Why is breastfeeding important?

An enormous and still-growing body of medical research demonstrates that breastfeeding is the optimal means of exclusively feeding babies through about six months of age and continues to provide benefits as a portion of a child's diet through at least two years of age. While the dangers of artificial feeding in industrialized countries are not of the order of magnitude that they are in developing countries (i.e., infant deaths ten times the rate of breastfed babies), there are still substantial health consequences to the choice of infant feeding method. For example, the use of formula instead breastfeeding in industrialized countries is associated with:

• More cases, and more severe cases, of respiratory and gastrointestinal infections. (1)
• Lower scores on tests of neurological development. (2)
• Increased risk of allergies and greater intensity of problems from allergies. (3)
• Increased risk of childhood lymphomas (cancer). (4)
• Increased risk of breast cancer in women who were not breastfed. (5)
• Increased risk of breast cancer in mothers who don't breastfeed. (6)
• Increased risk of type I (juvenile, insulin-dependent) diabetes. (7)
• Increased risk of adult intestinal disorders (ulcerative colitis, Crohn's). (8)
• Cardiopulmonary disturbances during bottlefeeding. (9)
• Formula-fed babies must fast longer prior to surgery than breastfed babies. (10)

Yet only about 22% of U.S. babies are still being breastfed at 4 months of age. The number of U.S. babies who receive breastmilk as part of their diet through one year of age, as recommended by the American Academy of Pediatrics, or through two years of age, as recommended by the World Health Organization, is tiny. Obviously, a major public health education effort is necessary in order to inform parents of the lifelong health consequences of their infant feeding decisions.

Infant feeding choices have a significant financial impact. A supply of formula adequate for one baby costs about $1,000 in the U.S., and a study performed at the Kaiser Permanente health maintenance organization in Durham, North Carolina estimated that the average additional health care costs of a formula-fed infant over those of an breastfed infant were $1,400 for the first year alone. Thus, the annual savings in expenditures on formula and additional health care bills would be on the order of $2.4 billion if 1 million additional babies were breastfed in the U.S. each year. Much of these savings would be to public funds, since governments (through the W.I.C. and Medicaid programs) are the largest purchasers of formula and providers of health services to infants.

Environmental concerns are also raised by the use of formula: the vast herd of cattle (with their methane output being a major source of greenhouse gasses) that is necessary to supply the basic materials for formula, the energy required to manufacture and ship formula, plus the waste generated by discarded formula packaging are all unnecessary for breastfed babies.

Women are also empowered by breastfeeding. It is one of the unique powers of womanhood to provide the perfect food for a baby, with only her own body. No multinational corporation, no government, no power structure of any kind can do this.

There are other, more personal, advantages to breastfeeding:

• Breastfeeding is easier than formula feeding, once the initial period of adjustment is over. Breastmilk is always available, clean and pure, the right temperature and composition, and is uniquely suited to each individual baby's changing needs throughout infancy and early childhood. Night feedings are no effort, especially when the baby is sleeping in the same bed, or right next to the mother's bed.
• Breastfeeding requires no equipment, unless separation between the mother and baby in the early months requires the expression and storing of milk for later use. In contrast, formula and bottles must be bought, formula must be correctly mixed with pure water and brought to a proper temperature, and bottles must be kept scrupulously clean.
• Even a family with the mother working outside the home will find that expressing the mother's milk can be more convenient than using formula: because a breastfed baby will probably have less frequent and less severe illnesses than one who is fed formula, the parents can anticipate fewer days off to take care of a sick baby.
• Breastfeeding, by its very nature, requires the sort of skin-to-skin contact that babies need. It is a uniquely bonding experience.
• Finally, one of my favorite advantages of breastfeeding: the bowel movements of an exclusively breastfed child have a very mild, almost sweet odor, and are not at all unpleasant to clean up, whereas those of a formula-fed baby are much smellier and more unpleasant.

Medical Journal References on the Hazards of Not Breastfeeding
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Formula fed infants get more, and get more severe, infections

Borgnolo G, et al. A case-control study of Salmonella gastrointestinal infection in Italian children. Acta Paediatr 85:804-8 (1996) [Not breastfeeding was the single most important factor associated with a 5-fold increased risk of Salmonella infection.]

