Tag Archives: breastfeeding

Breastfeeding: Protection from Inflammatory Bowel Disease

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Xu L, et al. Systematic review with meta-analysis: breastfeeding and the risk of Crohn’s disease and ulcerative colitis. Aliment Pharmacol Ther. 2017;46:780-789.

https://doi.org/10.1111/apt.14291Thanks to Mike Hart for this reference.

From abstract:

Results

A total of 35 studies were included in the final analysis, comprising 7536 individuals with CD, 7353 with UC and 330 222 controls. Ever being breastfed was associated with a lower risk of CD (OR 0.71, 95% CI 0.59-0.85) and UC (OR 0.78, 95% CI 0.67-0.91). While this inverse association was observed in all ethnicity groups, the magnitude of protection was significantly greater among Asians (OR 0.31, 95% CI 0.20-0.48) compared to Caucasians (OR 0.78, 95% CI 0.66-0.93; P = .0001) in CD. Breastfeeding duration showed a dose-dependent association, with strongest decrease in risk when breastfed for at least 12 months for CD (OR 0.20, 95% CI 0.08-0.50) and UC (OR 0.21, 95% CI 0.10-0.43) as compared to 3 or 6 months.

From associated editorial by David Rakel:

This meta-analysis of 35 studies shows that there is a dose–response protective effect of the duration of breastfeeding on inflammatory bowel disease. The association shows as much as an 80% reduction in risk for both Crohn’s disease and ulcerative colitis for breastfeeding more than 12 months.

Breast Feeding Graph

Inflammatory bowel disease arises from a complex set of interactions related to genetic susceptibility, environmental exposures, and a dysregulated immune response to dysbiotic intestinal microbiota, according to the study authors. These data will give us one more reason to encourage breastfeeding, ideally for a year or more.

Related blog post: Nutrition Week (Day 7) Connecting Diet and Epidemiology in IBD

 

 

Breastfeeding and IQ -the Latest Data

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A recent study (JY Bernard et al J Pediatr 2017; 183: 43-50) takes a look at the relationship between breastfeeding, specific polyunsaturated fatty acid (PUFA) levels and intelligence quotient at age 5-6 years.

The authors used the French EDEN cohort with 1080 children.

Key findings:

  • Breastfed children had higher IQs by 4.5 points on Wechsler Scales –though this dropped to 1.3 (not significant) when adjusted for confounders
  • DHA was positively associated with higher IQ.  Children exposed to colostrum high in linoleic acid (LA)/ow in docosahexaenoic acid (DHA) had lower IQs than those exposed to colostrum high in DHA/low LA

The authors speculate that one reason that supplemental DHA has not been shown to be effective could be related to a high intake of LA.

Related article: CT Collins et al. NEJM 2017; 376: 1245-55.  In this study, the authors showed that enteral supplemental of DHA (60 mg/kg) did not result in a lower risk of physiological bronchopulmonary dysplasia in a randomized trial of 1273 born before 29 weeks gestation.

Related blog posts:

With a new ballpark in town, there are a lot of firsts: first HR, first hit, etc. And now this

 

Nutrition Week (Day 6) Iron Deficiency Anemia in Breastfed Infants

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In brief: A recent cross-sectional study (KM Clark et al. J Pediatr 2017; 181: 56-61) showed that breastfeeding at 9 months of age in Chinese infants was associated with iron deficiency anemia..  Iron deficiency can contribute to neurodevelopmental delays in addition to anemia.

  • In Zhejiang (n=142), 27.5% of breastfed infants had iron deficiency anemia (IDA) compared with 0% of formula-fed infants.
  • In Hebei (n=813) , 44% of breastfed infants had IDA compared with 2.8% of formula-fed infants.

My take: In later infancy (after 6 months of age), breastfeeding infants are at increased risk for iron deficiency anemia.

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Dietary Diversity in Infants

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A recent study (Woo JG et al. J Pediatr 2015; 167: 969-74) indicates that breastfed infants in a US cohort had lower dietary diversity at 6-12 months of age than a cohort from Shanghai and Mexico City.

