The Breastfeeding Debate

Breastfeeding is a surprisingly controversial subject. Some women are bullied and essentially accused of abuse for not breastfeeding their children. Other women wean their children at 6 years when they go them to school, or are chastized for breastfeeding in public. Others may add breastfeeding their partner to spice up their sex lives. The debate around this practice can be extremely heated at time.

The benefits of breastfeeding are touted by government agencies in Canada, the US , and the UK. The current beliefs are concisely stated on Health Canada’s site.

Breastfeeding – exclusively for the first six months, and sustained for up to two years or longer with appropriate complementary feeding – is important for the nutrition, immunologic protection, growth, and development of infants and toddlers.

For women, there are a number of reasons why breast feeding is not recommended, such as medical conditions or medications.

  • An infant diagnosed with galactosemia, a rare genetic metabolic disorder
  • The infant whose mother:
  • Has been infected with the human immunodeficiency virus (HIV)
  • Is taking antiretroviral medications
  • Has untreated, active tuberculosis
  • Is infected with human T-cell lymphotropic virus type I or type II
  • Is using or is dependent upon an illicit drug
  • Is taking prescribed cancer chemotherapy agents, such as antimetabolites that interfere with DNA replication and cell division
  • Is undergoing radiation therapies; however, such nuclear medicine therapies require only a temporary interruption in breastfeeding

In addition, there may be personal or financial reasons why breastfeeding is not the optimal solution for women. There are unable to express milk at all, or or may need to return to work for financial reasons. While some are able to manage breastfeeding while working full time, for many this is not feasible. Postpartum depression can also be a major factor in being unable to breastfeed. The choice may be due to pressure from their partners or other family members. Perhaps the reasons have to do with demands from other children in the family. In other words, there are as many reasons not to breastfeed as there are women who don’t. In every case, the reasons are invisible to the rest of us.

There is absolutely no reason to criticize or attack women who are unable to breastfeed, or make the choice to use formula. Parents of young children are under considerable stress, and none need the additional stress of personal or public shame and the associated guilt.

On the other side of the issue, there are also valid complaints from women who breastfeed in public or breastfeed for an extended amount of time. In 2012, Time magazine unleashed a furor of controversy when they used a cover image woman breastfeeding a toddler. Facebook has also created controversy by removing images of mothers breastfeeding children. One of the reasons cited for this criticism is the sexualization of women’s breasts by the media. Beyond criticism, this sexualization has been quoted in research as a reason mothers choose to formula feed or cease breastfeeding early.

Beyond the biases that women on both sides of the debate have and face, one of the primary concerns for all is the health of the infant. There are certainly advantages for neonates to be be breast fed for the first few days or weeks after birth. This has to do with the weak immune systems of neonates and the ability of mothers to pass along antibodies and growth factors. However, the question remains as to how long these benefits last.

I grew up on a dairy farm, and for the first 33 years of my life, I milked cows, fed calves, and shovelled shit.  Farmers have always been keenly interested in ways to improve the health of their livestock, such interest is critical to being able to earn a living and good science is an important part of modern farming. One of the things that is important for dairy farmers is the growth of healthy calves that will develop into the most productive cows, and the beginning of that comes from the early feeding of colostrum. Wikipedia provides a good introduction to colostrum with references for further reading.

Newborns have very immature digestive systems, and colostrum delivers its nutrients in a very concentrated low-volume form. It has a mild laxative effect, encouraging the passing of the baby’s first stool, which is called meconium. This clears excess bilirubin, a waste-product of dead red blood cells, which is produced in large quantities at birth due to blood volume reduction, from the infant’s body and helps prevent jaundice. Colostrum is known to contain immune cells (as lymphocytes)[4] and many antibodies such as IgAIgG, and IgM. These are the major components of the adaptive immune system. Inter alia IgA is absorbed through the intestinal epithelium, travels through the blood, and is secreted onto other Type 1 mucosal surfaces{citation needed}. Other immune components of colostrum include the major components of the innate immune system, such as lactoferrin,[5]lysozyme,[6]lactoperoxidase,[7]complement,[8] andproline-rich polypeptides (PRP).[9] A number of cytokines (small messenger peptides that control the functioning of the immune system) are found in colostrum as well,[10] including interleukins,[10] tumor necrosis factor,[11]chemokines,[12] and others. Colostrum also contains a number of growth factors, such as insulin-like growth factors I (IGF-1),[13] and II,[14] transforming growth factors alpha,[15] beta 1 and beta 2,[16][17] fibroblast growth factors,[18]epidermal growth factor,[19] granulocyte-macrophage-stimulating growth factor,[20] platelet-derived growth factor,[20] vascular endothelial growth factor,[21] and colony-stimulating factor-1.[22]

Colostrum is very rich in proteins, vitamin A, and sodium chloride, but contains lower amounts of carbohydrates, lipids, and potassium than mature milk. The most pertinent bioactive components in colostrum are growth factors and antimicrobial factors. The antibodies in colostrum provide passive immunity, while growth factors stimulate the development of the gut. They are passed to the neonate and provide the first protection against pathogens.