Beaudry M, et al. Relation between infant feeding and infections during the first six months of life. J Pediatr 126:191-7 (1995) [Not breastfeeding substantially increased risk of respiratory and gastrointestinal infections in first six months of life.]

Aniansson, G et al. A prospective cohort study on breastfeeding and otitis media in Swedish Infants. Pediatr Infect Dis. J. 13:183-88 (1994) [Acute otitis media frequency was significantly higher in the non-breastfed children in each age group (2,6, and 10 months of age); the frequency of upper respiratory infections was also increased in those children, but reduced in the breastfed group.]

Lerman, Y. et al. Epidemiology of acute diarrheal diseases in children in a high standard of living rural settlement in Israel. Pediatr. Infect. Dis. J. 13(2):116-22 (1994) [Children less than 12 months of age had a higher incidence of acute diarrheal diseases during the months they were being formula-fed than children who were breastfed during the same period.]

Pisacane A; Graziano L; Zona G; Granata G; Dolezalova H; Cafiero M; Coppola A; Scarpellino B; Ummarino M; Mazzarella G; Breast feeding and acute lower respiratory infection. 83 Acta Paediatr 714-18 (1994) [not breastfeeding is a strong risk factor for acute lower respiratory infection (i.e., pneumonia and bronchitis) in industrialized countries]

Harabuchi, Y. et al. Human Milk secretory IgA antibody to nontypeable Haemophilus influenzae: possible protective effects against nasopharyngeal colonization. J. Pediatr. 124:193-98 (1994) [Formula lacks specific secretory IgA antibody present in breastmilk, suggests a mechanism by which formula-fed infants have higher incidence of infection.]

Howie PW, et al. Protective effect of breastfeeding against infection. BMJ 300:11-16, 1990. [The added risk of formula-feeding can account for 7% of all infants hospitalized for respiratory infections.]

Duffy LC, et al. The effects of infant feeding on rotavirus-induced gastroenteritis: a prospective study. Am J Pub Health 76:259-263 (1986). [In industrialized nations, formula-fed infants have a 3-4 fold risk of diarrheal illness. Moderate to severe rotavirus gastroenteritis is five times more common in formula-fed infants.]

Cochi SL, et al. Primary invasive Haemophilus influenza b disease: a population based assessment of risk factors. J. Pediatr. 108:887-896 (1986). [A 4-16 fold higher risk exists for H influenzae bacteremia and meningitis in North American formula-fed babies.]

Children who were formula-fed score lower on indices of neurological development than do children who were breastfed.

Wang YS, Wu SY. The effect of exclusive breastfeeding on development and incidence of infection in infants. J Hum Lact 12:27-30 (1996) [Normal fullterm infants studied during the first year after birth. Those exclusively breastfed for the first four months differed significantly from those not exclusively breastfed: at one year, the artificially-fed group showed less advanced. Personal-Social and gross motor development on the Denver Developmental Screening Test, and higher cumulative incidence of infectious diseases.]

Pollock, J.I. Long-term associations with infant feeding in a clinically advantaged population of babies. Dev. Med. Child Neurol. 36(5);429-40 (1994) [Some aspects of intellectual attainment at five and ten years of age can be demonstrated to be inferior among children who were formula-fed compared with those that were exclusively breastfed for at least three months.]

Morley R., et al. Mother's choice to provide breastmilk and developmental outcome. Arch Dis Child 63:1382-1385 (1988). [Formula-fed preterm infants had lower Bayley Mental Develpment scores at 18 months, even after adjusting for social and demographic influence.]

Morrow-Tlucak, M, et al., Breastfeeding and cognitive development in the first two years of life. Soc Sci Med 26:635-639 (1988). [Scores on the Bayley Mental Development Index were lower in formula-fed at 1-2 years of age, and scores were directly correlated with duration of breastfeeding.]

Bauer G, et al. Breastfeeding and cognitive development of three-year-old children. Psychological Reports 68:1218 (1991). [Scores on the McCarthy Scales of Children's Abilities were significantly lower at three years of age as the duration of breastfeeding decreased.]

