In Ip’s 18 meta-analysis there would have been a reduction of 72% in hospital admissions for LRTI if all infants were exclusively breastfed for 4 months (OR 3.75). The odds ratio for infants contracting pneumonia if breastfed for between four and six months rather than > 6 months was 4.27. 21
- 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). 18 However, the effect does not appear to persist into later childhood or adulthood. 27
- 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). 18 28 Similar to the findings with atopic dermatitis, it is unlikely that the effect persists into adolescence and adulthood. 18 28 However, this descrepancy may be due to reverse causation (higher breastfeeding rates amnogst those who are at higher risk of allergy). 29
- Type 1 diabetes
- Type 2 diabetes
- Childhood leukaemia
- 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). 37 19 This effect seems to be dose related ie the effect increases with increasing duration of breastfeeding, 19 with one study finding a reduction of 4% in the risk of overweight for each month of breastfeeding. 38
- SIDS
- Meta-analyses 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), 18 and that this effect was more apparent for infants exclusively breastfed (O R3.7). 39 Another study found that infants not exclusively breastfed had higher odds of dying (OR 3.7) compared to infants who were exclusively breastfed one month prior to the death. 40
- Celiac disease
- Being breastfed at the time of the introduction of gluten reduced the incidence of coeliac disease by 52%. Additionally, reducing lengths of breastfeeding increases the risk of the infant developing celiac disease. 41 Some studies have found an increase in the incidence of celiac disease in infants who were introduced to gluetn before the age of four months and after the age of six months. 42
- Inflammatory bowel disease
- 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 infants. 18 Other studies have found that the development of NEC is also associated with the amount of infant formula 45 received and the use of bovine-based milk fortifier, rather than human-milk-based fortifier. 46
- Infant mortality
- The odds ratio of a formula fed infant in the USA dying in the first 12 months compared to an infant who was ever breastfed is 1.27. 47 This equates to approximately 720 post-neonatal deaths in the USA each year. A more recent study, also from the United States, calculated that 911 infant deaths could be prevented each year if all infants were exclusively breastfed for 6 months. 7
- The odds ratio of a formula fed infant in the USA dying in the first 12 months compared to an infant who was ever breastfed is 1.27. 47 This equates to approximately 720 post-neonatal deaths in the USA each year. A more recent study, also from the United States, calculated that 911 infant deaths could be prevented each year if all infants were exclusively breastfed for 6 months. 7
- Cognitive development
- Many observational studies have found a decrease in cognitive development in infants who have been formula fed. 48 49 50 51
- A 2006 paper 52 and subsequent review 18 suggest that this difference is a function of maternal intelligence rather than a function of breast milk or breastfeeding.
- However, another study, 53 adjusting for maternal cognitive ability and other confounders found a difference of 5.6 and 6.3 points in two different populations.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 fed. 19
- The association between breastfeeding and cognitive development was found to be modified by a gene involved in fatty-acid metabolism. 53 Another study has shown a relationship between the amount of breastmilk received as an infant and brain development at age 15 years. 54
- Mental health
- Maternal Type 2 diabetes
- There is an increased risk of type 2 diabetes in parous women who have not breastfed or breastfed for only a short time. 59 60 The risk decreased by 14-15% for each year a woman breastfed. 60 61 Breastfeeding does not appear to reduce the risk of developing type 2 diabetes for women with gestational diabetes. 62
- Breast and ovarian cancer
- Cardiovascular disease
- Other diseases where there is some data
- septicaemia and meningitis, urinary tract infection 66

Odds ratio of disease incidence with breast or formula-feeding
Notes
- # Labbok M (2008) Exploration of guilt among mothers who do not breastfeed: the physician\'s role.
- # Wiessinger D (2004) Watch your language
- # Cattaneo A et al. (2006) Infant feeding and cost of health care: a cohort study
- # Leung GM et al. (2005) Health consequences of breast-feeding: doctors\' visits and hospitalizations during the first 18 months of life in Hong Kong Chinese infants.
- # Paricio Talayero JM et al. (2006) Full breastfeeding and hospitalization as a result of infections in the first year of life.
- # Smith JP et al. (2002) Hospital system costs of artificial infant feeding: estimates for the Australian Capital Territory
- # Bartick M et al. (2010) The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis.
- # Giovannini M et al. (2008) Enterobacter sakazakii: an emerging problem in paediatric nutrition.
- # Cahill SM et al. (2008) Powdered infant formula as a source of Salmonella infection in infants.
- # Guan N et al. (2009) Melamine-contaminated powdered formula and urolithiasis in young children.