The diversity of consumed foods helps ensure intake of all necessary macro- and micronutrients.  One indicator, the “minimum dietary diversity” (MDD) developed by the World Health Organization has been used.  Infants meeting MDD standards between 6-23 months are less likely to experience stunting.

Key findings:

  • “Only 28% of Cincinnati [US cohort] infants fed >50% human milk achieved MDD between 6 and 12 months.”
  • Across all cohorts, dietary diversity increased from 31% at 6 months of age to 92% at 12 months of age.
  • Shanghai infants had the highest diversification, “largely accounted for by significant consumption of eggs”

This study shows that some of previous recommendations, prior to 2008, to avoid foods like eggs and peanuts to lessen atopic disease/food allergies may have affected introduction of a more diverse diet.  Newer data has shown that earlier introduction of foods lessens the likelihood of food allergies.

The associated editorial (pg 952-53) notes that despite the ‘breast is best’ philosophy, that “if this principle is taken to extreme and introduction of nutrient dense complementary foods is delayed well past 6 months of age, the extensively breastfed older infant is at risk for suboptimal intakes of multiple micronutrients, anemia, growth faltering, and other poor health outcomes.”

From recent painting class (it's an improvement from stick figure drawing)

From recent painting class (it’s an improvement from stick figure drawing)

More on Breastfeeding and Intelligence

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A recent prospective study with 30 year followup indicates that breastfeeding is associated with improved IQ and income.

A summary of the study from NBC/Today Health.  An excerpt:

Babies who are breastfed for at least a year grow up to be significantly more intelligent as adults and they earn more money, too, a new study shows….

Many experts have questioned whether it’s breastfeeding that makes babies grow up healthier and smarter, or something else that their mothers do — maybe spending more time with them. In other studies done in the U.S. and Europe, mothers who breastfeed longer tend to be more educated and affluent — and that clearly has an effect on their kids.

This study was different.

“What is unique about this study is the fact that, in the population we studied, breastfeeding was not more common among highly educated, high-income women, but was evenly distributed by social class,” Horta said.

Coverage of story from NY Times with link to original study: an excerpt:

The study, in the April issue of Lancet Global Health, began in 1982 with 5,914 newborns. The duration of breast-feeding and the age when the babies began eating solid foods was recorded. Thirty years later, researchers were able to interview and test 3,493 of the original group….

Still, the authors acknowledge that this is an observational study, and that many other unmeasured factors could have influenced their results.

Related blog posts:

How to Protect Children From Celiac Disease

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While many parents have asked what they can do to protect their children from celiac disease, the new answer will be more limited than in the past.  Two recent studies from NEJM indicate that timing of gluten introduction and breastfeeding do not appear to significantly influence the development of celiac disease.

Here are the links:

1st Study: Introduction of Gluten (6 months vs 12 months)

  • Results: (n=707) At 5 years of age, the between-group differences were no longer significant for autoimmunity (21% in group A and 20% in group B, P=0.59) or overt disease (16% and 16%, P=0.78 by the log-rank test).
  • CONCLUSIONS: Neither the delayed introduction of gluten nor breast-feeding modified the risk of celiac disease among at-risk infants, although the later introduction of gluten was associated with a delayed onset of disease. A high-risk HLA genotype was an important predictor of disease.

2nd Study: Gluten 16-24 weeks or Delayed  n=944

  • CONCLUSIONS As compared with placebo, the introduction of small quantities of gluten at 16 to 24 weeks of age did not reduce the risk of celiac disease by 3 years of age in this group of high-risk children.

Here’s a story from Boston Globe summarizing findings: Tactics to Prevent Celiac

Bottomline: These well-designed studies argue persuasively against the previously held views that breastfeeding and timing of gluten introduction influence the development of celiac disease.

Related blog posts:

NASPGHAN Educational materials for medical professionals –NASPGHAN Celiac Link

Why is Celiac Disease Becoming More Prevalent?

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A recent editorial helps provide some answers and even explains the term “protopathic bias.”  Ostensibly, the editorial’s task is to explain the potential interaction of maternal serum iron ingestion and the risk of celiac disease (see previous blog post: Is There a Link Between Maternal Iron Supplementation and …).  However, the editorial provides an explanation for the Swedish epidemic and the ongoing slower, wider epidemic.

