This issue of MCH LINKS will focus primarily on breast-feeding and will provide an overview of some of the research done in the last few years, underscoring the recommendation that human milk is the optimal feeding choice for the first 6 months of an infant's life.

Promotion of Breastfeeding by Physicians, 
from ObGyn Internet Discussion Group 

Table of Contents

#1 USDA to Focus on Breast-feeding

#2 What Makes Human Milk the "Gold Standard?"

#3 Breast-feeding Hospitalized Low Birth Weight Infants

#4 Fat Profile Differences between Human Milk and Infant Formula

#5 Cholesterol: Another Difference between Human Milk and Infant Formula

#6 Increase in Breast-feeding in U.S.

#7 Barriers and Contraindications to Breast-feeding Identified

#8 General Nutrition Guidelines for Breast-feeding

#9 How Do You Know A Breast-Fed Baby Is Getting Enough Milk?

#10 Economics Involved-Dollars Saved

#11 Role of Education in Breast-feeding

#12 Resources Available

#13 Electronic Connections

#14 Journal Articles Worth Noting

#15 How to Subscribe

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#1 USDA to Focus On Breast-feeding

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Recently Agriculture Secretary Dan Glickman announced a year-long campaign by federal and state WIC programs to promote breast-feeding by WIC mothers and to support all women who choose to breast-feed. The theme of the promotion is "Loving Support Makes Breast-feeding Work" and is the result of a cooperative agreement between Food and Consumer Services (FCS) of USDA and Best Start Social Marketing, Inc. The goals of this special effort include encouraging WIC participants to begin and continue breast-feeding; to increase referrals to WIC clinics for breast-feeding support; to increase general public acceptance and support for breast-feeding; and to provide support and technical assistance to WIC professionals in promoting breast-feeding.

Initially 10 locations will pilot the special promotion--Iowa, Arkansas, Nevada, California, New Jersey, West Virginia, Ohio, New York, Mississippi and the Chickasaw Indian Tribal Organization. Special resource materials, media packets and training will be available. The media phase of the project officially began during World Breast- feeding Week, August 1-7, 1997.

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#2 What Makes Human Milk the "Gold Standard?"

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Research conducted over the last several decades has established that breast milk provides the ideal food for infants to both nourish them and to protect them from illness. Human milk is a unique mixture of exactly the right amount of fatty acids, lactose, water, amino acids, vitamins, minerals and other components necessary for digestion, brain development and growth.

Benefits to the Infant: Breast-fed infants have fewer ear infections and less frequent incidence of diarrhea, respiratory illness, allergies and urinary tract infections than formula-fed infants. Scientists have also discovered that infants fed human milk have improved neural development, cognitive ability and visual acuity compared to formula-fed infants. The sucking action involved in breast-feeding strengthens the muscles of the babies' entire oral cavity in a way that enhances facial muscle and helps with the correct formation of teeth. Human milk appears to provide some protection from non-insulin dependent diabetes, Crohns' disease and lymphoma later in life. Recent studies have shown breast-fed babies have fewer doctor and hospital visits than their formula-fed cohorts. Taken together, these studies indicate that medical costs would be significantly lower in breast-fed infants than in formula-fed infants.

Benefits to the mother: Typically, breast-feeding allows the mother to recover from childbirth more quickly, experience less postpartum hemorrhaging, and less anemia. Breast-feeding also enhances the maternal-infant bonding process. Recent studies also indicate women who breast-fed their infants may have less risk of osteoporosis and breast cancer.

Reference: JADA 1993; 93:468-469

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#3 Breast-feeding Hospitalized Low Birth Weight Infants

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In the last few years, the nutritional benefits of human milk for the preterm infant, in terms of protein digestion, fat absorption, lactose digestion and amino and fatty acid patterns have been recognized. Human milk provides unique protection from such diseases as septicemia and necrotizing enterocolitis which is especially important in high-risk infants.

The lipids in human milk make up 50% of the calorie content and are structured in a way that promotes digestion and absorption--an ideal combination for an infant that needs to gain weight. However, since the amount of fat in human milk varies between individual mothers and from feeding to feeding, a strategy was needed to ensure that milk with the highest fat content was fed to the infant. Richard Schanler, M.D., professor of pediatrics at Baylor College of Medicine and lactation support program counselors at Texas Children's Hospital, devised a procedure to separate or fractionate the milk from each mechanical expression into two portions--foremilk and hindmilk. Foremilk is the initial milk of each feeding. Hindmilk follows after several minutes of nursing and is 2 to 3 times higher in fat content. Studies have shown lacto-engineering strategies that use only the hindmilk to feed the infants are successful in increasing the body weight gain of the preterm infant. Since these infants are not able to suck at the breast like a term infant, mothers pump their milk to be placed in feeding tubes for their infants.

