Breastfeeding and Breast Milk – from Biochemistry to Impact

Home , Breastfeeding, Breastfeeding promotion

A Multidisciplinary Introduction

About the Foundation Published by The Family Larsson-Rosenquist Foundation is one of the first foundations in the Family Larsson-Rosenquist Foundation world with a prime focus on promoting and supporting breast milk and breastfeeding. Based in Zug, Switzerland, it was founded in 2013 with the aim of promoting the scientific and public recognition of breastfeeding and breast milk as – given the current state of science – the best nutrition for newborns and infants. It considers itself as an instigator and promoter of new knowledge. The Book Foundation invests globally in projects and scientific research in breastfeeding and breast milk. It places high value on multidisciplinary collaboration and sup- ports projects with a sustainable impact on the well-being of mother and child. Preview

With compliments An Evidence-Based Reference Book: a Key Resource for Decision Makers and Practitioners Available at the end of September 2018 Authors from around the globe, each of all the benefits that breastfed infants a specialist within their field have readily enjoy. Based on sound science but written contributed to provide readers with a in popular science style, ensuring an easy Also available as an e-book comprehensive overview of breastfeeding read, the book provides a comprehensive and human milk to encourage and empower and solid foundation including sources and interested parties to move breastfeeding references. It also features a unique in-depth higher up on the public health agenda. scientific glossary of lactation that provides There are many books available looking definitions for a plethora of important at “how to” breastfeed or focusing on a terms of breastfeeding and human milk single topic within the field, others look at that are science based and reviewed by the biomedical aspects of milk, however acknowledged experts in the field. none address a wide range of research The book aims to provide a holistic overview, disciplines to provide a truly multidisciplinary and is divided into four parts with individual Breastfeeding and Breast Milk – from Biochemistry to Impact comprehensive overview: covering introductions. As each chapter covers a topic A Multidisciplinary Introduction topics from physiology and psychology, in depth, it can be also be read independently. Published by Family Larsson-Rosenquist Foundation culture, politics and economics to HIV and Furthermore, the book can be used as a Dip- Georg Thieme Verlag, Stuttgart, 2018 medications, NICU and human milk banking. In-and-Out book as each chapter provides Edition: 1 The topics are varied, yet all relevant and a summary of the topics covered at the Pages: 416 important elements in the quest to increasing beginning as well as a list of key findings Illustrations: 73 ISBN 978-3-13-220401-0 (Print) breastfeeding rates. and messages at the end of the chapter. This eISBN 978-3-13-220421-8 (e-book) eISBN 978-3-13-220411-9 (PDF) Multidisciplinary Introduction to Breast- allows the reader to quickly identify topics feeding and Breast Milk – from Biochemistry and peruse key findings to identify areas of to Impact is written for a wide and varied specific interest and to read the book in a For further information please visit Thieme Webshop: audience, ranging from nursing staff and more targeted manner. www.thieme.de/shop/p/000000000311610101 lactation experts who have daily contact Overall this book provides a unique insight or the Family Larsson-Rosenquist Foundation: with mothers and babies, to health ministers into a wide range of aspects of breastfeeding, who want to learn about how scaling up of humanmilk and lactation, empowering www.larsson-rosenquist.org/en/projects/ReferenceBook.html breastfeeding can contribute to reducing individuals with the knowledge to increase their health care expenditure. It is also a key public interest and towork towards the goal for doctors and researchers who have an of making breastfeeding the norm again. interest in the topic yet are not fully aware Contents 8 9

Contents 4.4 Physiology ...... 56 4.4.1 Origin of Milk ...... 56 4.4.2 Secretory Diﬀerentiation ...... 58 4.4.3 Secretory Activation ...... 59 Foreword ...... 5 4.4.4 Milk Ejection ...... 64 Preface ...... 7 4.4.5 Infant Suck, Swallow, and Breathe ...... 66 4.4.6 Established Lactation ...... 67 4.4.7 Reference Ranges ...... 70 Part 1 4.5 Changes to Physiology in Mother and Infant ...... 72 Setting the Scene 4.5.1 Menstrual Cycle ...... 74 4.5.2 Weaning and Involution ...... 74 1 Introduction ...... 18 4.6 Conclusion ...... 75 Peter E. Hartmann

5 Why Breastfeeding? ...... 78 2 Breast Milk, Global Health and Sustainable Development ...... 20 Berthold Koletzko Leith Greenslade 5.1 Introduction ...... 78 2.1 The Importance of Empowered Mothers ...... 20 5.2 The Evolution of Lactation ...... 78 2.2 The Benefits of Breast Milk ...... 20 5.3 Assessing Health Effects of Breastfeeding ...... 81 2.3 Breastfeeding as an Equity Strategy...... 21 5.4 Breastfeeding and Maternal Health ...... 82 2.4 The Cost-Effectiveness of Breastfeeding ...... 23 5.5 Breastfeeding and Infant Health ...... 82 2.5 Breastfeeding’s Poor Performance ...... 23 5.6 Conclusion ...... 86 2.6 Barriers to Breastfeeding ...... 24 2.7 A Collective Failure to Respond ...... 25 2.8 Investments in Breastfeeding Innovations ...... 26 2.9 Breaking Breastfeeding Barriers: a Call to Action ...... 27 Part 2 2.10 Breastfeeding and the Sustainable Development Goals ...... 28 Different Perspectives

3 Data Collection on Infant Feeding ...... 32 6 Introduction...... 92 Maria Quigley Rafael Pérez-Escamilla 3.1 Data Collection on Infant Feeding ...... 32 3.1.1 What Data Need to be Collected ...... 32 7 Human Milk: Bioactive Components and Their Eﬀects on the Infant and Beyond .. 93 3.1.2 Who Collects Data and How ...... 32 Donna Geddes, Foteini Kakulas 3.2 Problems with Data Collection ...... 36 7.1 What Science Tells Us about Human Milk ...... 93 3.2.1 How Exclusive is Exclusive Breastfeeding? ...... 37 7.2 Key Properties of Human Milk and their Functions ...... 93 3.2.2 Does Breastfeeding Include Breast Milk Feeding?...... 37 7.2.1 Fat ...... 95 3.2.3 How to Collect Complex Feeding Data: Preterm Infants, Multiples ...... 37 7.2.2 Protein ...... 96 3.3 Conclusion ...... 37 7.3 Carbohydrate: Lactose ...... 99 7.3.1 Human milk oligosaccharides (HMOs) ...... 99 4 How Breastfeeding Works: Anatomy and Physiology of Human Lactation ..... 39 7.4 Vitamins and Minerals ...... 100 Melinda Boss, Peter E. Hartmann 7.5 Human Milk Microbiome...... 101 4.1 Introduction ...... 39 7.6 Appetite Factors ...... 101 4.2 Background ...... 39 7.7 Metabolites...... 102 4.3 Gross Anatomy ...... 44 7.8 New Discoveries ...... 103 4.3.1 History ...... 44 7.8.1 Cells ...... 103 4.3.2 Foetal and Pubertal Development ...... 45 7.8.2 MicroRNA ...... 105 4.3.3 Non-Lactating Adult Breast ...... 46 7.9 What Does the Future Hold? ...... 107 4.3.4 Pregnancy ...... 48 4.3.5 Lactating Breast ...... 54 Contents Contents 10 11

