Breastfeeding: long-term effects on society

Associate Professor Wendy H Oddy BSc (Nutrition) MPH PhDTelethon Institute for Child Health Research University of Western AustraliaPerth, Western Australia

Global Breastfeeding Partners’ Forum October 17-19th Penang, Malaysia

Goals of this talk

1) Discuss breastfeeding rates globally

2) Determine the evidence for an association between the duration of breastfeeding and illness, disease and development in childhood

3) Targeting key determinants to successful breastfeeding

Universal breastfeeding has been the goal of the World Health Organisation; American Academy of Pediatrics and many other organisations for a quarter of a century.

The Australian National Health and Medical Research Council and the World Health Organisation recommends:

Exclusive breastfeeding for at least the first six months of life and up to two years.

The gradual introduction of nutritious foods for growth and development

To continue breastfeeding for 12 months and beyond

Exclusive breastfeeding: status worldwide

Source: The State of the World’s Children 2001.44129.3World4224.0Least Developed Countries44116.3Developing Countries-9.8Industrialized Countries-6.4CEE/CIS and Baltic States

3711.5Latin America/Caribbean5732.6East Asia/Pacific4635.7South Asia9.39.3Middle East/North Africa3424.0Sub-Saharan Africa

% exclusively breastfed (0-3 mos.)

2000

Births (millions)1999UNICEF Region

Breastfeeding Rates Around the Developed World

Sources: Baby Milk Action, Cambridge, UK; Center for Breastfeeding Information.

Australia (2004) 95 472057United States2163Britain2568Netherlands2480Canada1093Poland5098Norway5398Sweden

% who continue 6 months or longer% of mothers who startCountry

Duration of any, full and exclusive breastfeeding in Perth, Western Australia 2002

0102030405060708090

100

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 39 41 43 45 48 50 52

Duration (w eeks)

Perc

enta

ge BF Any

BF Exclusive

BF Fully

Mammals

MAMMALIAN EVOLUTION

Mammary gland evolves from epidermal glands in reptilian ancestors

Homo Sapiens

Diversification via genetic mutations and natural selection

Continued speciation

Early primates

PrototheriaEutheriaMetatheria

Some of the biochemically active substances in human milk

• Hormones• Growth factors• Cytokines• Colony-stimulating factors• Specific nutrients

MONOCYTE

Cell Content of Human Cell Content of Human BreastmilkBreastmilk

With thanks to Dr M Cregan

MACROPHAGE

Cell Content of Human Cell Content of Human BreastmilkBreastmilk

With thanks to Dr M Cregan

SECRETORY EPITHELIALCELL (LACTOCYTE)

Cell Content of Human Cell Content of Human BreastmilkBreastmilk

With thanks to Dr M Cregan

LYMPHOCYTE

Cell Content of Human Cell Content of Human BreastmilkBreastmilk

With thanks to Dr M Cregan

Some of the specific nutrients in human milk

• Protein• Nucleotides• Glutamine• Lactoferrin• Lipids• Oligosaccharides

IgA Antibodies

Oligosaccharides and glycoconjugates.

The microbiology of breast milk

Breast milk has a large impact on bowel development and gut microflora

Breastfed babies have a more healthy microflora than formula-fed babies’

Formula-fed infants have higher numbers and isolation frequencies of enterococci and clostridia in their faecal biliary than breastfed infants.

Newburg DS. J Pediatr Gastroenterol Nutr 2000; 30:S8-S17.

Epidemiological evidence

Common illnesses Feeding measure Risk Ratio range*

Acute diarrhea Breastfed < 3 mo 6.10 (4.1, 9.0)

Lower respiratory infections Breastfed < 4 mo 3.29 (1.8, 6.0)

Pneumonia No breastfeeding 16.7 (7.7, 36.0)

Ear infections acute Breastfed < 6 mo 1.61 (1.3, 1.8)*

** The risk ratios have been adjusted to reflect a level of risk of formula rather than protection of milk.

Arifeen, S. 2001Yoon PW. 1996César, V. 1999Hanson, LA. 1998

Less common illnesses

Necrotising enterocolitis 39% formula/ 7% breastfed 4.50 (3.00, 6.00)

Urinary tract infections Never breastfed 1.62 (1.35, 1.78)

Insulin dependent diabetes Breastfed < 4 months 1.63 (1.22, 2.17)

Acute lymphobastic leukemia Never breastfed 1.21 (1.09, 1.30)

Sudden infant death syndrome Current formula feeding 1.35 (1.09. 1.54)

Cholera Not breastfeeding 1.70 p<.0001 Nicoll A. 2002

Mårild S. 2004Kimpimäki T. 2001Davis MK. 2001Ford RP. 1993Clemens JD. 1997

Immunologic disease

Coeliac disease Breastfed < 3 months 1.63 (1.36, 1.79)

Crohn's disease Lack of breastfeeding 1.90 (1.50, 3.60)

Ulcerative colitis Lack of breastfeeding 1.50 (1.10, 2.10)

Juvenile rheumatoid arthritis Lack of breastfeeding 1.60 (1.19, 1.80)

Multiple sclerosis Breastfed < 7 months 1.62 (1.26, 1.81)

Ivarsson A.2002.Cashman KD. 2003.Corrao G. 1998. Bond A. et al. 1997.Sadovnick AD. 1996.

Development

Cognitive development in preterm Lack of feeding ↓ mean IQ of 8.3 pts

Cardiovascular disease Lack of feeding ↑ mean Tot Cholesterol

Metabolic development Lack of feeding ↑ ApoB values

Obesity Breastfed < 6 mo 1.25 (1.02, 1.43)

Reynolds A. Pediatr Clin North Am. 2001;48:159-71.Vestergaard M. Acta Paed 1999; 88: 1327-32.Ravellia ACJ. Arch Dis Child 2000;82: 248-52. Dewey KG. J Hum Lact 2003;19: 9-18.

