This essay is potentially vast in its scope as the advantages and disadvantages of breastfeeding can vary enormously depending on which authority one chooses to consult. (1) We shall therefore take an overview and present the generally accepted arguments in this area.

There is a substantial evidence base for the benefits of breastfeeding for not only the infant, but also the mother, the families and society as a whole. (2). The benefits are not only nutritional, but cover other areas such as development, immunity, psychological well-being, overall health risks, social and environmental areas (3)

Human milk is widely recommended as the food of choice for the otherwise healthy full-term newborn. Apart from providing the optimal nutrition it contains a number of cellular and humoral components such as phagocytes, immunocompetant cells, immunoglobulins and hormones and also plays a (as yet, not fully defined) role in promoting intestinal mucosal maturation. (4)

Because of these (and other) considerations, the World Health Organisation recommends exclusive breastfeeding for at least the first six months of life. (5)

There is widespread evidence that the trend towards universal breastfeeding is increasing (viz. 6) in most of the developed countries, Fewtrell gives a global figure of 2% per year. but studies show that this trend is not equal across all socio-economic and demographic groups. If we specifically consider the UK situation then we can show that the commencement of breastfeeding is equal in the working and non-working mothers groups, although if one considers the situation of how many mothers are still breastfeeding at six months post partum, the incidence in the working mothers group is less than half that in the non-working group. (7)

What then is the evidence base for the benefits of breastfeeding? In addressing this question we shall confine our comments to those relevant to the developed world. If we consider the Kramer study, which compared the benefits of continued breastfeeding from 3 months to 6 months, the authors were able to demonstrate that the additional 3 months produced benefits in terms of greater weight gain, greater growth (length) together with a reduced incidence of gastrointestinal infection. (8)

In absolute terms however, the benefits of breastfeeding over formula milks (or cows milk) is much greater. A huge number of potential childhood infections have been demonstrated to have a lower incidence in the breastfed child including bacterial meningitis, diarrhoea, respiratory tract infections, otitis media, urinary tract infections (9) as well as less common entities such as necrotising enetrocolitis (10). It is also significant that the all-cause mortality rates are 21% less in breast fed infants. We should note that this figure, although accurate, is misleading, as many high risk babies are not breast fed because of their intercurrent problems. (11)

Apart from infections, many other health benefits can be demonstrated. There is a reduction in the incidence in sudden infant death syndrome under the age of 1 yr. (12). Diabetes (Type I and Type II) is less common amongst breastfed babies (in later life) as are the incidences of conditions such as lymphoma, leukaemia and Hodgkin’s disease. (13). Breastfeeding tends to be associated with a lower incidence of obesity, hypercholesterolaemia and asthma. (14)

There is a slightly weaker evidence base to support the benefit of breastfeeding in terms of neurological development. Some authorities suggest that it can improve cognitive development. (15) and it may also reduce the perception of some painful stimuli. (16)

In addition to benefits for the child, there are also a number of demonstrable benefits for the mother who breastfeeds. If suckling occurs at the time of birth, the resultant release of oxytocin reduces the incidence of post partum haemorrhage and increases the speed of uterine involution. (17). In the period after the birth, breastfeeding reduces both fertility and menstrual loss, it facilitates a return to pre-pregnancy weight, it reduces the risk of both ovarian and breast cancer (18) and may well reduce the incidence of osteoporotic fractured hips (19)

In the opening segment of this essay we alluded to the benefits to the community as a whole. These can be defined in terms or reduced health costs to the community by virtue of the protective effects of breastfeeding. There are also less definable benefits in terms of reduced employee absenteeism. Some authorities have gone as far as to point to the environmental benefits of reduction in energy expenditure on production, distribution and disposal of formula feeds and their packaging. (20)