8 The Psychological Effects of Breastfeeding ...... 119 11 Human Milk in Economics Context ...... 176 Jennifer Hahn-Holbrook Subhash Pokhrel 8.1 Introduction ...... 119 11.1 Economics of Lactation ...... 176 8.2 Psychological Implications for Mothers...... 119 11.1.1 Breastfeeding as an Economic Decision ...... 176 8.2.1 Oxytocin and Prolactin ...... 119 11.1.2 Private Costs of Breastfeeding and Formula Feeding ...... 178 8.2.2 Maternal Bonding ...... 120 11.1.3 Supporting Women who Choose to Breastfeed ...... 179 8.2.3 Maternal Stress Regulation...... 121 11.2 Economics of Breastfeeding Support...... 179 8.2.4 Maternal Coping Strategies ...... 123 11.2.1 Benefits to Infants and Children ...... 180 8.2.5 Postpartum Depression ...... 124 11.2.2 Benefits to Mothers ...... 181 8.3 Psychological Impacts of Breastfeeding on the Infant ...... 125 11.2.3 Benefits to National Health Systems ...... 182 8.3.1 Attachment ...... 125 11.2.4 Benefits to Wider Society ...... 184 8.3.2 Temperament ...... 125 11.2.5 Cost-Effectiveness of Breastfeeding Promotion/Support Interventions ...... 184 8.4 Psychological Barriers to Breastfeeding...... 126 11.3 Making the Business Case for Breastfeeding Promotion and Support ...... 186 8.4.1 Societal Pressures ...... 127 11.3.1 Return on Investment (ROI) Analysis ...... 186 8.4.2 The Mother’s Partner ...... 128 11.3.2 The ROI from Breastfeeding Promotion/Support Interventions: an Example...... 187 8.4.3 Mental Health Barriers ...... 129 11.4 Summary ...... 190 8.5 Conclusions ...... 129 12 Commercial Aspects of Breastfeeding: Products and Services ...... 194 9 Sociological and Cultural Influences upon Breastfeeding ...... 137 Rebecca Mannel Amy Brown 12.1 Introduction ...... 194 9.1 Societal Attitudes Towards Breastfeeding ...... 140 12.2 Breastfeeding Products...... 194 9.1.1 Perceptions of the Breast...... 140 12.2.1 Milk Expression ...... 194 9.1.2 Perceptions of Breast Milk ...... 141 12.2.2 Alternative Methods of Feeding ...... 195 9.1.3 Attitudes to Breastfeeding in Public ...... 141 12.2.3 Breastfeeding Challenges ...... 197 9.1.4 Attitudes Towards Formula Milk...... 143 12.3 Human Milk Products...... 199 9.2 Societal Attitudes Towards Mothering ...... 144 12.3.1 Banked Donor Milk...... 199 9.2.1 Postnatal Depression ...... 145 12.3.2 Other Milk Products ...... 201 9.2.2 Work ...... 146 12.3.3 Other Human Milk Uses ...... 201 9.3 Familial Influences ...... 147 12.3.4 Milk From Other Mothers ...... 202 9.3.1 Fathers/Partner ...... 148 12.3.5 Internet Purchasing of Milk ...... 202 9.3.2 A Woman’s Own Mother ...... 148 12.4 Lactation Service Providers ...... 202 9.4 Ethnicity, Acculturation, and Religion...... 149 12.4.1 International Board Certified Lactation Consultants...... 202 9.4.1 Ethnicity in Western Regions ...... 149 12.4.2 Other Lactation Training and Certification ...... 203 9.4.2 Acculturation ...... 150 12.4.3 Mother-to-Mother/Peer Support...... 204 9.4.3 Religious and Cultural Beliefs ...... 150 12.4.4 Levels of Lactation Care ...... 204 9.5 The Way Forward...... 153 12.4.5 Insurance Coverage ...... 205 9.6 Summary ...... 154 12.4.6 Licensure/Regulation ...... 205 12.5 Conclusion ...... 206 10 Breastfeeding Promotion: Politics and Policy...... 163 Ashley M. Fox 13 The Promotion of Breastfeeding ...... 211 10.1 Introduction ...... 163 Rowena Merritt 10.2 The Three Frames of Breastfeeding Politics ...... 165 13.1 Breastfeeding Promotion ...... 211 10.2.1 Breastfeeding as a Women’s Rights Issue ...... 165 13.1.1 The Milk Code ...... 211 10.2.2 Breastfeeding as a Children’s Rights Issue ...... 166 13.1.2 Breastfeeding Promotion ...... 212 10.2.3 Breastfeeding as a Global Social Justice Issue ...... 168 13.1.3 Promotional Work and the Code ...... 212 10.3 Critiques and Tensions in the Three Frames ...... 170 13.2 Social Marketing and Breastfeeding Rates ...... 213 10.3.1 Tension 1: Trade-offs Between Mothers’ Rights and Children’s Rights Frame...... 171 13.2.1 Defining Critical Social Marketing ...... 213 10.3.2 Tension 2: Different Standards for Developed and Developing Countries? ...... 172 13.2.2 Learning from the Competition ...... 213 10.4 Conclusion ...... 173 Contents Contents 12 13

13.2.3 The Mother’s Perspective ...... 213 16.4 Managing Human Milk Feeding in the NICU ...... 252 13.2.4 What We Know ...... 214 16.4.1 Variability in Pumped HM in the NICU...... 252 13.3 Learning from the Formula Milk Industry ...... 214 16.4.2 Safe Handling of Human Milk in the NICU ...... 254 13.3.1 Advertising Strategies ...... 214 16.4.3 Summary – Managing Human Milk Feeding ...... 261 13.3.2 Promotion by Healthcare Professionals ...... 215 16.5 Feeding at Breast in the NICU ...... 261 13.4 Conclusions ...... 215 16.5.1 Maternal Goals and Expectations ...... 261 16.5.2 Developmentally-Based Breastfeeding Processes ...... 262 14 Infant Feeding in History: an Outline ...... 219 16.5.3 Physiologic Immaturity ...... 263 Maureen Minchin 16.5.4 Summary – Feeding at Breast ...... 267 14.1 Overview and Introduction ...... 219 16.6 Overall Summary ...... 267 14.1.1 Infant Feeding in Antiquity...... 220 14.2 The Middle Ages and Renaissance ...... 221 17 A Collective View of Human Milk Banking ...... 282 14.2.1 Infant Feeding in the Renaissance...... 221 João Aprigio Guerra de Almeida, Ben Hartmann, Kiersten Israel-Ballard, Guido E. Moro 14.3 17th to 18th Century ...... 222 17.1 Introduction ...... 282 14.3.1 Infant Feeding in the 17th and 18th Century ...... 222 17.2 Interviewer: What is Human Milk Banking?...... 282 14.4 The 19th Century ...... 223 17.2.1 Defining Human Milk Banking ...... 282 14.4.1 Infant Feeding in the 19th Century ...... 223 17.2.2 History and Future ...... 283 14.5 The 20th Century ...... 225 17.3 Why Human Milk Banks?...... 286 14.5.1 Infant Feeding in the 20th Century ...... 226 17.4 The Selling of Breastmilk ...... 289 14.6 The 21st Century ...... 231 17.4.1 Expert Collective Views ...... 289 14.6.1 Infant Feeding in the 21st Century ...... 232 17.5 Legal Aspect: Guidelines, Standards, Regulations, and Governing Bodies ...... 290 14.7 Current Overview and Conclusion ...... 234 17.6 Opening a Milk Bank ...... 294 17.6.1 Expert Collective Views ...... 294 17.7 Low-Middle Income Countries ...... 299 17.7.1 Expert Collective Views ...... 299 Part 3 17.8 Key Considerations ...... 300 Human Milk in Special Circumstances 17.9 Conclusions...... 301