Our results from the Western Australian Pregnancy Cohort

(Raine) Study….

Cumulative incidence of asthma at six years and other milk

*After adjusting for gender, gestational age < 37 weeks, attendance at childcare/playgroup and parental smoking

Doctordiagnosed

asthma

Wheezing 3 ormore times since

the age of 1Introduction of other milkat < 4 monthsORCIp-value

1.24 *(1.02-1.51)

.032

1.41*(1.13-1.76)

.002

Oddy et al. Brit Med J 1999

Prevalence of asthma at six years and other milk

*After adjusting for gender, gestational age of < 37 weeks, attendance at childcare/playgroup and parental smoking

Wheezinglast year

Sleepdisturbance due

to wheezeIntroduction of other milkat < 4 monthsORCIp-value

1.31*(1.05–1.63)

.017

1.42*(1.07–1.90)

.016

Oddy et al. Brit Med J 1999

Prevalence of atopy and other milk

*After adjusting for gender, gestational age < 37 weeks, attendance at childcare/playgroup and parental smoking

Skin Prick Test Positive

Introduction of other milkat < 4 monthsORCIp-value

1.28*(1.03–1.59)

.024

Oddy et al. Brit Med J 1999

0 20 40 60 80

0.5

0.6

0.7

0.8

0.9

1.0

Survival time (months)

% w

ithou

t ast

hma

Age of asthma diagnosis by age of introduction to other milks

Om>4

Om <=4

Oddy et al. Brit Med J 1999

Mental health/ behavioural scores by follow-up & breastfeeding <6 or 6+ mo

40

42

44

46

48

50

52

54

Age 2 Age 5 Age 8 Age 10 Age 14Follow-Up

Men

tal h

ealth

Mea

n Sc

ore

Breastfeeding < 6 monthsBreastfeeding ≥ 6 months

Oddy J Pediatrics 2010

International Diabetes Federation metabolic syndrome at 14 y & breastfeeding duration

0

1

2

3

4

5

6

7

8

1 2 3 4 5 6

B reastfeeding durat io n (mo nths)

MetS

No MetS*p <0 .0 5

Oddy (in prep) 2010

International Diabetes Federation waist criteria at 14 y & breastfeeding duration

0

5

10

15

20

25

30

35

1 2 3 4 5 6Breastfeeding duration (months)

Waist IDFNo Waist IDF

*p <0.05

* **

* * *

Oddy (in prep) 2010

Mean BMI over mean age based on age breastfeeding stopped at ≤ 4 /> 4 months

Chivers P, et al Oddy WH. Int J Obesity 2010

The introduction of milk other than breast milk was a significant risk factor for childhood asthma and allergy at six years of age.

Breastfeeding for less than six months was associated with poorer mental health and behavioural scores throughout childhood

Breastfeeding for less than six months was associated with increased diabetes risk, high waist circumference and BMI in adolescence

ConclusionThe body of research related to breast milk reinforces the benefits of full breastfeeding for at least the first six months of life and up to two years for the health of infants and children.

Targeting key determinants of breastfeeding success

• Need to address the factors that directly influence breastfeeding

• Three levels of factors identified

Hector et al. 2005

Determinants of Breastfeeding

GroupGroup

SocietySociety

IndividualIndividual

Individual-Level Factors

GroupGroup

SocietySociety

IndividualIndividual

SkillsSkills

KnowledgeKnowledge

AttitudesAttitudesConfidenceConfidence

Group-Level Factors

GroupGroupSocietySociety

IndividualIndividual

Hospitals/Health CareHospitals/Health Care

Group-Level Factors

GroupGroupSocietySociety

IndividualIndividual

Hospitals/Health CareHospitals/Health CareHome, Family, andHome, Family, and PeersPeers

Group-Level Factors

GroupGroupSocietySociety

IndividualIndividual

Hospitals/Health CareHospitals/Health CareHome, Family, andHome, Family, and PeersPeers

WorkWork

Group-Level Factors

GroupGroupSocietySociety

IndividualIndividual

Hospitals/Health CareHospitals/Health CareHome, Family, andHome, Family, and PeersPeers

WorkWorkCommunityCommunity

Society-Level Factors

GroupGroup

SocietySociety

IndividualIndividual

Cultural NormsCultural Norms

Gender RolesGender RolesPublic BreastfeedingPublic Breastfeeding Marketing BM SubstitutesMarketing BM Substitutes

Maternity LeaveMaternity Leave

Determinants of Breastfeeding

GroupGroup

SocietySociety

IndividualIndividual

SkillsSkills

KnowledgeKnowledge

AttitudesAttitudesConfidenceConfidence

Hospitals/Health CareHospitals/Health CareHome, Family, andHome, Family, and PeersPeers

WorkWorkCommunityCommunity

Cultural NormsCultural NormsGender RolesGender Roles

Public BreastfeedingPublic Breastfeeding Marketing BM SubstitutesMarketing BM Substitutes

Maternity LeaveMaternity Leave

Advantage of a Multi-Level Approach

• Determinants are often inter-related• Can identify which intervention strategies will

need to be coordinated to have an effect• Can identify those responsible for various

actions and coordinate efforts• Increase the rates, duration, and exclusivity of

breastfeeding

Acknowledgments Study staff, study participants and their families, and our

funders without whom this research would not be possibleThanks to Grant Smith and the CARE team for the level slides

Thank you for inviting me to talk to you today