Health risks of infant feeding with formula

Stelios Papaventsis MBBS MRCPCH DCH IBCLCPaediatrician Lactation Consultant Writer of parenting booksTemporary Director of IBFAN Greecewww.pediatros-thes.grwww.ibfan.gr

Campaign for breastfeeding promotion November 2012

www.mitrikosthilasmos.com

“Give him some formula.. He is hungry..It will do nothing wrong..”

• Embedded belief for decades that artificial feeding is the “standard”, “normal”, “safe” way to feed a baby

• But does it hold true with current scientific evidence?

Types of health risks with feeding infant formula

• Risks because of not breastfeeding (because of the lack of content in formula)

• Risks because of the content and constituents of infant formula

• Risks because of the use of infant bottles

• Risks of inadequate preparation of infant formula

1st category of health risks for infants, children and mothers because of..

Not breastfeeding (what is missing from infant formula)

Health risks of not breastfeeding

• 100% more risk of acute otitis media• 47% more risk for eczema (atopic dermatitis)• 178% more risk for diarrhea and vomiting (gastroenteritis)• 257% more risk of hospitalization for respiratory tract disease

within the first year of life• 35% more risk for asthma (no family history)• 32% more risk for childhood obesity• 64% more risk for diabetes type 2• 23% more risk for acute lymphocytic leukemia• 18% more risk for acute myelogenous leukemia• 56% more risk for sudden infant death syndrome• 138% more risk for development of necrotizing enterocolitis

(premature infants)• 4% more risk of breast cancer for the mother, compared to

mothers who breastfed for at least a year• 27% more risk of ovarian cancer, compared to mothers who

breastfed for at least a year US Surgeon General, 2011

The risks of not breastfeeding: United Kingdom (1)

If half of the mothers that currently do not breastfeed were breastfeeding for 18 months during their lifetime, then in the UK there would be:• 865 less diagnosis of breast cancer per year• With cost savings to the NHS of over £21 million•Improved quality of life equating to more than £10 million each year

If 45% of babies were exclusively breastfed for four months, and if 75% of babies in neonatal units were breastfed at discharge, each year there

would be:• 3,285 fewer babies hospitalised with gastroenteritis and 10,637 fewer GP

consultations, saving more than £3.6 million• 5,916 fewer babies hospitalised with respiratory illness, and 22,248 fewer GP consultations, saving around £6.7 million • 21,045 fewer ear infection GP visits, saving £750,000• 361 fewer cases of the potentially fatal disease NEC, saving more than £6 million

Preventing disease saving resources. UNICEF UK 2012Preventing disease saving resources. UNICEF UK 2012

The risks of not breastfeeding: United Kingdom (2)

• If the number of babies receiving any breastmilk at all rose by 1% this could lead to a small increase in IQ that, across the entire population, could result in more than £278 million gains in economic productivity annually

• A very modest increase in exclusive breastfeeding rates could lead to at least three fewer cases of Sudden Infant Death Syndrome annually, avoiding the loss of life and profound consequences for families and saving around £4.7 million in monetary costs

• Increasing breastfeeding rates could lead to around a 5% reduction in childhood obesity, which would save around £1.6million each year.

Preventing disease saving resources. UNICEF UK 2012Preventing disease saving resources. UNICEF UK 2012

Not breastfeeding and language IQ

• Prospective cohort study of 2868 infants in Australia from birth onwards

• Children that had not breastfed had on average:– 3.5 points lower language IQ at 5 years of age

– 4 points lower language IQ at 10 years of age

Compared to children breastfed (even not exclusively) for at least 6 months

Whitehouse AJ et al. Duration of breast feeding and language ability in middle childhood. Paediatr Perinat Epidemiol. 2011;25(1):44-52

Not breastfeeding and IQ score

• 3253 subjects born in Denmark between 1959 and 1961

• Followed and estimated IQ at age 18 to 27 years

• Subjects that had breastfed for less than a month had on average IQ score 99.4

• Subjects that had breastfed for at least 9 months had on average IQ score of 106

• Dose dependency in between

Mortensen EL et al. The association between duration of breastfeeding and adult intelligence. JAMA 2002;287(18):2365-2371.