Thus far we have considered the positive benefits of breastfeeding but in order to provide a balanced argument, we should also consider the disadvantages. The pre-term infant or severely underweight or ill baby has special needs and there are a number of reasons why they should not be breastfed. The pre-term infant has immature physiological systems and the kidneys may not be able to handle the osmotic gradients that are required to excrete the amount of fluid necessary to remove the amount of nutritional load required for adequate growth. This may result in respiratory problems and exacerbation of any pre-existing cardiac conditions (viz. patent ductus arteriosus). For this reason, most pre-term infant are electively parentrally fed and then weaned onto enteral feeding when their gastrointestinal tract and other physiological systems are mature enough to handle the fluid load. (21)

If the mother is ill or has a potentially communicable illness such as HIV/AIDS or TB, then breastfeeding is contraindicated, as it is in conditions when certain drugs (both medicinal and recreational) are taken by the mother. (22). We should also record that the evidence for HIV/AIDS spread is not secure, as some studies have suggested that breastfeeding actually confers a degree of protection against HIV/AIDS for the child. This is still an area of considerable debate. (23)

It is also clear from an examination of the literature on the subject, that there is a great deal of misinformation on the subject of breastfeeding in the popular press (and to a lesser extent in the medical press). Breastfeeding is not contraindicated in conditions such as Hepatitis B or C +ve. (24). Most febrile conditions are not a contraindication to breastfeeding as the maternal immune response will be passively given to the child in any event. Some authorities suggest that tobacco smoking is a contraindication to breastfeeding. If we remove considerations of general health from the consideration, there is no reason why tobacco smoke should be considered a bar to breastfeeding as such. (it clearly may be ill-advised however) (25).

Some authorities suggest on theoretical grounds that breastfeeding should be suspended during the period of physiological jaundice of the newborn. A number of recent studies have shown that this is not necessary and may cause insurmountable difficulties in rehabilitation-establishing breastfeeding after the event. (26)

In essence, within the scope of the exclusions referred to above, healthcare professionals should actively encourage and support mothers in their ability to breastfeed their offspring. In doing so, one should always consider the autonomy of the mother (27) and attempt to provide empowerment and education in order to facilitate the best result rather than compulsion or emotional blackmail. (28). This should help to ensure the maximum possible take up of breastfeeding from mothers who have been able to make a fully informed decision. If direct breastfeeding is not possible, then, generally speaking, expressed breast milk is the preferred substitute.

In this essay we do not presume to have covered anything like an exhaustive presentation of the arguments, but there is no doubt, from an overview of the evidence base on the subject, that in the vast majority of cases, both mother and child will derive substantial benefits from being able to breast feed for at least the first six months of life.

References

(1) Duerbeck N B (1998) Breast-feeding: what you should know so you can talk to your patients.

Comp Ther

1998 ; 24 : 310 – 318

(2) Kramer M S, Chalmers B, Hodnett E D, et al. (2001) Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus.

JAMA.

2001 ; 285 : 413 – 420

(3) Schanler R J. (2001) The use of human milk for premature infants.

Pediatr Clin North Am.

2001 ; 48 : 207 – 219

(4) Margolis L H and J. B. Schwartz (2000) The Relationship Between the Timing of Maternal Postpartum Hospital Discharge and Breastfeeding. J Hum Lact, May 1, 2000 ; 16 (2) : 121 – 128.

(5) Fewtrell M S , J. B Morgan, C. Duggan, G. Gunnlaugsson, P. L Hibberd, A. Lucas, and R. E Klein man (2007) Optimal duration of exclusive breastfeeding: what is the evidence to support current recommendations? Am. J. Clinical Nutrition, February 1, 2007 ; 85 (2) : 635S – 638S.

(6) Bonuck K A, K. Freeman, and M. Trombley (2006) Randomized controlled trial of a prenatal and postnatal lactation consultant intervention on infant health care use. Arch Pediatr Adolesc Med, September 1, 2006 ; 160 (9) : 953 – 960.

(7) Kramer M S, Kakuma R. (2001)

The Optimal Duration of Exclusive Breastfeeding.

Geneva, Switzerland: World Health Organization ; 2001

(8) Kramer M S , Guo T, Platt R W et al. (2003) Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive breastfeeding. American Journal of Clinical Nutrition, Vol. 78, No. 2, 291 – 295, August 2003

(9) Heinig M J. (2001) Host defense benefits of breastfeeding for the infant. Effect of breastfeeding duration and exclusivity.

