The main value of breast milk over other infant foods is in the maternal antibodies which help the baby who is as yet lacking in needed antibodies for the antigens in the environment it finds itself which (in most cases) the mother having been exposed to that environment for a longer time has developed. The value of breast milk is also in the purity, if the mother's nipple and immediate surrounding is clean before breast feeding and if the mother is not infected by a breast milk borne infectious agent. If however, the mother is having such infectious agent or breast milk is expressed into a container before feeding the baby, then the hygienic condition becomes a mater that may compromise - actually reducing its comparative value over other infant foods. You may however, need to clarify further, what you refer to as theoretical and practical value.

In HIV infection, exclusive breastfeeding helps reduce the chance of injury to the GIT as is often found in combination feeding, which increases the risk of mother-to-child transmission of the virus.

It is well established that some substances in breast milk can harm babies (eg HIV, syphilis). It is not established that there is anything in it that directly benefits the baby as compared to alternative infant foods fed in the same manner. Expensive breastmilk banks are set up based on this untested assumption.

There are a few studies, mostly related to very low birth weight babies and the benefit of breast milk vs synthetic. Perhaps answering this question results in too many variables to show definite correlation. From a biology standpoint, most synthetic formula is derived from cow's milk (with a few exceptions), which has a different protein make-up than human milk. We know that it only takes tiny differences in the structure of a protein to work or not work with other proteins, enzymes, etc. There is some research debate on when a human's GIT mucosa is developed. Could cow's milk potentially disrupt or hamper the development of human mucosa? Would a calf beginning life on human milk develop equally as a calf on cow milk? The position with which an infant is fed might produce some differences, but I don't think that is all inclusive.

Multiple studies have indicated a benefit to infants on breast milk vs formula. The reason for this might not come to light until a more in depth understanding of the interactions of genome elements is made. It is certainly an intriguing question.

"Multiple studies have indicated a benefit to infants on breast milk vs formula".

This is how they have been interpreted, but what they actually show is that formula feeding in adverse circumstances is far inferior to breast milk feeding.

Some feeding studies with LBW infants were done at Institute of Child Health/GOS, but I could never work out exactly how they were fed.

There are various customs of humans successfully breastfeeding animals, and of babies feeding directly from animals in old institutions since so many were dying when fed from (propped) bottles.

Very interesting. So, how do you think a study needs to be set up to answer this question?

First, my supine feeding theory is simple, even naive, so if wrong, it should not take an expert more than a few hours to effectively demolish it from existing knowledge, in which case we can all move on to other things. In four days now, no one has produced a single reference to show that breast milk, as opposed to breastfeeeding, benefits babies, so I am close to concluding that none exist, as I suspected.

Second, I have tried to be positive about my theory, rather than negative about others. The history of science, however, shows that no new theory succeeds without the old one imploding.

Third, someone independent from myself should review the literature, especially from a century ago, as a hypothesis test of my theory. In any case, this would show that many cherished beliefs about breastfeeding are simply wrong. It would also dig up a few studies that would not nowadays be ethically allowed, and also considerably prune out plausible but incorrect alternative theories.

Fourth, it should not be necessary in the first instance to set up any new study. There is no need to spend money, and while it won't be possible to prove my theory correct from existing data, it is surely possible to show if it is clotted nonsense, and at least establish if it is the best of a bad lot of alternative theories.

The breast milk is living milk with live proteins, regulatory peptides and lipoproteins (antibodiies)!

The formula... Is death milk with denaturated proteins!

The breast milk is necessary for growth and development! The formula is only for growth.

Anthony, I found a couple articles that examined different portions of the infant vs the type of milk/formula they received. I did not "critically" read the articles, but scanned them... thought they might give you further perspective if you haven't already seen them. The first is Lucas & Cole (1990) who focused on necrotizing enterocolitis in pre-term infants, and the other is Carnielli et el (1998) who examined the absorption of polyunsaturated fats in pre-term infants. The first appeared to show breast milk to be more beneficial, and the second showed that formula that added phospholipids was more beneficial.

