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A brief annotated bibliography

When breastfeeding is not fully practiced, infant formulas are generally used. The World Health Organization International Code of Marketing of Breast-milk Substitutes requires that parents be informed about the health hazards of unnecessary or improper use of infant formula. This brief annotated bibliography gives some examples from the extensive body of research documenting the importance of breastfeeding and in turn the associated risks of formula feeding. The World Health Organization recommends exclusive breastfeeding for six months, the introduction of nutritious complementary foods at six months and continued breastfeeding for two years and beyond.

Increased risk of asthma
A study of 2184 children done by the Hospital for Sick Children in Toronto determined that the risk of asthma and wheezing was approximately 50 per cent higher when infants were formula fed compared to infants who were breastfed for nine months or longer. (1)

Researchers in West Australia studied 2602 children to determine the development of asthma and wheeze at six years of age. Not breastfeeding increased the risk of asthma and wheeze by 40 per cent compared to infants who were exclusively breastfed for four months. The authors recommend exclusive breastfeeding for at least four months to reduce the risk of asthma. (2)

The reviewers looked at 29 studies to evaluate the protective effect of breastfeeding on asthma and atopy. After applying strict criteria for assessment, 15 studies remained in the review. All 15 showed a protective effect of breastfeeding (a risk of formula feeding). They concluded that the evidence is clear and consistent that breastfeeding protects against asthma and atopy. (3)

Increased risk of allergy
Children in Finland who had been breastfed the longest had the lowest incidence of atopy, eczema, food allergy and respiratory allergy. At 17 years of age, the incidence of respiratory allergy for those who had little breastfeeding was 65 per cent and for those who were breastfed the longest 42 per cent. (4)

A longitudinal prospective study of 1246 healthy infants in Arizona, USA, aimed to determine the relationship between breastfeeding and recurrent wheeze. The results showed that non-atopic children at the age of six years, who had not been breastfed, were three times more likely to have recurrent wheezing. (5)

Infants with a maternal history of respiratory allergy or asthma were assessed for atopic dermatitis during the first year of life. Seventy-six Dutch children with and 228 children without atopic dermatitis were examined. Exclusive breastfeeding for the first 3 months was found to have a protective effect against dermatitis. (6)

Reduced cognitive development
A total of 3880 Australian children were followed from birth to determine breastfeeding patterns and later cognitive development. Those breastfed for six months or more scored 8.2 points higher for females and 5.8 points higher for males in vocabulary tests over those who had never been breastfed.(7)

School-aged children (439) who weighed less than 1,500 g at birth and were born in the US between 1991 and 1993 were given a variety of cognitive tests. The very low-birth weight infants who were never breastfed were found to have lower test scores in overall intellectual function, verbal ability, visual-spatialand visual motor skill than those who were breastfed. (8)

To determine the impact of exclusive breastfeeding on cognitive development for infants born small for gestational age, this US based study evaluated 220 infants, using the Bayley Scale of Infant Development at 13 months and the Wechler Preschool and Primary Scales of Intelligence at five years. The researchers concluded that exclusively breastfed (without supplements) small for gestational age infants had a significant advantage in cognitive development without compromising growth. (9)

The benefits of breastfeeding have long term potential on a person’s life through its influence on childhood cognitive and educational development concludes this UK study. Regression analysis was used to determine that breastfeeding was significantly and positively associated with educational levels obtained by age 26 as well as cognitive abilities at age 53. (10)

Increased risk of acute respiratory disease
A number of sources were used to examine the relationship between breastfeeding and the risk of hospitalization for lower respiratoryt ract disease in healthy full-term infants with access to adequate health facilities. Analysis of the data concluded that in developed countries, infants who were formula fed experienced more than three times the severity of respiratory tract illness and required hospitalization compared to infants who were exclusively breastfed for four months.(11)

To determine the modifiable risk factors for acute lower respiratory infection in young children, this Indian hospital based study compared 201 cases to 311 controls. Lack of breastfeeding was one of the key modifiable risk factors for lowerrespiratory infection in children under five years of age. (12)

Increased risk for infection from contaminated formula
A case report from a recent US based outbreak of Enterobacter Sakazakii in a neonatal intensive care unit documents the death of a 20 day old infantwho developed fever, tachycardia, decreased vascular profusions and seizures at 11 days. E. sakazakii cultures were identified from the spinal fluid and traced to contaminated powdered infant formula used in the NICU. (13)