Taylor B, et al. Breastfeeding and child development at five years. Dev Med Child Neurol 26:73-80 (1984). [Formula-fed children showed reduced performance on developmental tests at age five years.]

Lucas, A. et al. Breast milk and subsequent intelligence quotient in children born preterm. Lancet 1992;33;261-62. [Formula-fed preterm infants had lower IQ scores at age 7-8 years than preemies fed expressed breastmilk; the association held after controlling for mother's education and social class, and regardless of whether the mother attempted to express milk and failed or never attempted to express milk.]

Lucas, A., et al. A randomised multicentre study of human milk versus formula and later development in preterm infants. Arch. Dis. Child 70:F141-146 (1994)

There is a higher incidence of allergies among formula-fed children

Saarinen UM, Kajosaari M. Breastfeeding as prophylaxis against atopic disease: prospective follow-up study until 17 years old. Lancet 1995; 346:1065-69. ["We conclude that breastfeeding is prophylactic against atopic disease, the effect extending into early adulthood. Breastfeeding for longer than 1 month without other milk supplements offers significant prophylaxis against food allergy at 3 years of age, and also against respiratory allergy at 17 years of age. Six months of breastfeeding is required to prevent eczema during the first 3 years, and possibly also to prevent substantial atopy in adolescence." The article also states that the differences by infant feeding method were so pronounced that it "suggested an influence of early milk feeding that may exceed the heredity burden."]

van den Bogaard C; van den Hoogen HJ; Huygen FJ; van Weel C; Is the breast best for children with a family history of atopy? The relation between way of feeding and early childhood morbidity. 25 Fam Med 471-45 (1993) [In families with a history of allergies, not breastfeeding was related to higher levels of childhood illness both in the first and the first three years of life. In the first year of life they had more episodes of gastroenteritis, lower respiratory tract infections, and digestive tract disorders. Over the next three years of life they had more respiratory tract infections and skin infections.]

Merrett TG, et al. Infant feeding and allergy: twelve-month prospective study of 500 babies born in allergic families. Ann Allergy 61:13-20, 1988. [Formula feeding is associated with higher incidence of wheezing, diarrhea, vomiting and prolonged colds.]

Host A., et al. A prospective study of cow's milk allergy in exclusively breastfed infants. Acta Paediatr Scand 77:663-670, 1988 [Formula given to newborns in the hospital nursery contributed to the development of subsequent cow milk allergy among infants who were exclusively breastfed thereafter.]

Israel D, et al., Protein induced allergic (PAC) colitis in infants. Pediatr. Res. 25:116A, 1989. [PAC is associated with formula-feeding and supplementation.]

Formula-fed children have a higher incidence of certain cancers

Schwartzbaum, J. et al. An exploratory study of environmental and medical factors potentially related to childhood cancer. Med & Pediat Oncology 19(2): 115-21 (1991).

Davies, M. et al. Infant feeding and childhood lymphomas [cancer]. Lancet 2:365-368 (1988). [There was as much as an 8 fold increase in risk of developing lymphomas among children artificially fed or breastfed less than six months.]

Women who were formula-fed as infants have higher rates of breast cancer

Mothers Who Formula-Feed Increase Their Risk of Breast Cancer

Newcomb, P.A. et al. 1994 Lactation and a reduced risk of premenopausal breast cancer. The New England Journal of Medicine 330(2):81-87. ["An increasing duration of lactation was associated with a statistically significant trend toward a reduced risk of breast cancer (P<0.001). Lactation at early ages and for long durations was associated with more substantial reductions in risk. If women who do not breastfeed or who breastfeed for less than 3 months were to do so for 4 to 12 months, breast cancer among parous premenopausal women could be reduced by 11 percent, judging from current rates. If all women with children lactated for 24 months or longer, however, then the incidence might be reduced by nearly 25 percent. This reduction would be even greater among women who first lactate at an early age."]