Again, I think this is a very interesting topic and you peaked my interest.

Breast milk and neonatal necrotising enterocolitis

The Lancet, Volume 336, Issue 8730, Pages 1519-1523

A. Lucas, T.J. Cole

Intestinal absorption of long-chain polyunsaturated fatty acids in preterm infants fed breast milk or formula.

V P Carnielli, G Verlato, F Pederzini, I Luijendijk, A Boerlage, D Pedrotti, and P J Sauer

I apologize for not giving full or consistent citations. But I thought it would be enough for you to investigate further if you were interested.

G'day Anthony,

Intuitively it certainly makes sense that the type of milk we have evolved over several million years to ingest as infants would be better for our babies than milk we steal from a different mammal, with a different diet, metabolism, etc.

The maternal antibodies thus received are selected by the mother's life exposures, and so are typically going to be very appropriate to the environment the infant grows up in.

I have read your article;

http://ajcn.nutrition.org/content/72/4/1063.2.long

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This metastudy claims to correct for the confounders you discuss, and still shows improved cognitive outcomes for breast fed over formula fed children;

http://ajcn.nutrition.org/content/70/4/525.abstract

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You might want to check out the references to these articles, if you haven't already seen them...

http://www.jaoa.org/content/106/4/203.full

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http://pediatrics.aappublications.org/content/129/3/e827.abstract

.

>

http://www.theatlantic.com/health/archive/2012/04/the-benefits-of-breastfeeding/255206/

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In countries where clean water is hard to source, and where water-borne diseases like cholera are not uncommon, there are obvious advantages to breast milk over formula. Nestlé's promotion of formula milk in such countries probably led to lots of unnecessary morbidity and infant mortality.

http://blsciblogs.baruch.cuny.edu/mgt4880nestle/2013/04/22/crisis-facts-problems-and-issues/

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http://www.infactcanada.ca/chandra_feb72006.htm

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>

http://www.unicef.org/nutrition/index_breastfeeding.html

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And the additional benefit not mentioned above is the increased maternal/child bonding that breastfeeding promotes, and the reduced incidence of post-natal depression amongst mothers who breast feed.

Personally, I trust the WHO with regards to these sorts of questions;

http://www.euro.who.int/__data/assets/pdf_file/0004/98302/WS_115_2000FE.pdf

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Paul.

Kendall, I was not thinking about enterocolitis, but about the major killers of the world's babies, respiratory and gastrointestinal infections. So whatever is the case for NEC, it is not relevant to the big picture. You will need to go back many decades further for easier to interpret data.

"the Academy offers a long list of the ways breast milk can improve or safeguard infants' health".

No, it is a useful list of improved outcomes in breastfed over non-breastfed infants (though not everyone would agree all the benefits on the list had yet been established).

I am trying to challenge two supposedly self-evident assumptions:

1. That it is the breast milk per se that makes the difference.

2. That the differing outcomes as summarized above are because breastfeeding bestows some benefit. I think the correct way to look at this is that failure to breastfed or using unnatural feeding methods can induce harm.

You don't make the basic differences between live human milk for human babies, cow mik for baby cow and denaturated formula milk?! Are you medicine doctors??!! Your discussion is very similar with political and marketing discussion about facts which are not for discussion! Naturally you don't speak with colleagues which don't agree with you...

" water-borne diseases like cholera are not uncommon".

Sorry, I could not let that pass. I agree vibrios lurk in water, but it does not follow that they get into the body by drinking water. Can we have one reference to a cholera outbreak traced to a contaminated water supply, hopefully less ambiguous than Snow's original report, so far not replicated as far as I can find out?

Nikola, the whole point of something like RG is that I can put out unusual ideas so as to invite or provoke contrary opinions, especially from experts. So far, very few can be bothered to engage. I suggest you contact these experts, and ask them to contradict my points in specific detail.