242 15 Introduction ...... 18 Pasteurisation ...... 304 Paula P. Meier Lukas Christen 18.1 Introduction ...... 304 244 16 Human Milk in the Neonatal Intensive Care Unit ...... 18.2 Pasteurisation Methods ...... 304 Paula P. Meier, Beverly Rossman, Tricia J. Johnson, Janet L. Engstrom, Rebecca A. Hoban, 18.2.1 Pasteurisation of Human Milk ...... 304 Kousiki Patra, Harold R. Bigger 18.2.2 Thermal Pasteurisation ...... 305 16.1 Introduction ...... 244 18.2.3 LTLT or Holder Pasteurisation ...... 306 16.2 Human Milk Feedings for Premature Infants: Health Outcomes, Costs, and Mechanisms 18.2.4 HTST or Flash Pasteurisation ...... 306 of Protection ...... 244 18.2.5 Pressure Pasteurisation ...... 306 16.2.1 Health Outcomes of HM Feedings ...... 244 18.2.6 Ultrasound Pasteurisation or Ultrasonication ...... 306 16.2.2 Cost of Human Milk Feedings ...... 246 18.2.7 Ultrasound and Thermal Combination or Thermo-Ultrasonication ...... 307 16.2.3 Protective Mechanisms of HM for Premature Infants ...... 246 18.2.8 Ultraviolet Irradiation ...... 307 16.2.4 Protection via HM Feedings ...... 246 18.2.9 Electron, X-Ray, and Gamma Irradiation ...... 308 16.2.5 Donor HM as a Supplement/Substitute for HM ...... 247 18.2.10 Microwave Irradiation ...... 308 16.2.6 Summary – Human Milk Feedings for Premature Infants ...... 248 18.2.11 Pulsed Electric Field ...... 308 16.3 Prioritising Initiation and Maintenance of Established Lactation in Mothers of Premature 18.2.12 Oscillating Magnetic Field...... 308 Infants in the NICU ...... 249 18.2.13 Bactofugation (Separation by Weight) ...... 308 16.3.1 Breast Pump Dependency ...... 249 18.2.14 Filtration (Separation by Size)...... 308 16.3.2 Strategies to Prioritise Established Lactation for Breast Pump-Dependent Mothers ...... 250 18.3 Potential Alternative Pasteurisation Methods for Human Milk ...... 308 16.3.3 Summary – Prioritising Initiation and Maintenance of Established Lactation ...... 252 Contents Contents 14 15

19 Human Immunodeficiency Virus (HIV) ...... 313 Part 4 Anna Coutsoudis The Way Forward 19.1 Research Perspective...... 313 19.1.1 Development of Infant Feeding Guidelines ...... 313 21 Introduction...... 342 19.2 Risk Factors for Transmission ...... 315 Leith Greenslade 19.2.1 Non-exclusive Breastfeeding...... 315 19.2.2 Breast Pathology ...... 315 22 Scaling-up Breastfeeding Protection, Promotion, and Support Programmes .... 343 19.2.3 ARVs in Breastmilk ...... 315 Rafael Pérez-Escamilla 19.3 Remaining Research Questions ...... 315 22.1 Introduction ...... 343 19.3.1 ARV Therapy ...... 315 22.2 Key Principles for Scaling-up of Breastfeeding Programmes ...... 345 19.3.2 ARVs and Breastmilk Components ...... 316 22.3 Key Concepts behind Scaling-up of National Breastfeeding Programmes ...... 346 19.3.3 Role of Vaccines ...... 316 22.3.1 Breastfeeding Protection, Promotion, and Support ...... 346 19.4 Safe Breastfeeding Strategies ...... 316 22.3.2 Scaling-up ...... 346 19.4.1 Exclusive Breastfeeding in the First 6 Months ...... 316 22.3.3 Implementation Science ...... 347 19.4.2 Breastmilk Pasteurisation/Heat Treatment...... 316 22.3.4 Social Marketing ...... 350 19.5 Infant Feeding Options ...... 317 22.3.5 Key Ingredients of Successful Large-Scale Breastfeeding Programmes ...... 352 19.5.1 Developed Countries ...... 317 22.3.6 A Model for Scaling-up of Breastfeeding Programmes ...... 355 19.5.2 Developing Countries...... 317 22.3.7 Indicators for Scaling-up of Breastfeeding Programmes ...... 356 19.6 Policy Implications of Infant Feeding Recommendations ...... 318 22.4 WHO Tool ...... 357 22.5 The World Breastfeeding Trends Initiative (WBT) ...... 359 20 Breastfeeding and the Use of Medications ...... 323 22.6 Conclusions and Vision for the Future ...... 361 Thomas W. Hale, Teresa Ellen Baker 20.1 Introduction ...... 323 23 Towards a Common Understanding of Human Lactation ...... 365 20.2 Evaluating the Age of the Infant ...... 323 Melinda Boss, Peter E. Hartmann 20.3 Neonatal Pharmacokinetics...... 324 23.1 Preface ...... 369 20.4 Maternal Drug in Human Milk ...... 324 23.1.1 Alphabetical List of Terms...... 366 20.5 Bioavailability ...... 325 20.6 Calculating Infant Exposure...... 326 20.7 Review of Important Selected Drug Classes ...... 326 Part 5 20.7.1 Analgesics ...... 326 Addendum 20.7.2 Anti-Infectives ...... 328 20.7.3 Antidepressants ...... 328 24 Epilogue ...... 388 20.7.4 Immune Modulating Agents...... 330 20.7.5 Monoclonal Antibodies ...... 331 25 List of Figures...... 391 20.7.6 Recreational Drugs ...... 331 20.7.7 Drugs Altering Milk Supply...... 333 26 List of Tables ...... 395 20.8 Summary ...... 333