Pediatr Clin North Am.

2001 ; 48 : 105 –123

(10) Dewey K G, Heinig M J, Nommsen-Rivers L A. (1995) Differences in morbidity between breast-fed and formula-fed infants.

J Pediatr.

1995 ;126 : 696 – 702

(11) Chen A, Rogan W J. (2004) Breastfeeding and the risk of postneonatal death in the United States.

Pediatrics.

2004 ;113 (5)

(12) Horne R S, Parslow P M, Ferens D, Watts A M, Adamson T M. (2004) Comparison of evoked arousability in breast and formula fed infants.

Arch Dis Child.

2004 ; 89 (1) : 22 –25

(13) Davis M K. (1998) Review of the evidence for an association between infant feeding and childhood cancer.

Int J Cancer Suppl.

1998 ; 11 : 29 – 33

(14) Toschke A M, Vignerova J, Lhotska L, Osancova K, Koletzko B, von Kries R. (2002) Overweight and obesity in 6- to 14-year old Czech children in 1991: protective effect of breast-feeding.

J Pediatr.

2002 ; 141 : 764 – 769

(15) Horwood L J, Darlow B A, Mogridge N. (2001) Breast milk feeding and cognitive ability at 7–8 years.

Arch Dis Child Fetal Neonatal Ed.

2001 ; 84 : F23 – F27

(16) Carbajal R, Veerapen S, Couderc S, Jugie M, Ville Y. (2003) Analgesic effect of breast feeding in term neonates: randomized controlled trial.

BMJ.

2003 ; 326 : 13

(17) Labbok M H. (2001) Effects of breastfeeding on the mother.

Pediatr Clin North Am.

2001 ; 48 : 143 – 158

(18) Rosenblatt K A, Thomas D B. (1993) Lactation and the risk of epithelial ovarian cancer. WHO Collaborative Study of Neoplasia and Steroid contraceptives.

Int J Epidemiol.

1993 ; 22 : 192 – 197

(19) Paton L M, Alexander J L, Nowson C A, et al. (2003) Pregnancy and lactation have no long-term deleterious effect on measures of bone mineral in healthy women: a twin study.

Am J Clin Nutr.

2003 ; 77 : 707 – 714

(20) Jarosz L A. (1993) Breast-feeding versus formula: cost comparison.

Hawaii Med J.

1993 ; 52 : 14 – 18

(21) Denne, S. C., Karn, C. A., Ahlrichs, J. A., Dorotheo, A. R., Wang, J. & Liechty, E. A. (1996) Proteolysis and phenylalanine hydroxylation in response to parenteral nutrition in extremely premature and normal newborns. J. Clin. Invest 97 : 746 -754

(22) Read J S; (2003) American Academy of Pediatrics, Committee on Pediatric AIDS. Human milk, breastfeeding, and transmission of human immunodeficiency virus type 1 in the United States.

Pediatrics.

2003 ; 112 : 1196 – 1205

(23) Coutsoudis A, Rollins N. (2003) Breast-feeding and HIV transmission: the jury is still out.

J Pediatr Gastroenterol Nutr.

2003 ; 36 : 434 – 442

(24) Pickering : (2003) American Academy of Pediatrics. Transmission of infectious agents via human milk. In: Pickering LK, ed.

Red Book: 2003 Report of the Committee on Infectious Diseases

. 26th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2003 : 118 – 121

(25) American Academy of Pediatrics, (2001) Committee on Drugs. Transfer of drugs and other chemicals into human milk.

Pediatrics.

2001 ; 108 : 776 – 789

(26) American Academy of Pediatrics, (2004) Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.

Pediatrics.

2004 ; 114 : 297 – 316

(27) Sines D (1995) Impaired autonomy: the challenge of caring. Journal of Clinical Nursing 4 (2) 109 -115.

(28) Marinker M.(1997) From compliance to concordance: achieving shared goals in medicine taking. BMJ 1997 ; 314 : 747 – 8.

###############################################################

12.05.07 PDG Word count 2,183