Not breastfeeding and behavioral problems

• Ten thousand term infants (Millenium Cohort Study: large prospective cohort study at Oxford University, started 2000)

• At 5 years of age, children that had never breastfed had 33% increased chance for behavioral problems, compared to children that had breastfed (even not exclusively) for at least 4 months

Heikkilä K et al. Breast feeding and child behaviour in the Millennium Cohort Study.Arch Dis Child. 2011 May 9. [Epub ahead of print]

Not breastfeeding and childhood epilepsy

• Large prospective cohort study in Denmark (69750 infants born 1997 – 2003)

• Children never breastfed had increased risk of developing childhood epilepsy by:– 26%, compared to those breastfed for at least 5 months– 39%, compared to those breastfed for at least 8 months– 50%, compared to those breastfed for up to 12 months– 59%, compared to those breastfed for more than 12

monthsDose dependency, no upper limit

Sun Y et al. Breastfeeding and Risk of Epilepsy in Childhood: A Birth Cohort Study. J Pediatr. 2011 Jan 11. [Epub ahead of print]

Not breastfeeding and obesity (1)

• 2066 children 9 to 16 years of age from Australia• Children never breastfed had double risk of being

overweight or obese, compared to children that breastfed for at least 6 months

• At population level, a 20% of childhood obesity can statistically be attributed to feeding infants formula

United States Breastfeeding Committee. Statement on Breastfeeding as a Critical Strategy for Obesity Prevention. Washington, DC: United States Breastfeeding Committee, 2010.

Scott JA et al. The relationship between breastfeeding and weight status in a national sample of Australian children and adolescents. Am J Respir Crit Care Med. 2012 Feb 3. [Epub ahead of print]

Not breastfeeding and obesity (2)

• ½ kg more fat mass and ½ kg less muscle mass for children age 4 years who never breastfed, compared to children breastfed for at least 12 months

Robinson, 2009

• Among siblings: 6 kgs more on average at the age of 14 years for the sibling that didn’t breastfeed

Metzger, 2009

• Not breastfeeding related to central deposition of subcutaneous fat, evident from 6 months of age, persistent at 24 months of age

Durmus, 2011

Not breastfeeding and childhood asthma

• Children never breastfed had increased risk of wheezing, breathing difficulty, dry cough and persistent mucus for the whole 4 first years of life, compared to children breastfed for at least 6 months

• Increased risk of asthma at 4 to 6 years of age

• Increased risk of asthma at 8 years of age

Sonnenschein-van der Voort, 2011

Silvers, 2012

Kull, 2010

Not breastfeeding and obstructive sleep apnea

• A prospective cohort of toddlers who snored persistently at night had significantly more behavioral problems, particularly hyper-activity, depression and attention deficit

• Whilst none of the children given breastmilk for at least 12 months developed persistently noisy breathing, almost 1 in 4 children never breastfed developed persistent noisy breathing

• Link to hypertrophic adenoids

Dean W. Beebe DW et al. Persistent Snoring in Preschool Children: Predictors and Behavioral and Developmental Correlates. Pediatrics; originally published online August 13, 2012

Not breastfeeding and cardio-respiratory stamina at puberty

• 1025 children 10 years of age and 971 adolescents of 16 years of age

• Evaluation of cardio-respiratory function (fitness test)

• Dose-response relationship depicted: the more the duration of breastfeeding in infancy, the higher the cardio-respiratory stamina

Labayen I et al. Exclusive breastfeeding duration and cardiorespiratory fitness in children and adolescents. Am J Clin Nutr. 2012 Feb;95(2):498-505. Epub 2012 Jan 11.

Not breastfeeding, general morbidity and mortality

• At world population level, not breastfeeding is related to 10 to 15% of all deaths of children less than 5 years of age

• 40 thousand infant deaths worldwide each day

• Breastfeeding and reduction of post-neonatal mortality by 21% in a developed country

Αmerican Academy of Pediatrics. Breastfeeding and the Use of Human Milk. Pediatrics 2005;115;496-506

• The risk of chronic disease is 30 to 200% greater for those never breastfed, compared to those breastfed

• The proportion of the whole burden of chronic disease in adulthood that is attributed statistically to not breastfeeding is 6 to 24%

Smith JP et al. Chronic disease and infant nutrition: is it significant to public health? Public Health Nutr. 2010 Jul 13:1-11. [Epub ahead of print]

Indications that not breastfeeding is associated with..(1)

• More frequent and more severe infant colic ande infant constipation

• Feeding difficulties, neophobia and food aversion at toddler age

• Unhealthy diet/ less consumption of vegetables

Shim JE et al. Associations of Infant Feeding Practices and Picky Eating Behaviors of Preschool Children. J Am Diet Assoc. 2011 Sep;111(9):1363-1368

Burnier D et al. Exclusive breastfeeding duration and later intake of vegetables in preschool children. Eur J Clin Nutr. 2011;65(2):196-202.