Yoo,KY, et al. Independent protective effect of lactation against breast cancer: A case-control study in Japan. American Journal of Epidemiology, Vol 135, No.7, pp726-33, 1992

Byers T, et al. Lactation and breast cancer: evidence for a negative association in premenopausal women. American Journal of Epidemiology Vol 121, pp664-74, 1985

Siskind V, et al. Breast cancer and breastfeeding: results from and Australian case-control study. American. Journal of Epidemiology, Vol 130, pp229-36, 1989

Layde PM, et al. The independent associations of parity, age at first full term pregnancy, and duration of breastfeeding with the risk of breast cancer. Journal of Clinical Epidemiology, Vol 42, pp963-73, 1989.)

Formula-feeding is a risk factor in the development of juvenile diabetes

Verge CF, et al. Environmental factors in childhood IDDM. A population-based, case-control study. Diabetes Care 17:1381-9 (1994) [Study showed an increased risk of IDDM associated with early dietary exposure to cow's milk-containing formula, short duration of exclusive breast-feeding, and high intake of cow's milk protein in the recent diet]

Virtanen SM, et al. Early introduction of dairy products associated with increased risk of IDDM in Finnish children. Diabetes 42:1786-90 (1993). [Introduction of cow's milk-based formula a significant risk factor in IDDM]

Mayer EJ, et al. Reduced risk of insulin-dependent diabetes mellitus among breastfed children. Diabetes 37:1625-1632 (1988) [Formula feeding accounts for as much as 26% of insulin dependent diabetes mellitis in children.]

Borch-Johnson, K., et al., Relation between breastfeeding and incidence of insulin-dependent diabetes mellitus. Lancet 2:1083-86 (1984) [It is postulated that insufficient breast-feeding of genetically susceptible newborn infants may lead to beta-cell infection and IDDM later in life]

Formula Feeding is a risk factor in Crohn's disease and ulcerative colitis

Rigas A, et al. Breast-feeding and maternal smoking in the etiology of Crohn's disease and ulcerative colitis in childhood. Ann Epidemiol 3:387-92 (1993) [Lack of breastfeeding was associated with higher rates of inflammatory bowel disease in children and adolescents]

Koletzko S., et al. Role of infant feeding practices in development of Crohn's disease in childhood. Br. Med. J. 298:1617-18 (1989)

Bergstrand O; Hellers G. Breast-feeding during infancy in patients who later develop Crohn's disease. Scand J Gastroenterol 18:903-6 (1983) [Lack of breastfeeding appears to be a risk factor in development of Crohn's disease]

Formula-Fed Babies Suffer From Cardiopulmonary Disturbances

Koenig JS, Davies AM, Thach BT. Coordination of breathing, sucking and swallowing during bottle feedings in human infants. J Appl Physiol 69: 1623-1629, 1990. [Infants fed by bottle are at increased risk of cardiopulmonary disturbances, including prolonged airway closure and obstructed respiratory breaths due to repeated swallowing.]

Matthew O. Breathing patterns of preterm infants during bottlefeeding: role of milk flow. J Pediatr 119:960-965, 1991. [Preterm infants have shown decreased oxygen saturation accompanied byapnea (absent airflow for >20 sec), bradycardia (heart rate <100 beats per minuite) and cyanosis (blue coloring) during bottle-feeding, due to frequent swallowing and limited breathing time with high flow nipples.]

Matthew O, Clark ML, Ponske MH. Apnea, bradycardia, and cyanosis during oral feeding in term neonates. J Pediatr 106:857, 1985. [Term infants can experience oxygen saturation below 90% when bottlefeeding. Nine of 50 healthy term infants in one study experienced bradycardia during bottlefeeding. Six of these episodes were preceded by apnea, three showed hypopnea (marked reduction in ventilation) and one had central apnea (no respiratory efforts) ]

Formula-Fed Babies Must Fast Longer Prior to Surgery

Schreiner, M.S. Preoperative and postoperative fasting in children. Ped Clinics N Amer 41(1):111-20 (1994) [Preoperative fasting time for breastfed children is shorter. Breastfeeding may continue until 3 hours before arrival time at the hospital in healthy children having elective surgery.]

Litman, R.S. et al. Gastric volume and pH in infants fed clear liquids and breast milk prior to surgery. Anesth Analg 79:482-85. (1994) [Three hours appears to be a reasonable fasting interval before surgery in breastfeeding infants.]

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