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6 COVER STORY › es if the child is breastfed for less than six months. [23, 24] And not breastfeeding for at least this long increases the risk of middle ear infections. [25] Diabetes Not breastfeeding increases the risk of diabetes type 2 (IDDM). This correlation is dose-dependent both for children and for [26, 27, 28, 29] their mothers. Obesity The less time a baby is breastfed, the higher the risk of obesity in childhood. [30] Childhood Cancer Breastfeeding for six months reduces the risk of leukemia in childhood by 19 %. [31] The high amount of TNF-related apoptosis-inducing ligands (TRAIL) in colostrum and mature mother’s milk also act against other kinds of cancer in childhood. [32] Malocclusion The connection between breastfeeding and normal oral development is not yet completely clear – partially due to the small number of subjects and partially due to confounding factors, such as partial breastfeeding and the use of pacifiers. Nevertheless, a recent study [33] has shown that children who were exclusively breastfed between 3 and 5.9 months had 41 % less malocclusion than children who were never breastfed. Those children who were exclusively breastfed for six months had 72 % less malocclusion. Multiple Sclerosis There are still very few studies which explore the effect of breastfeeding on the development of multiple sclerosis in the child’s later life. According to one study from the 1990s [34] there is a two- to threefold increased risk for multiple sclerosis if a baby is breastfed for fewer than seven months (or not at all). Newer research indicates that breastfeeding for at least four months halves the risk of MS in later life. [35] Long-term Breastfeeding is also good for mothers For young women and those of middle age, a shorter breastfeeding duration increases the risk of developing diabetes 2. For women who have given birth within the previous 15 years, every year of breastfeeding reduces the risk by another 15 %. [36] A study in China indicates that a mother who breastfeeds less than six months compared to a woman who breastfeeds a child for two years, doubles her risk of breast cancer. [37] A meta-analysis of 30 countries also confirms that increased risk. [38] The relative risk of breast cancer is reduced by 4.3 % for every 12 months a mother breastfeeds. This study also shows that the advantages for mothers who have breastfed for more than two years over their lifetime were doubled by comparison to mothers who breastfed for one year. The risks for ovarian [39] and uterine [40] cancer for women under 55 who have had a shorter period of breastfeeding are also increased. Breastfeeding in the Second Year of Life and Beyond What arguments are there for continuing breastfeeding after the first birthday? Surprisingly, there are quite a lot of them. Nutrition, for example. Mother’s milk has 70 [41] -75 [42] kilocalories per 100 ml. These calories can make a great difference to the toddler’s nutritional status – especially, but not only, in developing countries. A classic but still relevant work in this area [43] cites research to the effect that, in some areas, children over 18 months who are still breastfeeding in addition to eating complementary foods, may have a 17 % higher energy intake than those who are weaned from the breast. Between the 6 th and the 24 th month of life, the amount of breastmilk is about 500 ml per day and, thus, contains a large proportion of the calories that a child needs in these months. Should it be necessary, the milk production can be increased and a child who normally eats solids can again, for a short period, be exclusively nourished by breastmilk. Between 12 and 23 months, 448 ml of mother’s milk covers: [44] 29 % of the energy requirement 43 % of the protein requirement 36 % of the calcium requirement 75 % of the Vitamin A requirement 76 % of the folic acid requirement 94 % of the Vitamin B12 requirement 60 % of the Vitamin C requirement Bioavailability, Vitamins and Minerals The calories in mother’s milk are not empty calories. Mother’s milk remains an important source of protein, vitamins and other nutrients – high quality and bioavailable. How much of a nutrient is in the milk is not the most interesting question. Rather, we should be asking: “Is it bioavailable?” It’s no use if it is only there and the baby cannot make use of it. Protein in mother’s milk, for instance is particularly well-absorbed. In the second year of life, mother’s milk covers about 29 % of the child’s protein needs. And the story with vitamins and minerals is even more gratifying. In the second year of life, mother’s milk covers three-quarters of the child’s vitamin A requirements. In developing countries this can be particularly important. In Africa, for instance, non-breastfed children have a six-to-eight fold increased risk of being afflicted with xerophthalmia (“dry eyes”), caused by a lack of vitamin A, compared to breastfed children. [45] This protection continues throughout the entire breastfeeding period. About 43 % of the iron requirement between one and two years can be met through the mother’s milk. The iron level is, indeed, lower in mother’s milk than in cow’s milk but up to 50 % is absorbed [46] (4 % of the iron in cow’s milk is absorbed) so a breastfed child is better supplied with iron than is a non-breastfed child. Immune Factors Immune factors remain important in the second and third years of life and beyond. Today it is known that the amount of immunoglobulin rises after the sixth month of life, apparently as a reaction to the declining amount of milk. In a new article [47] the authors write “Human milk in the second year postpartum contained significantly higher concentrations of total protein, lactoferrin, lysozyme and immunoglobulin A, than milk bank samples…” The milk in the second year postpartum was compared to pooled, unpasteurized milk samples from 51 approved donors less than one year postpartum. When we consider this, it is also quite logical that some protective factors increase at this time because children become quite mobile from about six months. They go everywhere and put everything in their mouths. They need as much protection as we can offer them! This protection comes about through various immune factors, among them: Lysozyme, an unspecific antimicrobial factor which is concentrated in mother’s milk reaches its highest level after six months. [48] 1 ml of mother’s milk contains around 4000 living cells (predominantly lymphocytes and macrophages) which hinder the growth of bacteria, virus, fungi and parasites. The bifidus factor in mother’s milk continues to promote the growth of lactobacillus bifidus in the child’s intestine www.elacta.eu Lactation & Breastfeeding 3 • 2016