A Belgian based outbreak of necrotizing enterocolitis (NEC) is traced back to infant formula contaminated with Enterobacter sakazakii. A total of 12 infants developed NEC during the outbreak and two infants (twin brothers) died. (14)

Increased risk of childhood cancers
Not breastfeeding is known to increase the risk of cancer. This novel study found a significant level of genetic damage in infants aged 9 to 12 months who were not breastfed. The authors speculate that this may play a role in the development of cancer in childhood or later life. (15)

The UK Childhood Cancer Study analyzed 3500 childhood cancer cases and the relationship to breastfeeding. Results showed a small reduction for leukaemia and for all cancers combined when infants had “ever been breastfed”. (16)

A case controlled study in the United Arab Emirates looked at 117 cases of acute lymphocytic leukemia and 117 controls. They found that the breastfeeding duration of those with leukemia was significantly shorter than the breastfeeding duration of the controls. They concluded that breastfeeding duration of six months or longer may protect against childhood acute leukaemia and lymphomas. (17)

Increased risk of chronic diseases
A review of infant feeding practices and childhood chronic diseases shows increased risk for Type I diabetes, celiac disease, some childhood cancers, and in-flammatory bowel disease associated with artificial infant feeding.(18)

Celiac disease may be triggered by an autoimmune response when an infant is exposed to a food containing gluten proteins. In order to investigate the impact of breastfeeding on this response, Ivarsson and her team of researchers looked at the breastfeeding patterns of 627 children with celiac disease and at 1254 healthy children to determine the effect of breastfeeding during the time of introduction of gluten containing foods on the outcome of the development of celiac disease. An astounding 40 per cent risk reduction was reported for the development of celiac disease in children at two years of age or younger for those who were breastfed when dietary gluten was introduced. And the effect was even more pronounced in infants who continued to be breastfed after dietary gluten was introduced, the authors noted. (19)

Increased risk of diabetes
Early introduction of infant formula, solids and cow’s milk are factors shown to increase the incidence of Type I diabetes later in life. Swedish (517) and Lithuanian (286) children aged 0 to 15 years who were diagnosed with Type I diabetes were compared to controls. The results showed that exclusive breastfeeding for longer than five months and total breastfeeding for longer than seven or nine months is protective against diabetes. (20)

To determine the link between cow’s milk consumption (cow’s milk based infant formula) and the development of antibody response to cow’s milk protein, Italian researchers measured the antibody response of 16 breastfed and 12 cow’s milk fed infants under four months of age. Cow’s milk fed infants had elevated levels of beta-casein antibodies when compared to breastfed infants. The researchers concluded that breastfeeding for the first four months prevented the production of antibodies and could have a preventive effect on the development of Type I diabetes. (21)

In this case-controlled study, 46 native Canadian Type II diabetes patients were matched with 92 controls. Pre and postnatal risk factors were compared. Breastfeeding was found to reduce the risk of Type II diabetes. (22)

Increased risk of cardiovascular disease
A prospective study followed 7276 term UK infants for 7.5 years. Full data was available for 4763 children. For those not breastfed, both systolic and diastolic pressures were found to be higher at age 7 years than for those who were breastfed. There was a 0.2 mm Hg reduction for each 3 months of breastfeeding. The authors suggest there may be significant benefits during adulthood as a 1% reduction in population systolic blood pressure is associated with a 1.5% reduction in overall mortality. (23)

A UK study looked at the cholesterol levels of 1500 13 to 16 year olds and determined that breastfeeding may have long term benefits in preventing cardiovascular disease by reducing the total cholesterol and the low-density lipid cholesterol. The research suggests that early exposure to breastmilk may program fat metabolism in later life, resulting in lower blood cholesterol levels and therefore a lower risk of cardiovascular disease. (24)

To confirm links between infant nutrition and health risks in later life, British researchers measured the blood pressure of 216 children at 13 to 16 years of age who had been born prematurely. For those who had received preterm infant formula or routine infant formula, blood pressure was higher than for those who had received breastmilk during infancy. The authors concluded that for children born prematurely, breastfeeding lowers blood pressure in later life and that this conclusion can be extended to term infants as well. (25)

