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MATERNAL & CHILD HEALTH Technical Information Bulletin A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States Ruth A. Lawrence, M.D. Technical Information Bulletin Technical MATERNAL & CHILD HEALTH MATERNAL October 1997 Cite as Lawrence RA. 1997. A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States (Maternal and Child Health Technical Information Bulletin). Arlington, VA: National Center for Education in Maternal and Child Health. A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States (Maternal and Child Health Technical Information Bulletin) is not copyrighted with the exception of tables 1–6. Readers are free to duplicate and use all or part of the information contained in this publi- cation except for tables 1–6 as noted above. Please contact the publishers listed in the tables’ source lines for permission to reprint. In accordance with accepted publishing standards, the National Center for Education in Maternal and Child Health (NCEMCH) requests acknowledg- ment, in print, of any information reproduced in another publication. The mission of the National Center for Education in Maternal and Child Health is to promote and improve the health, education, and well-being of children and families by leading a nation- al effort to collect, develop, and disseminate information and educational materials on maternal and child health, and by collaborating with public agencies, voluntary and professional organi- zations, research and training programs, policy centers, and others to advance knowledge in programs, service delivery, and policy development. Established in 1982 at Georgetown University, NCEMCH is part of the Georgetown Public Policy Institute. NCEMCH is funded primarily by the U.S. Department of Health and Human Services through the Health Resources and Services Administration’s Maternal and Child Health Bureau. Published by National Center for Education in Maternal and Child Health 2000 15th Street, North, Suite 701, Arlington, VA 22201-2617 (703) 524-7802 (703) 524-9335 fax Internet: [email protected] World Wide Web: http://www.ncemch.org Single copies of this publication are available at no cost from: National Maternal and Child Health Clearinghouse 2070 Chain Bridge Road, Suite 450 Vienna, VA 22182-2536 (703) 356-1964 (703) 821-2098 fax This publication has been produced by the National Center for Education in Maternal and Child Health under its cooperative agreement (MCU-119301) with the Maternal and Child Health Bureau, Health Resources and Services Administration, Public Health Service, U.S. Department of Health and Human Services. Preface publication. Technical reviews and recommen- dations were contributed by many individu- In its report Breastfeeding: WIC’s Efforts to als, including Dr. Cheston M. Berlin, Jr., Promote Breastfeeding Have Increased (1993), the Pennsylvania State University; Dr. Margaret U.S. General Accounting Office (GAO) recom- Davis, Centers for Disease Control and mended that the U.S. Department of Prevention; Dr. Armond S. Goldman, Univer- Agriculture (USDA) and the U.S. Department sity of Texas; Dr. Audrey Naylor, Wellstart of Health and Human Services (DHHS) International; Dr. Mary Francis Picciano, develop written policies defining the condi- Pennsylvania State University; Dr. Walter J. tions that would contraindicate breastfeeding Rogan, National Institute of Environmental and determining how and when to communi- Health Sciences; and Dr. Carol West Suitor, cate this information to all pregnant and Institute of Medicine. Thoughtful comments breastfeeding participants of the Special were received from Ms. Brenda Lisi and Ms. Supplemental Nutrition Program for Women, Alice Lockett, representing the U.S. Infants and Children (WIC). The Maternal Department of Agriculture. The document also and Child Health Bureau, DHHS, and WIC, reflects the contributions of NCEMCH com- USDA, developed a plan to respond to GAO’s munications staff—Carol Adams, director of recommendation. In late 1994, MCHB award- communications; Jeanne Anastasi, editor; ed a contract to Dr. Ruth Lawrence, a nation- Anne Mattison, editorial director; and Oliver ally recognized expert in the area of breast- Green, graphic designer. feeding, to develop a policy document on the medical contraindications of breastfeeding. The policy document was reviewed by other national experts in the field of infectious dis- Benefits and Risks eases, environmental toxins, acute and chron- ic diseases, and metabolic disorders. In July Benefits 1996, the policy document was submitted to GAO to assist states in developing policies. To In any statement about breastfeeding and ensure widespread dissemination, the docu- breastmilk (human milk), it is important first ment has been prepared as a technical