Indications that not breastfeeding is associated with..(2)

• Less strong bones at 17 years of age

• Diabetes type 1

• Smaller size of thymus gland by half at 6 months of age (the factory of the immune system)

Molgaard C et al. Are early growth and nutrition related to bone health in adolescence? The Copenhagen Cohort Study of infant nutrition and growth. Am J Clin Nutr. published 17 August 2011, 10.3945/ajcn.110.001214

Alves JG et al. Breastfeeding Protects Against Type 1 Diabetes Mellitus: A Case-Sibling Study. Breastfeed Med. 2011 Aug 5. [Epub ahead of print]

Indications that not breastfeeding is associated with..(3)

• 3 times bigger chance of child abuse or neglect

• Increased risk of atherosclerosis or hypertension at puberty or adult age

Khan F et al. The beneficial effects of breastfeeding on microvascular function in 11- to 14-year-old children. Vasc Med 2009;14(2):137-42.

Strathearn L et al. Does Breastfeeding Protect Against Substantiated Child Abuse and Neglect? A 15-Year Cohort Study. Pediatrics 2009; 123: 483 – 493

Not breastfeeding: more consequences for the mother (1)

• Increased risk of postnatal depression• Increased risk of early conception and pregnancy• A mother of 2 children that never breastfed is at 57

years of age on average 6.5 kilos heavier compared to a mother of 2 children who breastfed overall for 4 years

• Less bone mass, increased risk of osteoporosis after menopause, compared to women who breastfed overall for at least 2 years

McIntyre, 2012

Wiklund, 2011

Not breastfeeding: More consequences to the mother (2)

• Women age 45 – 58 years who never breastfed, compared to women who breastfed for at least 3 months have on average:

– 28% more abdominal fat

– 6.5cm bigger waist size

– 4 times more chance for calcification (atherosclerosis) of the aorta and of coronary arteries

Schwarz 2010, McClure 2011

Not breastfeeding: more consequences for the mother (3)

  What percentage of women who never breastfed suffer from..

What percentage of women who breastfed for at least a year suffer from..

Hypertension 42.1% 38.6%

Diabetes 5.3% 4.3%

Hyperlipidemia 14.8% 12.3%

Coronary artery disease

9.9% 9.1%

140 thousand women of 63 years average age

Schwarz EB et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol. 2009;113(5):974-82

2nd category of health risks for infants, children

and mothers because of..

The content/ constituents of infant formula

5 to 10 product recalls per year worldwide (1)

– Metal pieces of nickel inside the milk powder– Pieces of glass or plastic– Lack of vitamins in the powder because of

interaction with the plastic package– Presence of cadmium, bronze, lead, arsenic,

chrome and other heavy metals that increase concentration with the boiling of water

– Coloring from the typed labels– Huge doses of iodine, excess dose of vitamin

D – Inadequate concentration of iron or vitamin C– Nitrates well above the safe dose

www.ibfan.org

5 to 10 product recalls worldwide every year (2)

– Excess concentration of magnesium and 80 times more manganese compared to breastmilk

– Association with botulism in infants– Aluminium, melamine and perchlorate– Large amounts of disphenol-A, of phthalates

and of silicone from the package– Presence of aflatoxines or pesticides– High concentrations of muco-estrogens– Concentrations in substances different from

what is written on the package

www.ibfan.org

Infant powder formula is NOT a sterile product

• Cronobacter (Enterobacter Sakazakii) present in 14% of samples

• Clostridium spores present in 20% of samples

• Salmonella reported

• GUIDELINE: Avoid giving powder milk to premature infants and infants less than a month old

(European Food Safety Committee 2004, Health Ministry of New Zealand 2011)

“Special formulas”: experimenting on infants without any safety studies

• For a medication for children to be released, its safety profile and effectiveness should be proved first

• One can find in infant formulas:– Coconut oil, soy, carob, sunflower etc– Proteins from cow’s milk, soy, fish, nuts– Carbohydrates from potato, corn– Elements of fish, egg or fungi– Genetically modified substances such as genetically

modified soy and corn– Absence of lactose, low fat

• Have there ever been any independent randomised control trials looking at the immediate or long-term consequences of such experimentations?

• Have there ever been any independent randomised control studies looking at the effectiveness of these experimentations?

3rd category of health risks for infants, children

and mothers because of..

The use of infant bottles and teatsΑπό την χρήση μπιμπερό

Documented risks of the prolonged use of infant bottles

• Infant carries • Dental crowding and overlapping • Long narrow jaw receding• High arched, long and narrow palate• Protruding tongue, mouth breathing• Hypertrophic adenoids• Obstructive sleep apnea• Speech disorder (dysarthria)

Bottle feeding and wheezing in infancy

• 2833 infants (Infant Feeding Practices Study)

• With bottle feeding (either formula or breastmilk): increased risk of developing coughing episodes of wheezing episodes during the first 12 months of life, compared to feeding directly at the breast

Soto-Ramirez N et al. Modes of Infant Feeding and the Occurrence of Coughing/Wheezing in the First Year of Life. J Hum Lact. published 22 August 2012, 10.1177/0890334412453083

Use of infant bottles and pyloric stenosis

• 70 thousand infant in Denmark followed prospectively from birth until the end of infancy