To meet the very high nutritional needs of the premature infants, Dr. Schanler has studied various methods to fortify human milk. These fortifiers contain additional protein and minerals necessary for the optimal growth of the premature infant. The investigators involved in these studies have observed positive reactions from the mothers of the high-risk infants. By providing their own milk, they know they are participating in the care of their infants and giving them the best start possible under difficult circumstances. With the combination of lactation support and fortification strategies, neonatologists can ensure even the low-birth-weight infant receives the extra protection of human milk.

References: Clinics in Perinatology 1995; 22:207-222, Journal of Pediatric Gastroenterology & Nutrition 1994; 18:474-477

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#4 Fat Profile Differences Between Human Milk and Infant Formula

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Fat is a key nutrient, particularly for a growing infant. There is some evidence that preterm and full-term infants fed human milk have better cognitive development and visual acuity than their formula-fed cohorts. One of the differences may be the composition of the fat in human milk. Human milk contains two long chain fatty acids, arachidonic acid (AA) and docohexaenoic acid (DHA), that are critical to normal brain development, eyesight and growth. Formula fed infants must make these fatty acids from their precursors alpha-linolenic (ALA) and linoleic acids(LA).

Two Baylor College of Medicine scientists, William C. Heird, M.D., professor of pediatrics, and Craig L. Jensen, M.D., assistant professor of pediatrics, have conducted several studies of the role of DHA in infant growth and development. These investigators have studied both term and preterm infants to determine their ability to make the important fatty acids, to discover optimal amounts for supplementing infant formula and have also looked at various sources of DHA to supplement the diets of breast-feeding mothers.

Key study findings: both term and preterm infants can convert linoleic and alpha linolenic acids into AA and DHA and the ability to do so does not seem to increase with age as had previously been thought; infants fed a high intake of ALA, or a low LA/ALA ratio, have more DHA in their blood but do not see any better than infants fed lower intakes; infants fed a high intake of ALA do not grow as well as infants fed a lower intake; none of the four ALA intakes (or ALA/LA ratios) studied result in DHA or AA levels similar to breast-fed babies. Additionally, studies in term infants suggest that DHA status in early infancy might be associated with a modest neurodevelopment advantage at 12-15 months of age.

Because the amount of AA & DHA varies widely in human milk, Heird and Jensen supplemented the diets of breast-feeding mothers with high-DHA egg, fish oil capsules and algae-derived DHA to determine if they could increase the level of DHA in the mothers' blood and also in the blood of the infant. Measurements indicated that supplementation effectively increases the DHA content of milk and also the babies' plasma. Whether supplementation benefits the infant has not yet been determined.

The scientific community is currently debating whether to recommend supplementing infant formula with these fatty acids. Supplementation is a complex issue involving the safe and adequate amounts of the fatty acids, the best sources of the fatty acids and the ratios between the fatty acids.

References: Current Opinion in Lipidology 1997, 8:12-16; J Pediatr 1997,

131:200-209

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#5 Cholesterol Content: Another Difference between Human Milk and Infant Formula

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Cholesterol is an essential component of cell membranes and is critical for brain development and production of the myelin sheath, which protects nerves and nerve endings. There have been many studies about the way dietary cholesterol is regulated in adults, but none in infants. William W. Wong, PhD., professor of pediatrics at Baylor College of Medicine, used stable isotopes to determine the effects of dietary cholesterol on cholesterol synthesis in breast-fed and formula-fed infants.

The total nutrient intake from either human milk or infant formula was measured in infants between 4 and 5 months of age. Formula-fed infants consumed more energy, fat and protein than breast-fed infants. However, breast-fed infants were found to consume 5 times more cholesterol than the formula-fed infants. Formula-fed infants produced cholesterol 3 times faster than their breast-fed counterparts but still had much less cholesterol in their blood. Current casein-based, or cows milk-based, formulas have less than 25% of the cholesterol found in human milk. Infant formulas with a soy base contain even less cholesterol.