27 Index of Authors ...... 396

Index ...... 399 2.3 Breastfeeding as an Equity Strategy 20 21

2 Breast Milk, Global Health and Sustainable [2], and enzymes for optimal digestion. There is fits on healthcare costs and economic growth, re- now widespread acceptance that the health bene- porting that increases in breastfeeding rates could Development fits of breastfeeding continue well into early child- save US$400 million in healthcare costs in the US, hood, and potentially beyond. The benefits of UK, Brazil, and China alone, and inject US$300 bil- breastfeeding for women include reduced risk of lion into economies from more productive work- pregnancy and potentially lower lifetime risks of forces [19]. Leith Greenslade, MPP, MBA certain cancers, obesity, diabetes, and heart disease [3]. 2.3 where that is not possible, to donor breast milk Several Lancet series on maternal, newborn, and ! Expected Key Learning Outcomes from the newborn period onwards. child health and nutrition have laid out the evi- Breastfeeding as an Equity ● Why breastfeeding is so important It is critical that development actors confront dence for the benefits of breast milk. The Maternal Strategy ● How breastfeeding can help reduce the in- Setting the Scene the reality that for almost all mothers — an esti- and Child Undernutrition Series [4], the Maternal equalities in health mated 140 million women give birth every year — and Child Nutrition Series [5], the Childhood Children born to low income families in high-risk ● The health and economic benefits from in- breastfeeding is not always a choice. Depending on Pneumonia and Diarrhoea Series [6], the Every environments disproportionately benefit from the creasing breastfeeding rates the severity of the barriers, a mother may be so Newborn Series [7], and the Breastfeeding Series special protective properties of breast milk be- ● Reasons why mothers do not breastfeed constrained by forces beyond her control (e.g., lack [8] all cite evidence that breastfed babies are much cause they are more likely to be exposed to infec- despite all the evidence from research of education, lack of family support, the need to more likely to survive the first six months of life tions exacerbated by poor living conditions and demonstrating the benefits earn an income) that she cannot exercise a prefer- [9], that initiation of breastfeeding within 24 less likely to access quality healthcare as formal ● The required change of policy focus needed ence to breastfeed. For many tens of millions of hours of birth could reduce the risk of newborn health services so often fail to reach them. A re- to support a global increase in breastfeed- mothers, breastfeeding is not possible in the envi- death by 43% of all newborn deaths [10], [11], [12] cent study reported that a 10% increase in breast- ing rates ronments in which they live. For these women, re- and that breastfeeding could prevent 823,000 feeding prevalence across all households resulted ducing or removing the external constraints is child deaths and 20,000 breast cancer deaths an- in a larger absolute reduction in child deaths in what will ultimately lead to sustained increases in nually [13]. Other sources accord with these find- the poorest households [20]. The authors con- 2.1 breastfeeding. ings, including the Born Too Soon Report, which cluded that breastfeeding is better positioned to Women facing the most significant barriers to The Importance of Empowered stresses the importance of breast milk for preterm reduce wealth-related child health inequalities breastfeeding are also most likely to live in com- Mothers babies [14], and the Global Burden of Disease than other interventions. munities where the costs of not breastfeeding fall Study 2016, which ranks “suboptimal breastfeed- Although breastfeeding is one of the few health most heavily on children. These are the popula- ing” as a leading behavioural risk factor in child Nature has empowered mothers with control over interventions where the gaps in coverage between tions where very low breastfeeding rates coexist death, especially across African and Asian coun- the production and distribution of an extraordi- high and low income households are narrow in with very high rates of newborn and child sickness tries [15]. According to this body of evidence, no narily protective substance for the health and de- low income countries, early and exclusive breast- and death. Empowering mothers in these high-risk other single intervention has the power to prevent velopment of their babies — breast milk. This evo- feeding rates among poor families remain very environments to exercise a real choice to breast- newborn and child deaths at the scale of breast lutionary innovation provides all of the nutrition low [21]. Globally, just 40% of infants from the feed in supportive homes, workplaces, and public milk. an infant needs for the first six months of life and poorest households are exclusively breastfeed for spaces should be the primary focus of develop- There is less consensus about the long-term affords protection from infectious diseases, re- the first six months of life, and in many countries ment efforts to increase breastfeeding rates. health and related benefits of breastfeeding for duces the risk of sickness and death, and contrib- with the highest child mortality breastfeeding both breastfeeding mothers and breastfed infants. utes to healthy digestive and brain development rates are even lower [22]. For example, the ten The many studies that report adult health benefits well into early childhood. 2.2 countries with the highest child mortality rates all including reductions in heart disease, diabetes, Unlike the vast majority of health interventions, have exclusive breastfeeding rates below 50% The Benefits of Breast Milk and cancers; cognitive improvements including breast milk is wholly owned and operated by (▶ Table 1.1), and several have rates below 20%. higher IQ; and even economic gains including mothers who function as “doctors” administering Further, eight of the ten countries with the largest In the past 15 years the health benefits of breast- higher educational performance and income [16] their “medicine”. To unleash the protective powers numbers of child deaths have exclusive breastfeeding have become extremely well known and all suffer from methodological weaknesses as they of breast milk, mothers must not only be knowl- feeding rates below 50% (▶ Table 1.2). These in- extensively promoted. There is consensus among are based on cross-sectional retrospective studies edgeable about the benefits of breast milk. They clude India, Nigeria, Pakistan, China, Democratic the global health community that breast milk con- rather than randomised control trials. A recent must also be freely able to exercise their choice to Republic of Congo, Indonesia, Angola, and the Phil- fers its powerful protective properties on children meta-analysis of these studies cautioned that breastfeed, unfettered by external barriers. If ippines. by providing all of the nutrients, vitamins, and these methodological challenges limit the ability mothers cannot breastfeed due to sickness or ab- Despite recent improvements in breastfeeding minerals children need in the first six months of to draw firm conclusions [17], [18]. sence, they should be able to ensure that their ba- rates in some countries, the rate of progress over- life, alongside antibodies that combat infectious The 2016 Lancet Breastfeeding Series quantified bies have access to their own breast milk and, all has been slow over the last 25 years [23]. diseases, especially diarrhoea and pneumonia [1], the impact of these health and development bene- 2 – Milk, Health, Development 2.5 Breastfeeding’s Poor Performance 22 23