Here’s the link, http://ow.ly/vQGQ7, and here’s an excerpt:

The Swedish epidemic of CD of 1985–1994 has been extensively documented, and resulted in the development of hypotheses regarding environmental risk factors for this disorder.7 This epidemic was restricted to children younger than 2 years; in that age group, the incidence of diagnosed CD rose from 65 cases per 100,000 person-years to 198 cases per 100,000 person-years. In contrast, incidence data for older children were relatively flat during this period. The epidemic abruptly ended in 1995, although children born during the period of the epidemic have an ongoing increased risk of developing CD. Subsequent investigation led to the hypothesis that infant feeding practices affect the risk of CD in young children. The epidemic occurred during a period of relatively low rates of breastfeeding at the age of 6 months and during the same period of time, the quantity of gluten in infant formula greatly increased. Although it is difficult to separate the relative importance of each feeding practice, it seemed that high quantity of initial gluten intake without overlapping with breastfeeding was responsible for this epidemic. Although a systematic review of the issue has concluded that breastfeeding has not been definitively proved to be associated with risk of CD,8 subsequent research has indicated that the timing of gluten introduction is important in determining risk.9PreventCD, a prospective randomized trial of infants with a family history of CD, is testing specifically whether the introduction of small quantities of gluten beginning at age 4 months of age will induce tolerance to gluten in this high-risk group.

The second epidemic is more diffusely spread over time and space. Studies from the United States and elsewhere have shown that the seroprevalence of CD (as defined by positive tissue transglutaminase and endomysial antibodies) has increased markedly in recent decades. An analysis of stored serum from military recruits at the Warren Air Force Base in the years spanning 1948–1954 found a CD seroprevalence of 0.2%, whereas 2 recent cohorts from Olmsted County (spanning the years 2006–2008) matched by year of birth and age at sampling found a seroprevalence of 0.9% and 0.8%, respectively.11 An analysis of another cohort in this country found a doubling in seroprevalence during adulthood from 1974 (0.21%) to 1989 (0.45%).12 The mode of presentation of CD has changed in the past generation, with rising numbers of patients presenting without diarrhea.13 Patients presenting with anemia may have more severe disease expression (as measured by the degree of villous atrophy and the presence of metabolic bone disease) than patients presenting with diarrhea.14 Because most individuals in the United States with CD are undiagnosed,15 this is largely a hidden epidemic, but there is no reason to believe that the prevalence has peaked. In Finland, which had a higher prevalence of CD than the United States to begin with, the seroprevalence of CD doubled between the years 1978 (1.05%) and 2000 (1.99%).16 It is not known whether this epidemic will subside or if the prevalence of CD will continue to rise to a new set-point. But given the morbidity associated with CD17 and the cost and difficulty of the gluten-free diet18, 19 these data have sparked interest in identifying the cause of this less visible epidemic.

Certain infections (eg, rotavirus among infants20 and Campylobacter among adults21) have recently been shown to be associated with a increased risk of CD, but rates of these infections have not increased markedly, and so are not likely to be driving this epidemic. In contrast, a lack of exposure to certain microbes is a hallmark of modern times, and the increase in CD disease is congruent with the hygiene hypothesis, which states that decreased exposure to microbes may be driving the rise in autoimmune and atopic conditions. This hypothesis is particularly compelling in light of a recent study that found a dramatically different seroprevalence of CD in Finland (1.4%) and the Russian Karelia (0.6%), geographically proximate areas with a similar prevalence of HLA DQ2 and DQ8 but with major differences in economic development.22

Further evidence implicating the modern relationship with microbes is now accumulating. Children who were born by elective cesarean section are at increased risk of developing CD, whereas those born by emergent cesarean section (and may have had contact with the birth canal) are not.23 In addition, there seems to be an inverse relationship between Helicobacter pylori colonization and CD.24 Drugs are another modern innovation that may be affecting the CD epidemic. Population-based studies from Sweden have shown that prescription of antibiotics25 and proton pump inhibitors26 are each associated with an increased risk of the subsequent development of CD.

The associations identified in these studies are not necessarily causal. Studies of drug exposure in particular may be prone to protopathic bias, wherein early symptoms of the outcome of interest (CD) may lead to the prescription of the exposure (eg, antibiotics or proton pump inhibitors).