Dr. Wong found the greater cholesterol intake of the breast-fed infants was associated with elevated plasma LDL-cholesterol concentrations but not HDL-concentration levels. In adults, LDL is a risk factor for heart disease, but its role in infants is different. Since the breast-fed infants were consuming more cholesterol than was needed for growth, cholesterol synthesis in infants may be efficiently managed by a down- regulating mechanism when infants are challenged with high intakes of dietary cholesterol. These findings lead to questions about whether infants who receive formulas low in cholesterol and respond by making more cholesterol might be 'programmed' to have problems with high cholesterol levels later in life. Infants fed human milk with its abundant supply of cholesterol instead might experience a protective effect. Animal studies have shown a beneficial effect of feeding cholesterol in early infancy on cholesterol homeostasis in later life. Further research will increase our understanding of the long-term effects of large intakes of cholesterol during infancy.

Reference: J Lipid Res 1993: 34:1402-1411

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#6 Increase in Breast-feeding in U.S.

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More women are choosing to breast-feed their infants and are doing so for a longer period of time according to data from the Ross Laboratories Mothers' Survey. Comparing the rates from 1989 and 1995, the initiation of breast-feeding increased more than 14% (from 52.2% to 59.7%). There was also a 19.3% increase in the rate of breast-feeding at 6 months of age (from 18.1% to 21.6%). In addition to the increases noted, there was an increase among groups that historically have not had high rates of breast-feeding. Those groups include: women who are African Americans, less than 25 years of age, in the lowest income group, no more than grade school educated; women who had low-birth-weight babies; women who work full time away from home; and women who participated in the WIC program. Typically, white or Hispanic women over age 25, with more education, higher incomes, not working away from home and who had infants of normal birth weight were most likely to breast-feed.

Reference: Pediatrics 1997; 99(596)

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#7 Barriers to Breast-feeding Identified

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With all the advantages of breast-feeding, why do some women choose not to do so? Focus group interviews with women across all socioeconomic groups and in various parts of the country list two major reasons for choosing not to breast-fed: embarrassment and lack of support from family and friends. Additional personal barriers identified include a number of misconceptions and misunderstandings including the necessity to eat an ideal diet that does not include some of their favorite foods. Other concerns involve the possibility of pain when an infant nurses and a lack of confidence in their ability to provide all the milk an infant needs.

In addition to personal barriers, system barriers are mentioned such as: receiving conflicting information; being in a hospital that routinely supplements all infants with formula or water; and mothers and babies being kept in separate rooms rather than together.

Contraindications--There are several specific circumstances in which breast-feeding is not indicated: when the mother is undergoing chemotherapy for cancer; is HIV-positive; or uses illegal drugs. Many medications are safe even when breast-feeding, but each drug, even over- the-counter ones, should be specifically discussed with a physician or a pharmacist.

Reference: Lawrence, R.A. 1994. Breast-feeding: A Guide For the Medical Profession, 4th Ed.

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#8 General Nutrition Guidelines for Breast-feeding Mothers

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The American Dietetic Association offers the following recommendations for nursing women:

*Drink plenty of liquids--at least 8 cups daily

*Eat a variety of foods--from each of the food groups

*Eat at least three meals daily and don't skip breakfast

*Limit foods that are high in sugar and fat while being low in nutrients

*Eat about 500 calories more each day than typically eaten before pregnancy

*Avoid dieting to lose weight rapidly

Reference: Breast-feeding: Nature's Best for You and Your Baby, American Dietetic Association, 1993

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#9 How Do You Know A Breast-Fed Baby Is Getting Enough Milk?

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Signs of sufficient intake after the first few days of life include:

*8 or more feedings each day

*6 wet diapers each day

*2-4 stools each day

*Clear urine

Infant weight loss guidelines:

*5-7% from birth weight is common

*Greater than 10% indicates inadequate intake and possible dehydration

*Baby should regain birth weight within two weeks

Reference: AJDC 1991; 145:917-921

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#10 Economics Involved, Dollars Saved

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A recent benefit-cost study was done on the Colorado WIC program to determine whether infants who were breast-fed for six months while being enrolled in WIC would be associated with a reduction of Medicaid costs during that period of time. The findings were as follows: compared with formula-feeding, breast-feeding each infant enrolled in WIC saved $161 after consideration of the formula manufacturers' rebate; a Medicaid savings of $112 per infant was realized by the breast-feeding cohort; and pharmacy costs for the breast-feeding cohort were approximately 50% lower than costs for the formula-feeding infants.