Increased risk of obesity
In order to determine factors associated with the development of overweight and obesity, 6650 German school-aged children between the ages 5 to 14 years of age were examined. Breastfeeding was found to be protective against obesity. The protective effect was greater when the infants were exclusively breastfed. (26)

To determine the impact of infant feeding on childhood obesity, this large Scottish study looked at body-mass index of 32,200 children aged 39 to 42 months. After elimination of confounding factors, socioeconomic status, birthweight and sex, the prevalence of obesity was significantly higher in the formula fed children; leading to the conclusion that formula feeding is associated with an increase in childhood obesity risk. (27)

German researchers collected height and weight data of 9375 school children to determine the impact of early childhood feeding on the development of obesity. The prevalence of obesity was found to be 4.5 per cent - nearly 40 per cent higher - in those who had never been breastfed compared to 2.8 per cent for those who had been exclusively breastfed.(28)

Increased risk of gastrointestinal infections
A comparison between infants who received primarily breastmilk during the first 12 months of life to infants who were exclusively formula fed or who were breastfed for three months or less found that diarrheal disease was twice as high for the formula fed infants than for those who were breastfed. (29)

Seven hundred and seventy-six infants from New Brunswick, Canada were assessed for the relationship between respiratory and gastrointestinal illnesses, and breastfeeding during the first six months of life. Although the rates of exclusive breastfeeding were low, the results showed breastfeeding had a significant protective effect against total illness during the first six months of life. For those breastfed, the incidence of gastrointestinal infections was 47% lower; the rate of respiratory disease was 34% lower than for those who were not breastfed. (30)

Breastfeeding promotion in Belarus signifcantly reduced the incidence of gastrointestinal infections by 40 per cent. (31)

Increased risk of mortality
The researchers examined 1204 infants who died between 28 days and 1 year of age from causes other than congenital anomaly or malignant tumor, and 7740 children who were still alive at 1 year, to calculate mortality and whether or not the infant was breastfed as well as the duration-response effects. Children who were never breastfed had a 21 per cent greater risk of dying in the postneonatal period than those who were breastfed. Longer breastfeeding was associated with lower risk. Promoting breastfeeding has the potential to save ~720 postneonatal deaths in the United States each year. In Canada this would be ~ 72 deaths. (32)

Compared with exclusive breastfeeding, children who were partially breastfed had a 4.2 times increased risk of death due to diarrheal disease. No breastfeeding was associated with a 14.2 times increased risk of death due to diarrheal disease in Brazilian children. (33)

Infants in Bangladesh who were partially breastfed or not breastfed had a risk of acute respiratory infection death 2.4 times greater than exclusively breastfed infants. If children were predominantly breastfed the risk of death due to acute respiratory infection was similar to that of exclusively breastfed children. (34)

The authors of this review discuss the impact of breastfeeding on child spacing and estimate that exclusive breastfeeding can lead to decreased mortality of 20 per cent when infants are spaced at least two years apart. (35)

Increased risk of otitis media and ear infections
The number of episodes of acute otitis media increased significantly with decreased duration of and exclusivity of breastfeeding. US infants who were exclusively breastfed for four months or more had a 50 per cent reduction of episodes compared to infants who were not breastfed. A 40 per cent reduction of episodes was reported for breastfeeding infants who were supplemented before four months of age. (36)

Between six and 12 months of age the incidence of first episodes of otitis media increased from 25 per cent to 51 per cent in infants exclusively breastfed. In infants that were exclusively formula fed the incidence rose from 54 per cent to 76 per cent during the second half of the first year. The authors concluded that breastfeeding even for a short period (three months) would significantly reduce the episodes of otitis media during infancy. (37)

Increased risk of side effects of environmental contaminants
A Dutch study showed that at six years of age, cognitive development is affected by prenatal exposure to PCBs and dioxins. An adverse effect of prenatal exposure on neurological outcome was also demonstrated in the formula fed group but not in the breastfed group. Despite higher PCB exposures from breast milk, the study found at 18 months, 42 months, and at six years of age, breastfeeding had a beneficial effect on the quality of movements, in terms of fluency, and in cognitive development tests. The data gives evidence that prenatal exposure to PCBs has subtle negative effects on neurological and cognitive development of the child up to school age. The study also gives evidence that breastfeeding counteracts the adverse developmental effects of PCBs and dioxins. (38)

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