▶ Tab. 1.1 Breastfeeding rates in countries with the highest child mortality rates, 2015. leverage the equity impact of breastfeeding in full Yet despite the evidence of the cost-effective- Country Child Mortality Rate % Early Breastfeeding % Exclusive both within and between countries, it is critical ness of breastfeeding support programmes, inter- 2016 (0–1 hour) Breastfeeding that the global development community priori- national development spending on breastfeeding 2008–2015 (0–6 months) tises breastfeeding support in the populations programmes has never been high. Indeed, it has 2008 2015 – with the lowest absolute rates of breastfeeding been declining since the 1990s and is now at his- Angola 157 55 No data and breastfeeding progress, the weakest health in- torically low levels relative to other health preven- Somalia 133 26 5 frastructure, and the highest burdens of newborn tion areas, most notably vaccines and insecticide- Chad 127 29 3 and child death. treated bed nets [28]. The relatively high level of investment in vaccines and in malaria prevention Central African Republic 124 44 34 is one of the reasons why they are responsible for Sierra Leone 114 54 32 2.4 preventing such a large proportion of child deaths Mali 111 46 34 The Cost-Effectiveness of since 1990 in so many countries [29]. The fact that Setting the Scene Nigeria 104 33 17 Breastfeeding breastfeeding contributed so little to the 50% re- Benin 98 50 41 duction in child deaths achieved over the life of Democratic Republic of Like many prevention efforts, breastfeeding in- the Millennium Development Goals begs a critical 94 52 48 Congo vestments are highly cost-effective. The 2013 Lan- question: Could we have actually achieved the 66% Cote d’Ivoire 92 53 23 cet Maternal and Child Nutrition Series reports reduction in child deaths required to achieve Goal 4 with greater investments in breastfeeding pro- Niger 91 53 23 that breastfeeding promotion compares very fa- vourably with other nutrition intervention pack- motion and support? Global Average 41 43 40 ages and has the power to reduce hundreds of Source: World Bank and UNICEF, latest. thousands of child deaths at an annual cost per life 2.5 saved of $US175. Of ten single nutrition interventions assessed by The Lancet, only the manage- Breastfeeding’s Poor ▶ Tab. 1.2 Breastfeeding rates in countries with the highest newborn and child deaths, 2015. ment of severe acute malnutrition and preventive Performance Country Number Newborn Number Child % Early % Exclusive zinc supplementation saved more lives than Deaths Deaths Breastfeeding Breastfeeding breastfeeding promotion, and of four intervention Despite the significant health and equity benefits (0–1 month, (0–5 years, 2015) (0–1 hour) (0–6 months) 2015) packages modelled, only the management of acute of breastfeeding, and the cost-effectiveness of malnutrition saved more lives at lower cost than breastfeeding support services, rates of breast- India 696,000 1,201,000 41 62 breastfeeding promotion [26]. feeding in most countries fall below the World Nigeria 240,000 750,000 33 17 Further, the 2014 Lancet Newborn Series re- Health Organization’s (WHO) recommendations Pakistan 245,000 432,000 18 38 ported that the earlier breastfeeding support serv- (early initiation of breastfeeding within one hour China 93,000 182,000 41 28 ices reach mothers after birth, the greater the im- of birth, exclusive breastfeeding until 6 months of Democratic Repub- 94,000 305,000 52 48 pact on newborn health and breastfeeding dura- age, and continued breastfeeding until 2 years of lic of Congo tion. The Series cited that education and counsel- age or older), and the World Health Assembly’s Indonesia 74,000 147,000 49 42 ling can improve exclusive breastfeeding rates by target of at least 50% exclusive breastfeeding [14]. 43% the day after birth and by up to 30% in the first Globally, just 40% of babies are breastfed exclu- Angola 53,000 169,000 55 No data month after birth. Kangaroo mother care, a strat- sively for the first 6 months and 43% in the first Sudan 39,000 89,000 73 55 egy that improves the health of babies born too hour after birth, far below the coverage rates Kenya 34,000 74,000 58 61 small, also encourages breastfeeding, with studies achieved by other child survival interventions Philippines 30,000 66,000 50 27 showing a 27% increase in breastfeeding rates at such as vaccines (86%), Vitamin A (72%), and Source: UNICEF, 2015 and World Bank, latest. one to four months after birth and an increased skilled birth attendance (78%). Currently, only 32 breastfeeding duration. This body of research esti- countries have achieved the 50% exclusive breast- mates that where a specific population can feeding target and many countries struggling with achieve 90% coverage of breastfeeding promotion high burdens of newborn and child mortality have Among the 33 countries with the slowest rates of struggling to prevent child deaths implies that exclusive breastfeeding rates can increase by 15% rates far below 50%. reduction in child mortality, only four have exclu- there are considerable equity gains to be made in in newborns and by 20% in children aged one to Progress in closing the high breastfeeding cover- sive breastfeeding rates above 50% – Burundi, To- targeting their most vulnerable populations for five months [27]. age gaps has also lagged other areas of global go, Papua New Guinea, and Lesotho [24]. This lack breastfeeding improvements, particularly in the health. According to the Countdown to 2015 Final of improvement in breastfeeding rates in countries countries with very low vaccination rates [25]. To 5.2 The Evolution of Lactation 78 79

5 Why Breastfeeding? ▶ Tab. 5.1 Selected anti-infectious and anti-inflammatory components in human milk. Cellular components Humoral and other components

Neutrophil, granulocyte, Immunoglobulins (sIgA, IgG, IgM, IgD) Haptocorrin Berthold Koletzko, Univ-Prof. Prof. h.c. Dr. med. habil. Dr. h.c. macrophages Lymphocytes Complement and complement receptors Osteopontin 5.2 Mammary gland epithelial cell Toll-like receptors Fibronectin ! Expected Key Learning Outcomes The Evolution of Lactation membranes ● The importance of optimum nutrition in Milk fat globoli membranes Soluble CD14 Lactoperoxidase the first months after birth Breastfeeding is the natural form of infant feeding β-Defensin-1 Human milk oligo- and polysac- ● The eﬀect of early nutrition on later life and is universally recommended [5]. The composi- charides and glycoconjugates

● The importance of good health and nutri- Setting the Scene tion of human milk is believed to have developed Cytokines, e.g. IL-10, TGFβ Monoglycerides and non-esteri- tion for mothers during pregnancy and during a very long evolutionary process to match fied fatty acids throughout lactation the needs of both lactating women and their in- TNFα and IL-6 receptors Complex lipids fants optimally. Lactation and milk feeding in IL-1 receptor antagonist Nucleotides mammalian species is believed to have evolved κ-Casein, α-lactalbumin Mucins 5.1 over a period of about 250–300 million years, and Lysozyme Lactadherin Introduction to have originated from synapsid animals that pro- Lactoferrin, lactoferricin B and H vided fluid from cutaneous glands to protect their There is no other period of time in human life parchment-shelled eggs from desiccation [6], [7]. Modified from [57]. when the quantity and quality of nutritional sup- These ancestral cutaneous glands are thought to ply are of greater importance than during the first have evolved by combining features of skin glands months after birth. This is due to the extremely into new functional entities. Gland secretions ▶ Tab. 5.2 Milk composition (% weight) among nine species. rapid growth of infants who normally double their were then provided with antimicrobial properties Water Protein Fat Lactose Ash birth weight in 4–5 months and triple it in the first to protect eggs and hatchlings from infection, and Human 87.7 1.8 3.6 6.8 0.1 organic components to supplement offspring nu- year; such a growth rate demands a very high re- Cow 86.6 3.4 4.6 4.9 0.7 quirement of energy and nutrients per kilogram of trition [8]. The immune properties of milk from Buffalo 84.2 3.9 6.6 5.2 0.8 body weight [1], [2]. The capacity to compensate various mammalian species show wide variation Sheep 79.4 3.5 8.6 4.3 1.0 for a diet that is insufficient in quantity or inad- in anti-inflammatory and immunomodulating equate in nutritional value is limited. Body re- agents, including immunoglobulins, iron-binding Pig 89.6 1.3 4.8 3.4 0.9 serves of nutrients are very restricted and, partic- proteins, lysozyme, oligosaccharides, and leuko- Dog 75.4 11.2 9.6 3.1 0.7 ularly during the first months of life, some body cytes. This variability appears to compensate for Rat 68.3 11.3 14.8 2.9 1.5 differences in developmental delays in early post- functions are not fully developed, such as nutrient Whale 70.1 9.5 19.6 1.8 1.0 absorption, metabolism, and renal conservation. natal production of antimicrobial factors among Seal 32.3 11.2 34.8 2.6 0.9 In addition to this fast rate of body mass gain there species [9], [10]. Moreover, the composition and is a rapid development and differentiation of tis- concentrations of different immunological agents sues and organs. During this period of develop- in mammalian milks relate to differences in pla- mental plasticity, environmental cues such as nu- cental type and function, lactation pattern, and closely related to offspring growth velocity trition and metabolism have modifying effects on environments and also follow different evolution- of lactation to the needs of the species, this change (▶ Fig. 5.1). The relatively low protein concentra- growth, development, and long-term function and ary strategies. is in accordance with the decrease in protein re- tion in human milk is an adaptation to the lower health. An increasing body of evidence indicates Similarly, the evolutionary development of quirement with increasing postnatal age, which is needs of human infants who have slower weight that nutrition, particularly during the first two highly nutritious milks has led to diverse variation a consequence of a slowing of infant growth rate. gain rates compared to, for example, calves or kit- Recent genome studies provide support for the years of life, has a marked impact on later physiol- in mammary gland anatomy, milk output, length tens. Moreover, the protein supply in human milk ogy, health, and disease risks; this is commonly re- of lactation, and nutrient content (▶ Table 5.1, hypothesis that during the evolution of lactation, falls substantially with increasing duration of lac- ferred to as the ‘metabolic programming of life- ▶ Table 5.2), and in the relative contribution of the maternal energy cost of breastfeeding has tation. The protein intake per kilogram body ff long health and disease’ or the ‘developmental ori- milk feeding to the offspring’s total nutrient sup- been limited while aiming to maximise o spring weight of a breastfed infant at 6 months repre- ff gins of adult health’ [1], [3], [4]. ply during their initial growth period. For exam- survival. In e ect, this would have promoted sur- ple, the wide inter-species variation in milk pro- sents only about 55% of the intake after birth vival of the maternal-offspring pair and therefore tein content, a key driver of offspring growth, is (▶ Fig. 5.2). Underlining evolutionary adaptation survival of the species. The genome analysis of 5 – Why Breastfeeding? 5.3 Assessing Health Effects of Breastfeeding 80 81