Other studies have compared the number of work days lost by parents due to the illness of their infant and the cost of treatment for those illnesses between breast-fed and formula-fed infants. Findings include: each ear infection cost $60-$80 and resulted in 1-2 days off work unless ear tube surgery was required; in that case the cost was from $400-$1650 and resulted in 2-3 days off work; bronchitis or pneumonia cost $60-$80 if hospitalization was not required; if hospitalization was required, the cost was $4600-$5000 and resulted in 2-7 days away from work.

References: JADA 1997; 97:379-385; Breast-feeding Works For Working Women, Texas Bureau of Nutritional Services

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#11 Role of Education in Breast-feeding

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Almost every article about breast-feeding mentions the importance of education for the mother and her family members. The timing of that education appears to be best when it is done early in the pregnancy. That allows time for the woman to think about feeding options and to secure more information.

Experienced educators know how personal the decision is to breast-feed and underscore the importance of providing accurate information, answering questions as fully as possible and then respecting and supporting the woman's decision--whichever choice she makes.

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#12 Resources Available

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I. Title: Comprehensive Management and Training Guide for an In-Home

Breast-Feeding Support Program.

Target Audience: Professionals and paraprofessionals who work with pregnant and lactating women of all ages and levels of education, but especially targeted to limited resource audiences.

Topics: 3 manual set including all the resources needed to manage the program plus train a staff. Includes complete teaching materials--slides, overheads, and masters of all handout materials. Contains the latest information, written in conjunction with scientists at the Children's Nutrition Research Center.

Cost: $180 per complete set, also available separately

Information: contact Susan Baker, M.Ed., North Carolina State

University, ssbaker@amaroq.ces.ncsu.edu or 919-515-9126.

II. Title: Colorado Breast-feeding Update: A newsletter for Health Care Professionals

Topics: A wide range of current issues in breast-feeding

Cost: $15.00 per year by subscription--4 issues

Order from: Colorado Breast-feeding Task Force, Center for Human

Nutrition UCHSC, 4200 E. 9th Avenue, Box C225, Denver, CO 80262

III. Certified lactation consultants have extensive training and experience in facilitating and sustaining breast-feeding. Local WIC offices and local La Leche League chapters have information and support for breast-feeding women and their families.

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#13 Electronic Connections

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Children's Nutrition Research Center www.bcm.tmc.edu/cnrc

AAP, Dept of Community Pediatrics, Work Group on Breast-feeding www.aap.org/visit/breastww.htm

Internet journal PEDIATRICS www.pediatrics.org

American Council on Science & Health www.acsh.org

Dept. of Health & Human Services www.healthfinder.gov

HealthGate Healthy Woman www.healthgate.com/

PharmInfoNet www.pharminfo.com/

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#14 Journal Articles Worth Noting

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a. Motil K, Kertz B, Thotathuchery M. Lactational performance of adolescent mothers shows preliminary differences from that of adult women. Journal of Adol Health 1997; 20:442-449. This article outlines the differences in milk production, milk composition and lactational behavior of adolescents.

b. Visness C, Kennedy K. Maternal employment and breast-feeding: findings from the 1988 national maternal and infant health survey. Amer J Public Health 1997; 87:945-950. Article describes findings that low rates of breast-feeding are not due to women working away from home, but returning to work is associated with earlier weaning.

c. Kalkwarf H, Specker B, Bianchi D, Ranz J, Ho M. The effect of calcium supplementation on bone density during lactation and after weaning. N Eng J of Med 1997; 337:523-528. Discusses temporary bone mineral loss during lactation and its reversal after weaning.

d. Hoey C, Ware J. Economic advantages of breast-feeding in an HMO setting: a pilot study. Amer J of Managed Care 1997; 3:733-737. Describes cost savings of breast-feeding over bottle-feeding from an industry point of view.

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#15 How to Subscribe

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Karen L. Konzelmann, National Program Leader, Maternal & Child Health Cooperative State Research, Education and Extension Service USDA/ARS Children's Nutrition Research Center:

1100 Bates Street

Houston, Texas 77030-2600

Voice phone: 713-798-7070 FAX: 713-798-7098

Internet: MCHLINKS@bcm.tmc.edu

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Karen Konzelmann, NPL,
Maternal and Child Health
CSREES/USDA

http://www.bcm.tmc.edu/cnrc