For calves the best research shows that the importance of colostrum decreases rapidly following the first few hours of birth.

Timing is critical to a successful colostrum-feeding management program. The ability of a calf’s small intestine to absorb immunoglobulins drops rapidly over the first few hours of life. By 24 hr of age, the ability to absorb immunoglobulins is nearly nonexistent, as shown in Figure 1. If a calf has not received any colostrum within 12 hr of birth, it is unlikely to be able to absorb enough antibodies to have adequate immunity. For this reason, a calf should receive the first feeding of colostrum within 1 hr of birth when possible

Recommendations suggest feeding colostrum either fermented or frozen for the first 3-4 weeks following birth, if that is not possible, regular milk can be used. Following that, commercial milk replacers are used. Again, it is important to remember that the nutritional value to the calf decreases almost to zero by 3 days post-birth.

Examining the accuracy of the prevailing wisdom that mother’s milk is the only appropriate food for infants up to six months of age has been difficult. Differing societal pressures and cultural make variables for age, socio-economic status, degree of community and family and other factors very difficult to find eliminate possible confounders in studies. On way to do this is to compare the children of women who breastfed some of their children and bottle fed others.

“Many previous studies suffer from selection bias. They either do not or cannot statistically control for factors such as race, age, family income, mother’s employment – things we know that can affect both breast-feeding and health outcomes,” said Cynthia Colen, assistant professor ofsociology at The Ohio State University and lead author of the study. “Moms with more resources, with higher levels of education and higher levels of income, and more flexibility in their daily schedules are more likely to breast-feed their children and do so for longer periods of time.”

Previous research has identified clear patterns of racial and socioeconomic disparities between women who breast-feed and those who don’t, complicating an already demanding choice for women who work outside the home at jobs with little flexibility and limited maternity leave.

Colen’s study is also rare for its look at health and education benefits of infant feeding practices for children age 4 to 14 years, beyond the more typical investigation of breast-feeding’s effects on infants and toddlers….

The study measured 11 outcomes that are common to other studies of breast-feeding’s effects: body mass index (BMI), obesity, asthma, hyperactivity, parental attachment (secure emotional relationships between parents and child) and behavior compliance, as well as scores predicting academic achievement in vocabulary, reading recognition, math ability, intelligence and scholastic competence. Colen constructed statistical models for the analysis.

As expected, the analyses of the samples of adults and their children across families suggested that breast-feeding resulted in better outcomes than bottle-feeding in a number of measures: BMI, hyperactivity, math skills, reading recognition, vocabulary word identification, digit recollection, scholastic competence and obesity.

When the sample was restricted to siblings who were differently fed within the same families, however, scores reflecting breast-feeding’s positive effects on 10 of the 11 indicators of child health and well-being were closer to zero and not statistically significant – meaning any differences could have occurred by chance alone.

Interestingly, the one difference she found to be significant, gave the benefit to formula.

The outlying outcome in this study was asthma; in all samples, children who were breast-fed were at higher risk for asthma, which could relate to data generated by self-reports instead of actual diagnoses.

Colen brings her findings back to policy decisions.

“If breast-feeding doesn’t have the impact that we think it will have on long-term childhood outcomes, then even though it is very important in the short-term we really need to focus on other things,” she said. “We need to look at school quality, adequate housing and the type of employment parents have when their kids are growing up.

“We need to take a much more careful look at what happens past that first year of life and understand that breast-feeding might be very difficult, even untenable, for certain groups of women. Rather than placing the blame at their feet, let’s be more realistic about what breast-feeding does and doesn’t do.”

As a society, we should be using research to inform our policies for the best use of our (taxpayers) money—I know, I can be an idealist by times. More realistically, let’s support parents who are struggling to do the best they can for their children. If women want to breastfeed in public or feed a toddler, great. If others want or need to bottle feed, more power to them. Criticism and bullying have no place in the decision.

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