▶ Fig. 5.1 Protein content of mam- tween the slow evolutionary adaption of the hu- The author of this article is aware of only one malian milks relative to time to doubling of offspring weight. Note the man genome affecting biological characteristics randomised controlled trial performed at the end 12 th Rat low human protein milk content in such as breastfeeding and human milk composi- of the 20 century. In this trial conducted in four humans matching relatively slow off- tion and the rapid environmental and human life- antenatal clinics in Nairobi, Kenya, women in- 10 Cat spring growth. style changes particularly within the last century. fected with human immunodeficiency virus type These questions warrant investigation in future 1 (HIV-1) infection were randomly assigned to ei- 8 Dog studies. ther breastfeeding (n=185) or formula feeding 6 (n=186) their infants to assess potential effects on vertical HIV transmission [16], [17]. Mortality Goat 5.3

Milk protein (g/dl) Milk protein 4 Cow rates adjusted for HIV-1 infection status, morbid- Horse Assessing Health Effects of ity, and nutritional status were monitored during 2 Human Breastfeeding the first two years of life. Today, enhanced knowl- Setting the Scene edge of strategies to mitigate the risk of HIV trans- 0 0 20 40 60 80 100 120 140 160 180 There is considerable data supporting the health mission during breastfeeding and particularly ef- Approx. time to doubling weight (d) effects and benefits of breastfeeding for mother fective antiretroviral therapy has changed the ap- and infant, and these have been evaluated in sys- proaches to breastfeeding in HIV-positive women tematic reviews [10], [11], [12], [13], [14], [15]. in low income countries. Therefore, such a rando- Given that breastfeeding is widely considered as mised trial in HIV-positive women would no lon- the natural and optimal mode of infant feeding, it ger be feasible today. those with nutritional or immunological charac- is generally thought unethical to randomise in- However, it has been considered ethical to clus- teristics. This leads to speculation that evolution- ter-randomise hospitals to standard or enhanced 1,8 fants to either breastfeeding or breast milk substi- ary selection (specifically of these genes) occurred tutes. As such, the evidence is almost entirely breastfeeding promotion. With the aim to evaluate 1,6 in response to different environmental and nutri- based on epidemiological data from observational the effects of breastfeeding promotion in hospitals 1,4 tional needs and to infectious challenges. Interest- studies. A limitation to this is that the decision to on breastfeeding success, such a cluster-rando- ingly, most conserved genes are those for proteins mised trial (the PROBIT trial) was performed in 31 1,2 breastfeed and the duration and exclusivity of of the milk fat globule membrane, suggesting they breastfeeding are associated with a variety of fac- hospitals in Belarus [18]. The PROBIT trial com- 1 may have a central biological role. tors that predict health outcomes, e.g., socioeco- pared an experimental intervention modelled on 0,8 In spite of its high metabolic cost, the evolution nomic status, education, and lifestyle factors in- the World Health Organization and United Nations of lactation has been accompanied by the global ’ 0,6 cluding smoking habits, physical activity, dietary Children s Fund Baby-Friendly Hospital Initiative biological success of mammalian species. This sup- choices, and use of preventive healthcare. Thus, with a control intervention. The experimental in- 0,4 ports the hypothesis that there are major benefits tervention emphasised health care worker assis- Milk protein intake (g/kg day) per intake protein Milk there is a high risk that the effects and effect sizes 0,2 to lactation due to the nutritional and antimicro- of breastfeeding are overestimated if there is no tance with initiating and maintaining breastfeed- bial properties of milk and the associated ex- 0 adjustment for such confounding factors. Even ing, and lactation and postnatal breastfeeding sup- 12 346 tended period of mother-infant contact. The regu- with adequate adjustment, there remains the risk port [18]. Although not primarily designed for Infant age (months) lar and frequent transfer of milk, particularly in of residual confounding, partly because not all such a purpose, the study followed children to lat- humans and other non-human primates, provides confounders can be quantitatively assessed. A re- er ages to evaluate the health effects of varying ff ▶ Fig. 5.2 Decrease in milk protein intake in a breastfed o spring with close interaction with their mother view and analysis by Ip and co-workers details the breastfeeding duration [19], [20]. Studies have also human infant in the first six months reflecting the decrease and therefore more learning opportunities, which methodological issues and considerable differen- randomised breastfed infants to earlier or later in- in infant growth rate. Milk protein intake is calculated as may have facilitated the development of high lev- ces in the quality of studies assessing breastfeed- troduction of complementary feeding, and hence 75% of crude protein intake. els of intelligence found in humans and other pri- ing effects. This report rated study quality with re- to different durations of exclusive or predominant mates. gard to study methodology when evaluating the breastfeeding [21], [22], and to earlier or later in- While we have yet to learn much about the evo- evidence, a practice not often considered by other troduction of specific complementary feeds [23], seven mammalian species (human, cow, dog, lutionary process of lactation over the last 250– authors. Ip, et al. concluded that prospective longi- [24], [25]. These rare randomised trials are ex- mouse, rat, opossum, and platypus) indicates a 300 million years and the biological consequences tudinal cohort studies provide a better opportu- tremely valuable, but their conclusions are limited high degree of conservation of milk genes and for humans today, the available evidence indicates nity for adequate assessment of confounding vari- to the questions originally addressed. The discus- mammary genes. Such conservation seems to have that human breastfeeding has evolved to be highly ables than retrospective or cross-sectional studies sion on the health effects of breastfeeding pre- evolved more slowly than for other genes, even in adapted to the needs of both mothers and infants. [14]. sented here is based primarily on observational cows selectively bred for effective milk production A tempting question is whether new areas of vul- studies, with the caveat that the reported effects [7]. The most variable parts of the lactome were nerability might arise from the discordance be- and effect sizes are likely to be confounded by oth-