COVER STORY 7 so that staphylococci cannot proliferate. Interferon, an anti-virus factor and lactoferrin which hinders the growth of E. coli, salmonella, staphylococcus aureus and some forms of candida, are also in mother’s milk. The “natural” weaning age It is clear from the research that mother’s milk retains its nutritional and immunological value as long as it is produced. Nevertheless, the breastfeeding relationship must come to an end at some point – but when? The anthropologist, Katherine Dettwyler, has attempted to give an approximate answer to this question through comparative cultural and primate studies. I will skip many of the comparisons with other primates here – although they are very interesting and persuasive – and mostly consider the comparative cultural studies. In her search for a “hominide blueprint” for the “natural” weaning age, Dettwyler looked at a variety of criteria: › The age at which the child quadrupled his birth weight [49] › The age at which the child reached ⅓ of the average adult weight [50] › By comparison to the gestational time (6x the number of weeks for a full-term pregnancy – based on comparative primate data) [51] › The age at which the first permanent molars break through [52] Using any of these criteria, the earliest weaning age would be 2.3 years and the upper limit would be six years for girls and seven years for boys. Incidentally, the time when the (human) child’s own immune system is mature and independent is six years. Up to this point, Dr. Dettwyler writes, the lymphokines in mother’s milk can increase the active immune response – both in the serum and also in the secretory cells. [53] Is the idea that mother’s milk could have a positive effect on the child’s immune system up to the age of six so extreme? Actually it’s not. Consider this: The use of donor milk with older children and adults as a treatment for various illnesses has been reported repeatedly. › Marinkovich [54] (1988) reported treatment of IgA insufficiency with 100 ml of fresh mother’s milk daily. › Merhave and colleagues [55] reported on treating a liver transplant patient for IgA insufficiency with 12 ounces (ca. 340 ml) mother’s milk daily. › Asquith [56] reported on the use of mother’s milk during therapy for leukemia and bone marrow transplantation. › Young [57] reported on the use of mother’s milk to provide burned children with an energy source that is easily metabolized and, in addition, has immunoglobulins, bacteriostatic protection and growth factors for healing wounds › Wright [58] used fresh mother’s milk for adults in the first few days after a liver transplant and › Wiggins and Arnold reported on a successful use of donor milk to treat gastroesophageal reflux in an adult patient. [59] Is it then so difficult to believe that the milk of a child’s own mother can serve as an effective stimulus for the child’s immune system for a long period of time – even up to primary school age? But should we set our recommendation for an appropriate weaning age so high? Not necessarily. As La Leche League has long said: “Ideally, the breastfeeding relationship will continue until the child has outgrown it.” One child grows out of the stage earlier, another one later. And, because breastfeeding is a partnership, the mother’s needs and wishes also play a part. We don’t want to issue new regulations but rather, by looking at the scientific and anthropological data, create an expanded vision of a “normal” weaning age and greater tolerance for mothers whose breastfeeding practices deviate from the cultural norm. SOURCES › [1] www.who.int/nutrition/topics/exclusive_ breastfeeding/en/ › [2] BMJ 2011; 342 doi: http://dx.doi. org/10.1136/bmj.c5955 (Published 13 January 2011) › [3] info.babymilkaction.org/news/ policyblog140111 › [4] archive.babymilkaction.org/press/ press23dec09.html › [5] Anneli Ivarsson, Olle Hernell, Hans Stenlund, and Lars Åke Persson, Breastfeeding protects against celiac disease, Am J Clin Nutr May 2002 vol. 75 no. 5 914-921 › [6] www.who.int/mediacentre/ news/statements/2011/ breastfeeding_20110115/en/ › [7] www.oz-online.de/-news/artikel/20371/ Angeklagte-Es-war-aus-reiner-Mutterliebe 23.09.2009 › [8] Innocenti Deklaration, 1990, S,1 › [9] Simondon KB, Simondon F. Age at introduction of complementary food and physical growth from 2 to 9 months in rural Senegal. Eur J Clin Nutr 1997; 51:703-707. › [10] Heinig MJ, Nommsen LA, Peerson JM, Lonnerdal, B, Dewey KG. Intake and growth of breast-fed and formulafed infants in relation to the timing of introduction of complementary foods: the DARLING study. Acta Paediatr Scand 1993; 82:999-1006. › [11] Kramer Ms, Chalmers B, Hodnett ED, et al. Promotion of breastfeeding intervention trial (PROBIT): a randomised trial in the Republic of Belarus. JAMA 2001; 319:815-819 › [12] WHA49.15 › [13] WHA54.2 › [14] WHA55.25 › [15] Innocenti Deklaration, 2005, S. 1 › [16] Ford, C.S: A Comparative Study of Human Reproduction. Yale University Publications in Anthropology, No. 32, 1945. New Haven, T: Human Relations Area Files Press. › [17] Lawrence, RA and Lawrence RM. Breastfeeding: A Guide for the Medical Profession, 7 th ed. St. Louis: Mosby, 2011, p. 153-195. › [18] Kramer MS, et al. Breastfeeding and child cognitive development: new evidence from a large randomized trial. Arch Gen Psychiatry, 2008, May; 65 (5):578-84. ›
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Page 3 and 4: CONTENTS 3 © Enzenhofer © BDL 2 E
Page 5: COVER STORY 5 optimal feeding, whic
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