A century ago in the UK, many infants died through being fed Nestle tinned condensed milk. However, this had nothing to do with contamination, since mortality was higher for condensed milk than for other breast milk substitutes which were far more likely to be full of harmful bugs.

My faith in the judgement of WHO has been severely impaired by their support for the Millennium Development Goal of reducing under-5 mortality, Again, a century ago, it was realized that causes of neonatal, post-neonatal and child deaths were totally different, so should be disaggregated. So, even when there is good news like the recent global falls in U-5 mortality, it is is impossible to work out why when everyone is focused on the overall composite rate.

I understand the point Anthony, but many people believe that the provocation is the true! It is the basic of new propaganda style, and the relativisation the facts.

You posted that " In four days now, no one has produced a single reference to show that breast milk, as opposed to breastfeeeding, benefits babies", and you have been giving resources that do point out benefits. Along with respiratory and GI infections, low birth weight is one of the highest contributors to global infant mortality. A great deal of these LBW babies die from necrotizing enterocolitis. Breast milk has been shown to lower this rate as opposed to formula.

As far as cholera outbreaks, you might explore Haiti and the studies done there after their outbreak a couple years ago.

I honestly don't think that 4 days is significant time to fully exhaust all research on one topic. I am currently working on my dissertation and am constantly finding different search criteria that brings me more results. I also feel that there are certain phenomena that cannot be explained. That is not to say it does not exist, it is not yet understood.

Good luck with your inquiry

Anthony,

Are you seriously suggesting cholera is not contracted by ingesting contaminated water?

Having spent a bit of time in very poor countries where gastrointestinal infections are a leading cause of death, I find it very hard to understand why you would doubt that a water-borne disease that causes massive watery discharges from the sufferer can be easily transmitted in drinking water. Perhaps you believe (like many of Dr John Snow's contemparies) that infectious diseases are spread by "miasma"?

>

http://www.nichd.nih.gov/Pages/index.aspx

>

http://www.scielosp.org/scielo.php?pid=S0042-96862003000300010&script=sci_arttext&tlng=pt

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Cholera is most often transmitted in developed nations from contaminated shellfish.

Cholera is most often transmitted in the developing world by faeces from an infected individual contaminating the drinking water.

http://www.ncbi.nlm.nih.gov/pubmed/14738797

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http://www.who.int/mediacentre/factsheets/fs107/en/

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http://www.cdc.gov/cholera/prevention.html

.

I would add to Kendall's point, and Nikola's.

You have not made any distinction at all about the type of milk, (whether human, cow, goat, horse, or dog, whether live, heat treated, dehydrated, whether likely or unlikely to be contaminated with viral, bacterial, fungal or chemical pathogens). This does seem oddly one-eyed of you.

Making an assertion that contradicts the accepted consensus of scientific opinion, and then daring anyone else to produce evidence that refutes your assertion, is not proving anything, (especially when it is posted in a forum like this RG conversation, which only has seven followers). Extraordinary claims require extraordinary proofs.

If your hypothesis is scientific, it should be falsifiable.

If you have evidence to support it, please present it. (Preferably in an arena where hundreds or even thousands of experts can review it, and respond, but here would do for a start).

If you want to draw conclusions based on a review of the available literature, you need to do something more than challenge a few people on RG to prove you wrong. You need to dispassionately review all the available evidence and draw a conclusion based on that, not seek the evidence that supports your pre-existing conclusion and ignore or discredit any confounding evidence.

If you do this properly, it should be easy to get a paper published in a peer-reviewed journal. And once your peers have had a chance to respond, you will be in a better position to make statements like this;

>

Paul.

"Are you seriously suggesting cholera is not contracted by ingesting contaminated water?"

Yes, absolutely. Lone cranks are not always wrong; after all, Snow was on his own when he came up with the waterborne theory.

150 years later, we ought to have enough evidence and the advantage of the internet to determine if he was right or wrong. Thanks Paul for going to the trouble of

checking the cholera literature, but these are secondary sources repeating the conventional wisdom. What I am still awaiting is a primary reference with data replicating Snow's study.