GTV / FLRF, Human Milk / Herr Heft / 2. AK / Stand: 26.7.18 GTV / FLRF, Human Milk / Herr Heft / 2. AK / Stand: 26.7.18 11.1 Economics of Lactation 176 177

11 Human Milk in Economics Context tems may consider the need to support breast- ▶ Fig. 11.1 depicts this notion of the decision feeding women through maternity pay and by cre- making process proposed by Racine and col- ating baby-friendly workplaces and hospitals [11]. leagues [10]. In this construct, the decision is an Maternal employment appears to be negatively economic choice; the postpartum women weigh Subhash Pokhrel, PhD, MSc associated with breastfeeding initiation and dura- the benefits of breastfeeding against the costs of tion [12]. This is particularly relevant since exclu- continuing or discontinuing breastfeeding. Some positive return on investment (ROI) from breast- sively milk-feeding mothers would have to spend factors that are incentives for health systems (e.g., ! Expected Key Learning Outcomes feeding [2]. much more time every week on feeding their baby the health benefits of breastfeeding for infants/ ● The economic considerations for mothers The other side of the argument positions breast- compared with other mothers [9]. Understanding children and for mothers) are also incentives for ● The impact of breastfeeding on health sys- feeding as a costly enterprise to women because, if incentives or disincentives facing women that may women. Although provision of breastfeeding sup- tems they chose to breastfeed their babies, they would

influence their choices regarding initiation and port requires health systems to cover costs, this erent Perspectives ● Analysis of how far breastfeeding promo- be required to incur substantial private costs to ﬀ

duration of breastfeeding (any or exclusive) is support is also an incentive for women encourag- Di tion and support interventions offer good enable milk expression [5]. Like formula feeding, therefore critically important. ing them to choose to breastfeed. value for money breastfeeding is also associated with private costs. Economic theories help us to understand what Racine and colleagues implemented this model ● Effective ways to invest in breastfeeding In addition, breastfeeding may have implications those incentives and disincentives might be, and in a sample of 1,595 low-income families in the promotion for earnings and productivity of working women, how these may determine a women’s choice to US, and found that the decision to discontinue ● Outline of a business case made for breast- potentially requiring a longer maternity leave, breastfeed or formula feed and for how long. One breastfeeding was significantly associated with a feeding promotion and support in the ab- working part time, or missing opportunities for such theory is that of individual net-benefit (utili- number of disincentives: the Supplemental Nutri- sence of robust economic evaluation promotion [6], [7], [8]. It also takes a substantial ty) maximisation; in this case, individuals are as- tion Program for Infants, Women, and Children Human milk has several implications. Depending amount of a mother’s time to breastfeed her child sumed to make a choice (e.g., to initiate breast- (WIC) participation at 2–4 months, mothers re- on what perspective one chooses, the use of alter- [9]. Therefore, both the private costs and the for- feeding) that is perceived to benefit them and ad- turning to work for 20–40h per week, mothers not natives to human milk for feeding infants has at- gone opportunities women may experience by here to their decision until the benefits outweigh attending a postpartum doctor’s visit, fathers not tracted enormous debate in the past. This chapter choosing to breastfeed can be considerable. the costs [10]. In this framework, any factor that is being in the home, a smoker in the household, no surveys contemporary literature around the eco- Underneath these individual benefit-cost argu- perceived as a barrier or disincentive by a mother, receipt of breastfeeding instruction at the paediat- nomic value of breastfeeding and presents an ex- ments rests a question that has probably the most e.g., money, time, and negative feedback from ric office, the doctors not encouraging breastfeed- ample analysis to show how a business case for profound implications for any breastfeeding sup- friends or family, is a cost. Likewise, any factor that ing, and the mother experiencing depressive breastfeeding support could be made. port policy. Can a health system ask women to ini- is perceived as a facilitator or incentive, e.g., mon- symptoms [10]. The main implication of this find- tiate breastfeeding, and breastfeed for longer and ey saved by not buying formula, better health of ing is that any breastfeeding promotion pro- exclusively, particularly when we, as a society, rec- the child, bonding with their child, and access to gramme will need to address disincentives associ- 11.1 ognise that it is up to women themselves to make breastfeeding support, is a benefit. The model also ated with breastfeeding cessation. Understanding Economics of Lactation those explicit choices? What determines a wom- assumes that the incentives and disincentives to the economics of breastfeeding decisions is there- an’s decision to initiate (or cease) breastfeeding breastfeeding may change over time. fore helpful for policymakers. What economic value may human milk have? This and how those factors relate to the thinking of a question has featured in both academic and politi- healthcare system appear to be central to this cal debates for a long time. For some, human milk question [10]. Therefore, it is important to consid- is protective against certain disease conditions er whether breastfeeding is in fact an “economic” Incentives Choose to continue Disincentives and therefore it can provide substantial economic decision for women as well as for other stakehold- • Health and development of breastfeeding • Costs of breastfeeding benefits. Breastfeeding is beneficial not only to the ers. infants (less GP and hospital equipment health and wellbeing of a child and their mother, visits) • Current and new employment • Woman‘s own health prospects but it also generates substantial cost savings to the 11.1.1 Breastfeeding as an Economic • Support for breastfeeding • Amount of time needed to national health services. Health services would • Less monetary costs vs. Formula Currently breastfed breastfeed Decision • Time saved vs. bottle feeding • Lack of breastfeeding support have to treat fewer infant, childhood, and maternal • Belief that breastfeeding • Stress/mental health diseases with increasing breastfeeding prevalence Breastfeeding is an economic decision but its na- is natural • Belief that breastfeeding is ture varies according to the perspective taken. • Perception that breastfeeding harmful [1], [2]. In addition, some authors argue that wom- Choose to discontinue Working women may consider the consequences improves bonding with your en who choose to breastfeed actually produce and child breastfeeding supply breast milk and therefore contribute signif- of breastfeeding (i.e. opportunities foregone and/ icantly to the national economy [3], [4]. When or monetary costs of breastfeeding relative to for- costs of implementing breastfeeding support poli- mula feeding) when deciding whether to breast- Fig. 11.1 A schematic representation of the Net-Benefit (utility) Maximisation model of breastfeeding decision proposed feed their babies, while employers and health sys- ▶ cies are considered, society is more likely to get a by Racine et al. (Reproduced from [10]) 11 – Human Milk in Economics Context 11.2 Economics of Breastfeeding Support 178 179