infor- to establish breastmilk’s distinct and irre- mation bulletin (TIB) for distribution to placeable value to the human infant. DHHS and USDA regional offices, state and Breastmilk is more than just good nutrition. local health departments, WIC state and local Human breastmilk is specific for the needs of agencies, and other interested organizations the human infant just as the milk of thou- and health care providers. USDA is encourag- sands of other mammalian species is specifi- ing WIC state agencies to develop policies cally designed for their offspring. The unique regarding contraindications to breastfeeding composition of breastmilk provides the ideal that take into consideration the information nutrients for human brain growth in the first presented in this document and that are con- year of life. Cholesterol, desoxyhexanoic acid, sistent with the policies of their respective and taurine are particularly important. state health departments. Cholesterol is part of the fat globule mem- brane and is present in roughly equal Special thanks go to Ms. Katrina Holt, amounts in both cow milk and breastmilk. National Center for Education in Maternal and Maternal dietary intake of cholesterol has no Child Health (NCEMCH), Ms. Gerry Howell, impact on breastmilk cholesterol content. The Special Supplemental Nutrition Program for cholesterol in cow milk, however, has been Women, Infants and Children (WIC), and Ms. removed in infant formulas. These elements Denise Sofka, Maternal and Child Health are readily available from breastmilk, and the Bureau (MCHB), who were instrumental in essential nutrients in breastmilk are readily providing guidance in the preparation of this transported into the infant’s bloodstream. The A Review of the Medical Benefits and Contraindications to Breastfeeding in the United States 3 bioavailability of essential nutrients (includ- For decades, growth in infancy had been ing the microminerals) means that there is measured according to data collected on great efficiency in digestion and absorption. infants who were exclusively formula-fed, Comparison of the biochemical percentages of until the publication of data on the growth breastmilk and infant formula fails to reflect curves of infants who were exclusively breast- the bioavailability and utilization of con- fed.8 The physiologic growth curves of breast- stituents in breastmilk compared to modified fed infants show a pattern similar to that of cow milk (from which only a small fraction of formula-fed infants at the 50th percentile, some nutrients is absorbed).1 with significantly few breastfed infants in the 90th percentile. This is most evident in the The presence of living leukocytes, specific examination of the z scores, which indicate antibodies, and other antimicrobial factors that formula-fed infants are heavier compared protects the breastfed infant against many to breastfed infants.9 common infections. Protection against gas- trointestinal infections is well documented.1 Upper and lower respiratory tract infec- Protection against infections of the upper and tions have been evaluated in case–control lower respiratory system and the urinary tract studies, cohort-based studies, and mortality is less recognized, although those infections studies in both clinic and hospitalized chil- lead to more emergency room visits, hospital- dren in many countries of the developed izations, treatments with antibiotics, and world.1–3,10,11 The results all show clearly that health care costs for the infant who is not breastfeeding has a protective effect, especial- breastfed.2,3 ly in the first six months of life. A random- ized controlled trial indicated that withhold- The incidence of acute lower respiratory ing cow milk and giving soy milk provided infections in infants has been evaluated in a no such protective effect.7 The incidence of number of studies examining the relationship acute otitis media in formula-fed infants is between respiratory infections and breast- dramatically higher than in breastfed feeding or formula feeding in these infants.4–6 infants,12,13 not only because of the protective These studies confirm that infants who are constituents of human milk but also because breastfed are less likely to be hospitalized for of the process of suckling at the breast, which respiratory infection, and, if hospitalized, are protects the inner ear.14 When an infant bot- less seriously ill. In a study of infant deaths tlefeeds, the eustachian tube does not close, from infectious disease in Brazil, the risk of and formula and secretions are regurgitated death from diarrhea was 14 times more fre- up the tubes. Child care exposure increases quent in the formula-fed infant and the risk of the risk of otitis media, and bottlefeeding
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