Note: I accept that cholera can be spread by ingesting foods, especially shellfish, in adults, and that outbreaks of gastroenteritis occcur through contaminated water supplies. However, all this evidence relates to adults or older children, not to infants, and I think here absence of evidence is evidence of absence.

The outline of my theory backed up with some references was published in Lancet in 1981, not that anyone noticed or cared. My extraordinary claims about contamination in infant GE have been published in Lancet, Nature and JAMA. Up till now, this RG discussion has been the first challenge to these ideas. If they are wrong, seven followers should be more than sufficient to show this.

My question should be taken to refer to breastfeeding in humans in reference to the millions of infants dying from failure of breastfeeding.

There is a very good discussion of cholera, (which mentions John Snow), based on the Haitian outbreak (referred to, above, by Kendall) here;

http://www.ph.ucla.edu/epi/snow/cholera_haiti.html

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Unfortunately it appears that UN peace keeping forces stationed in Nepal, who were flown to Haiti in response to the humanitarian aftermath of the earthquakes, actually brought this strain of cholera with them. The disruption to sanitation and water supplies helped ensure that it spread. And many people, especially vulnerable infants, died as a result.

You appear to be quite lonely in your belief that cholera is not transmitted to infants via contaminated water. The fact that cholera rates are far higher amongst children in developing nations who are fed formula than infants who are breast-fed is uncontroversial.

Do you actually have any evidence to contradict this? Anthony, if you do, please link to it for us.

If you are a scientist, you should know that absence of evidence can never be presumed to indicate evidence of absence.

Paul.

The link (and other articles on the Haiti outbreak) provide no consensus as to how the cholera was spread or where it originated. I have not so far found an age breakdown of cholera in Haiti.

I gave a reference to an outbreak of cholera in bottle fed infants in Lancet 1981 (I think). The reason infants fed on their backs get diarrhea and/or pneumonia is that excess fluid pools in the middle ear, providing perfect culture medium for organisms lurking in the upper respiratory tract (rotovirus, measles, cholera, etc, etc) and nothing to do with bugs in the food.

There is recent data in Lancet on the global contribution of cholera to infant diarrhea, which from memory is quite small.

Sorry I am not very organised with respect to links., but have great faith in Google, which should find something if it is indeed there, but at some point one needs to say it really isn't there.

>

Actually, if you read the literature I think you will find that there is a very strong consensus that the Haitian outbreak has two possible origins.

One is that cholera dormant in the coastal waters exploded in population due to the extreme weather conditions, and that a break down of water supplies and sanitation services in the wake of the disaster helped it spread between humans.

The other is that it was carried to Haiti by some of the Nepalese Peace keepers, and the conditions mentioned above facilitated it's rapid dissemination.

The outbreak in Haiti was identified as Vibrio cholerae serogroup 01, serotype Ogawa, biotype El Tor by the National Laboratory of Public Health in Haiti and this genotypic identification was confirmed by the United States Centers for Disease Control and Prevention.

Exactly the same strain was responsible for the outbreak of Cholera in Nepal in late 2008 and 2009. The most recent cholera outbreak that occurred in Nepal was in Kathmandu, first cases reported on September 23, 2010, a fortnight before the troops left for Haiti, arriving between October 8 and 15, 2010.

In Haiti, the government reported the initial wave of cases on October 22, 2010 (a week after the Nepalese troops had arrived).

Some of the first cases occurred in Mirebalais (where the Nepalese peacekeeping troops were stationed), and others down-river in the Artibonite valley, and still others in communities by the coastal waters where the river ends. No initial cholera cases, however, appeared to be found up-river from Mirebalais, or in other neighbouring water-sheds, supporting the notion that the source came from the Mirebalais area.

A percentage of the human population are asymptomatic carriers of the disease. Some of the Nepalese troops may have acted as a vector for the disease without even realising that they had an infection.