Although the Net-Benefit (utility) Maximisation it is likely that the interests of the mother and the study found that women, particularly the first- 11.1.3 Supporting Women who model is a valuable way to identify determinants infant may not always align [13]. time mothers, in both groups, ‘spent money on Choose to Breastfeed of breastfeeding decisions that women may take Whether to breastfeed is thus a complex deci- items that were not needed or used only once or As seen above, breastfeeding is an economic (i.e. initiate, continue or discontinue; any or exclu- sion that postpartum women have to make by twice’ [5]. Higher spending was characterised by choice that women make. Therefore, it is impor- sive breastfeeding), the decision itself is complex. weighing the incentives (benefits) and disincen- education, socio-economic status and age. tant to support women to breastfeed for as long as The decision not to breastfeed infants is also the tives (costs) of breastfeeding relative to that of for- Although women included in the study spent they choose to. It appears that most women who decision to formula feed (i.e. use infant food or mula feeding. Breastfeeding is not a binary choice; more per week on breastfeeding compared with stop breastfeeding don’t want to and often consid- breast-milk substitutes). Infant food is often allo- it is rather a set of complex choices around initia- formula feeding, provision of better support (infor- er getting the help and support that would keep cated by markets. If we were to rely on markets to tion, duration, and exclusivity. What women de- mation) could have led the women to avoid pur- them breastfeeding for longer and exclusively [17]. allocate resources eﬃciently, consumers (i.e. post- cide to do on infant feeding may have far reaching chasing items that were unnecessary or to go for Supporting women who choose to breastfeed

partum women) would have to make informed implications beyond their families. cheaper alternatives where available. would therefore help align interests of the mother, erent Perspectives ﬀ

(rational) choices. These choices require that post- Depending on the healthcare context, there may the baby, and the health services. As breastfeeding Di partum women themselves are responsible for the be other forms of private monetary costs associ- 11.1.2 Private Costs of Breastfeeding (exclusive and/or longer duration) becomes more full costs and benefits of their infant food purchase and Formula Feeding ated with infant feeding. Frick and colleagues common as the result of this support, this will lead decisions. Much cultural knowledge of health risks identified food for the mother herself and medical to wider economic benefits too [2], [14]. of formula feeding is based on inaccurate or biased One of the economic disincentives (costs) associ- care use for herself or her child (in non-NHS/insur- Central to any policy debate around breastfeed- information and this, coupled with commercial ated with women’s infant feeding decisions is pri- ance settings) as potential private costs required ing should be the recognition that to breastfeed is vested interests, may not enable women to make vate costs [10]. Despite breast milk being consid- to enable mothers to breastfeed [16]. an exclusive choice of a new mother. Any breast- an informed (rational) decision [13]. It is known ered as the best form of nourishment for infants The choice of infant feeding is also associated feeding support policy therefore must acknowl- that not choosing to breastfeed leads to a decre- and usually in sufficient supply for the first few with time costs. In particular, ‘exclusive breast- edge that new mothers who have chosen to ment in infant and maternal health, thereby cost- months of life, it is not free for women who choose feeding is time intensive, which is economically breastfeed are well informed, well trained and ing health systems millions of dollars [1], [14]. to breastfeed. There are private costs associated costly to women’ [9]. In an Australian survey well supported for however long they choose to Those health systems costs are usually borne by with breastfeeding. Two types of private costs are (2005–2006), 139 new mothers were asked to re- breastfeed (exclusively or partially). It is possible taxpayers (as in the British National Health Service prevalent: monetary costs and time costs. port their average weekly time spent on feeding that a breastfeeding promotion policy may help [NHS]) or others (e.g., social/private insurance) In a study conducted in Liverpool, England 149 (milk or solids), feeds preparation, and the total of new mothers initiate breastfeeding; support and not by women who make consumption deci- women between the age of 18 and 43 were asked the two. Mothers who were exclusively breast- thereafter enabling women to breastfeed for lon- sions (purchase of breast-milk substitutes), a phe- to report the purchases associated with their in- feeding spent on average 7 hours extra per week ger is what generates health and economic bene- nomenon known as externalities (an attribute of fant feeding practices (mean age of infants: 13 on milk feeding their infants compared with other fits to the mother, the baby, and the health serv- market failure). This is particularly important as weeks) [5]. The study identified a number of mothers. This difference was statistically signifi- ices. the extent to which the women who choose to use equipment items needed to enable women to cant and implied that premature weaning was breast-milk substitutes are willing to bear this cost breastfeed. This included nursing bras, night- probable ‘for women who are time-stressed, lack is less understood. In this instance, the market shirts, breast pads, antiseptic nipple spray, breast household help from family, or cannot afford paid 11.2 price of artificial infant food becomes much lower cream, breast shells, nipple shields, breast pump, help’ [9]. Economics of Breastfeeding than its true economic costs to women who want breast-milk storage bottles, breast-milk freezer The time costs of breastfeeding have wider im- Support to purchase it, making breastfeeding a less attrac- bags, steriliser, and support pillow. Two separate plications. As exclusive breastfeeding is associated tive option [13]. models (high costs and low costs) were used to es- with substantial time commitment, working Having established the notion that supporting Another linked issue around the use of markets timate the average costs of purchasing the equip- women in particular may have to compromise on women who choose to breastfeed makes an eco- to allocate infant food efficiently is that of agency. ment. A set of breastfeeding equipment was pur- their earnings and productivity as choosing to nomic sense, it is important to look at the evi- In the case of infant feeding, one could argue that chased for £34.60 per week (high-cost model) or breastfeed means choosing to take longer mater- dence base to see what health benefits breastfeed- the infants are the actual consumers and not their £2.40 per week (low-cost model). Likewise, formu- nity leave or work part time and potentially miss ing may offer to mothers and their babies. How mothers. Mothers make decisions on behalf of la feeding mothers had bought bottles, teats, promotion opportunities [6], [7], [8]. For others, would the positive health effects of breastfeeding their infants – a classic principal-agent problem in steam steriliser, formula, bottle warmer, bottle the time spent on breastfeeding could have other translate into economic benefits both to national economics [15]. While agents (mothers) make de- carrier, powder dispenser and bottle/teat brushes. usage [10]. The opportunities forgone by choosing health systems and to wider society? At the micro cisions on behalf of their principals (infants), it is A set of formula-feeding equipment including the to breastfeed may therefore be considerable. level, do breastfeeding support interventions offer likely that agents are acting in their best interests food was purchased for £31.43 per week (high- Breastfeeding promotion policies must therefore good value for money? rather than in the best interests of their principals. cost model) or £6.30 per week (low-cost model). subsidise/share these costs through provision of It is argued elsewhere that given the difficulty to On average, breastfeeding cost women £11.58 various services, e.g., childcare, help with house- accommodate the needs of the breastfeeding per week compared with £9.60 per week for for- work, prolonged maternity leave, and if mothers mother in the context of institutional frameworks, mula-feeding (2002–2003 prices). However, the decide to return to work, the provision of breastfeeding breaks at the workplace [13].

GTV / FLRF, Human Milk / Herr Heft / 2. AK / Stand: 26.7.18 GTV / FLRF, Human Milk / Herr Heft / 2. AK / Stand: 26.7.18