From the NY Times: Gluten-free, veggie snacks, vegan desserts, spring salads. They’re all in our new recipe finder.

Feeling Guilty about Stopping Breastfeeding? (Part 2)

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Another study (J Pediatr 2014; 164: 487-93, editorial pg 440-42) echoes yesterday’s study.

Design: The authors used a nationally representative sample in a longitudinal survey of 7500 children.  In addition to breastfeeding practices, the authors explored parenting behaviors including putting an infant to bed with a bottle and frequency of reading.

Results: “there is a positive relationship between predominant breastfeeding for 3 months or more and child reading skills, but this link is the result of cognitively supportive parenting behaviors and greater levels of education among women who predominantly breastfed. We found little-to-no relationship between infant feeding practices and the cognitive development of children with less-educated mothers. Instead, reading to a child every day and being sensitive to a child’s development were significant predictors of math and reading readiness outcomes.”

Take-home message: the editorial states that parents should not be concerned that being unable to breastfeed will be detrimental to a child’s cognitive function. But, “encouragement of breastfeeding for other reasons, including health benefits to the infant and enhancement of mother-infant attachment”…merit recommendation along with good parenting practices (eg. reading to infants).

Feeling Guilty about Stopping Breastfeeding?

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From NY Times, Link: http://t.co/rBXCORx3mM

Excerpt:

Many women who are unable to breast-feed feel guilty about it and worry they may be depriving their children of a range of benefits. Groups like the American Academy of Pediatrics and the World Health Organization recommend six months of exclusive breast-feeding for all infants, citing studies that show breast milk is easily digestible and has nutrients that are superior to or absent from infant formulas, including immunological substances that reduce rates of infection and fatty acids important in brain development.

But now a new study suggests that many of the long-term benefits attributed to breast-feeding may be an effect not of breast-feeding or breast milk itself but of the general good health and prosperity of women who choose to breast-feed.

Researchers at Ohio State University compared 1,773 sibling pairs, one of whom had been breast-fed and one bottle-fed, on 11 measures of health and intellectual competency. The children ranged in age from 4 to 14 years.

The researchers recorded various health and behavioral outcomes in the sibling pairs, including body mass index, obesity, asthma, hyperactivity, reading comprehension, math ability and memory-based intelligence. The study, published online in Social Science & Medicine, found no statistically significant differences between the breast-fed and bottle-fed siblings on any of these measures.

By studying “discordant” siblings — one of whom had been breast-fed and the other not — the authors sought to minimize the possibility that racial, socioeconomic, educational or other differences between families could affect the results. Many earlier studies on breast-feeding failed to control for such factors, they say.

… researchers have consistently found large socioeconomic and racial disparities in breast-feeding rates. A C.D.C. survey in 2008 found that 75 percent of white infants and 59 percent of black infants were ever breast-fed, and in 2013, the agency reported that 47 percent of white babies but only 30 percent of black babies were still being breast-fed at 6 months. Compared with bottle-fed infants, breast-fed babies are more likely to be born into families with higher incomes, have parents with higher educational attainments, and live in safer neighborhoods with easier access to health care services.

Still, sibling studies such as this latest one do not solve all the problems of bias…

Geoff Der, a statistician at the University of Glasgow who has worked with the same data in previous studies, said that the findings in the present study were robust and the authors’ method for eliminating selection bias was powerful…“In a society with a clean water supply and modern formulas,” he said, “a woman who isn’t able to breast-feed shouldn’t be feeling guilty, and the likelihood that there’s any harm to the baby is pretty slim.”

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How Birth Can Affect Your GI Tract

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A recent review (JPGN 2013; 57: 543-49) provides information about the relationship between neonatal environment and subsequent inflammatory gastrointestinal disease.

While most of the review, focuses on physiology and pathophysiology, the most interesting part is the assertions (with references) in Table 1 which include the following:

  • Breastfeeding reduces risk of IBD
  • Cesarean section increases the risk of celiac disease, cow’s milk allergy, and other IgE-mediated food allergies
  • Many chronic adult diseases have been shown to have origins in neonatal life, particularly cardiovascular disease/metabolic syndrome

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