• The chance of having an operation for pyloric stenosis in infants who had bottle feeds before the operation was 4.6 times higher, compared to infants who didn’t feed with bottles

Krogh C et al. Bottle-feeding and the Risk of Pyloric Stenosis. Pediatrics Published online September 3, 2012

Infant bottles and obesity

Use of Use of bottles at 24 bottles at 24 months of months of ageage

No use of No use of infant infant bottlesbottles

Obesity at Obesity at 5.5 years of 5.5 years of ageage

22.9%22.9% 16.1%16.1%

• 6750 6750 children born in children born in USA in 2001USA in 2001• Bottle feeding shown Bottle feeding shown to be independent to be independent predictor of childhood predictor of childhood obesity obesity (Ο(ΟR 1.33)R 1.33)• Bottle emptying Bottle emptying behaviorbehavior

Gooze RA et al. Prolonged Bottle Use and Obesity at 5.5 Years of Age in US Children. J Pediatr. 2011 Apr 27. [Epub ahead of print]

The infant breastfed. Infant bottle The infant breastfed. Infant bottle afterwards?afterwards?

• 202 202 infants breastfed infants breastfed exclusively for 6 exclusively for 6 monthsmonths

• Divided thereafter to 2 Divided thereafter to 2 groupsgroups

• Evaluation at 4 years of Evaluation at 4 years of ageage

Continued Continued with infant with infant bottlesbottles

ContinueContinued with d with cupcup

Open Open mouthmouth

17% 17% moremore

Tongue in Tongue in correct correct positionposition

26%26% less less

Exclusive Exclusive mouth mouth breathingbreathing

63%63% 31%31%

Deformed Deformed palatepalate

Double Double figurefigure

Carrascoza KC et al. Consequences of bottle-feeding to the oral facial development of initially breastfed children.J Pediatr (Rio J). 2006;82(5):395-7.

4th category of health risks for infants, children

and mothers because of..

Inappropriate preparation of feeding bottles

Is this the “safe” and “standard” choice?

• 77% were not given any directions on how to prepare bottles correctly

• 33% did never read the instructions for preparation at the label

• 47% didn’t check the expiry date• 55% were not washing their hands before preparing the bottle• 32% were not cleaning the bottle adequately in between feeds• 35% used microwave for heating• 6% gave infant formula prepared more than 2 hours ago• 47% put solid food inside the bottle together with the milk• 20% let the infant sleep with the bottle in his mouth in

horizontal position• 73% didn’t receive any instructions for correct storage

Labiner – Wolfe J et al. Infant formula-handling education and safety. Pediatrics 2008;122 Suppl 2:S85-90.

Incorrect preparation of bottles• Wrong size of spoon contained in the package,

resulting in incorrect proportion of water and powder

• Wrong instructions for preparation in the package (40 degrees Celcius instead of 70!)

• Arbitrary dilution or condensation to make the baby less or more fat – by the mother or even after instruction from health professional!

• Scalding and burns• Inappropriate preparation: Often the only risk

realized by parents or doctors• Some think that the Code refers only to these risks

Finally where is the ideal, the standard and

the dangerous in infant nutrition?

BREASTFEEDING

INFANT FORMULA

IDEAL

STANDARD

DANGEROUS

BREASTFEEDING

INFANT FORMULA

IDEAL

STANDARD

POTENTIALLYDANGEROUS

With evidence based information, the way you look at the issue changes!

Risks of not Risks of not breastfeeding and of breastfeeding and of formula bottle feedingformula bottle feeding

Risks of continuing Risks of continuing breastfeeding when a breastfeeding when a mother has fever or takes mother has fever or takes a drug or doesn’t have a a drug or doesn’t have a proper diet etcproper diet etc

What we know so What we know so far about infant far about infant feedingfeeding

What we do not What we do not yet know about yet know about infant feedinginfant feeding

Are these findings likely to be overestimated or underestimated?• Well underestimated, because:

– Lack of will and money for independent research– Lack of cohorts that follow ideal practices (6 months exclusive

breastfeeding followed by at least 2 years of continued breastfeeding)– Lack of studies on breastfeeding > 12 months– No proper definitions in studies resulting in mediating of the effects– Recall bias in studies– Inability to perform randomized trials– Lack of good quality large prospective cohort studies looking at

several possible outcomes– Lack of research on safety of formula composition– Epigenetics, after successive generations with suboptimal infant

nutrition (?)

Conclusions: The role of infant formula on infant nutrition

• For the few acceptable medical reasons for not breastfeeding

• 4th choice when insufficient milk production or re-lactation (optimization of breastfeeding, breastmilk, donor’s milk)

• Any unjustified intervention can do more harm to the breastfeeding dyad than good