- # Velasquez EV et al. (2006) Pituitary-ovarian axis during lactational amenorrhoea. I. Longitudinal assessment of follicular growth, gonadotrophins, sex steroids and inhibin levels before and after recovery of menstrual cyclicity.
- # Kennedy KI (2002) Efficacy and effectiveness of LAM
- # Numan M (2006) Hypothalamic neural circuits regulating maternal responsiveness toward infants.
- # 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
- # Section on Breastfeeding (2012) Breastfeeding and the use of human milk.
- # 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
- # Rebhan B et al. (2009) Breastfeeding duration and exclusivity associated with infants\' health and growth: data from a prospective cohort study in Bavaria, Germany.
- # Duijts L et al. (2010) Prolonged and exclusive breastfeeding reduces the risk of infectious diseases in infancy.
- # Fisk CM et al. (2011) Breastfeeding and reported morbidity during infancy: findings from the Southampton Women\'s Survey.
- # Ladomenou F et al. (2010) Protective effect of exclusive breastfeeding against infections during infancy: a prospective 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
- # Kusunoki T et al. (2010) Breastfeeding and the prevalence of allergic diseases in schoolchildren: Does reverse causation matter?
- # Rosenbauer J et al. (2007) Early nutrition and risk of Type 1 diabetes mellitus - a nationwide case-control study in preschool children.
- # Das UN (2007) Breastfeeding prevents type 2 diabetes mellitus: but, how and why?
- # Owen CG et al. ( 2006) Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence
- # Rudant J et al. (2010) Childhood acute leukemia, early common infections, and allergy: The ESCALE Study.
- # Bener A et al. (2008) Does prolonged breastfeeding reduce the risk for childhood leukemia and lymphomas?
- # 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
- # Monasta L et al. (2010) Early-life determinants of overweight and obesity: a review of systematic reviews.
- # Harder T et al. (2005) Duration of breastfeeding and risk of overweight: a meta-analysis
- # Hauck FR et al. (2011) Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis.
- # Vennemann MM et al. (2009) Does breastfeeding reduce the risk of sudden infant death syndrome?
- # Akobeng AK et al. (2006) Effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies
- # Silano M et al. (2010) Effect of the timing of gluten introduction on the development of celiac disease.
- # Gearry RB et al. (2010) Population-based cases control study of inflammatory bowel disease risk factors.
- # Barclay AR et al. (2009) Systematic review: the role of breastfeeding in the development of pediatric inflammatory bowel disease.
- # Meinzen-Derr J et al. (2009) Role of human milk in extremely low birth weight infants' risk of necrotizing enterocolitis or death.
- # Sullivan S et al. (2010) An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products.
- # Chen A et al. (2004) Breastfeeding and the risk of postnatal death in the United States
- # Oddy WH et al. (2012) The long-term effects of breastfeeding on development.
- # Kramer MS et al. (2008) Breastfeeding and child cognitive development: new evidence from a large randomized trial.
- # Oddy WH et al. (2011) Breastfeeding and early child development: a prospective cohort study.
- # Oddy WH et al. (2003) Breast feeding and cognitive development in childhood: a prospective birth cohort study.
- # 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
- # Isaacs EB et al. (2010) Impact of breast milk on intelligence quotient, brain size, and white matter development.
- # Julvez J et al. (2007) Attention behaviour and hyperactivity at age 4 and duration of breast-feeding.
- # Montgomery SM et al. (2006) Breast feeding and resilience against psychosocial stress.
- # Oddy WH et al. (2010) The long-term effects of breastfeeding on child and adolescent mental health: a pregnancy cohort study followed for 14 years.
- # Sørensen HJ et al. (2005) Breastfeeding and risk of schizophrenia in the Copenhagen Perinatal Cohort.
- # Schwarz EB et al. (2010) Lactation and maternal risk of type 2 diabetes: a population-based study.
- # Stuebe AM et al. (2005) Duration of Lactation and Incidence of Type 2 Diabetes
- # Villegas R et al. (2008) Duration of breast-feeding and the incidence of type 2 diabetes mellitus in the Shanghai Women's Health Study
- # Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries.
- # Stuebe AM et al. (2009) Duration of lactation and incidence of myocardial infarction in middle to late adulthood.
- # Schwarz EB et al. (2009) Duration of lactation and risk factors for maternal cardiovascular disease.
- # Ram KT (2008) Duration of lactation is associated with lower prevalence of the metabolic syndrome in midlife–SWAN, the study of women's health across the nation.
- # Hanson LA (2004) Protective effects of breastfeeding against urinary tract infection