It seems pretty likely that the cholera was introduced accidentally by the Nepalese contingent, especially as it was the same strain of cholera reported in Nepal, and because infected people responded to the same antibiotics as were found effective in the outbreak in Nepal.

"The organism that is causing the disease is very uncharacteristic of (Haiti and the Caribbean), and is quite characteristic of the region from where the soldiers in the base came. ... I don't see there is any way to avoid the conclusion that an unfortunate and presumably accidental introduction of the organism occurred."

John Mekalanos, PhD, Professor and Chair of the Department of Microbiology and Molecular Genetics at Harvard University

Alternatively, the initial pattern of cases does not rule out a source in the coastal region, moving up-river to as far as Mirebalais via river transport and trade. As cholera can lie dormant in coastal waters for decades without human outbreaks, which typically occur when there are algal blooms or unusual weather conditions, there remains a possibility that the Nepalese connection is a coincidence.

The fact that we cannot know for sure which of these hypothesis is correct does not mean there is a lack of consensus amongst researchers and public health professionals about where the cholera may have come from, or how it subsequently spread.

While the general consensus appears to favour the Nepalese hypothesis, (see links below) we will never know for sure. Admitting that you don't, and often can't, know things with absolute certainty is the basic level of honesty required for scientific research.

Entertaining more than one possibility is not a failure, it is just good science.

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http://www.ph.ucla.edu/epi/snow/CMI18_E158_E163_2012_Nepalese_origin_article.pdf

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3030187/

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>

Generally, most deaths from Cholera are in the 2 to 4 age-group.

I can't tell you how many infants have died so far from the ongoing Haitian epidemic, but there are figures for children under 5 here;

http://www.cidrap.umn.edu/cidrap/content/fs/food-disease/news/jan0913cholera.html

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Paul.

Thanks Paul for your summary of the Haiti cholera outbreak. Two diametrically opposed theories for its origin have been proposed. In the absence of definitive epidemiolological data, I am inclined to believe the world's leading cholera expert, Rita Colwell, holder of 48 honorary degrees and the 2010 Stockholm Water Prize, who thinks the outbreak arose from the natural vibrio reservoirs in the coastal waters, and thus spread upstream.

I am not surprised you failed to find data on infant deaths. Due to the MDGs, everyone now is obsessed with aggregated under-5 mortality, which makes it almost impossible to study breastfeeding mortality and diseases with characteristic incidence and epidemiology in infancy.

Hi Anthony,

The two hypotheses are not diametrically opposed at all. They both are based on what is known of cholera, and what is known about the specific circumstances of this outbreak. They both accept that cholera is a water borne infection. The only difference is the suggested original source of the outbreak.

I did mention the hypothesis Colwell supports as one of two logical options, and said there was a possibility that the outbreak was not a result of the "Nepalese Connection." Please see my post above.

For example, ballast water dumped by ships from Asia could easily have introduced that particular strain to coastal waters years, perhaps decades, before environmental conditions were right for an outbreak amongst the humans in Haiti.

As more than one strain of Cholera have been identified by Colwell's team, it is equally possible that BOTH the hypotheses I mentioned above are true.

So we seem to agree that Rita Colwell is a highly respected authority on cholera. I need to ask you something;

Does she deny that cholera is often transmitted by ingesting contaminated water?

>

http://www.npr.org/blogs/health/2012/06/18/155311990/scientists-find-new-wrinkle-in-how-cholera-got-to-haiti

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It would be nice if you might occasionally provide links to the various studies/references/authorities you quote or allude to, old bean.

Regards,

Paul.

This is an extract from my email correspondence with AJE:

" In her book review, Colwell stated that cholera results "from ingestion of untreated water". I have been trying unsuccessfully for many years to find any epidemiological evidence that cholera is spread through mains or tap water, and have concluded that this is a plausible myth. Can Colwell please quote any epidemiological evidence of transmission via water (no Snow please)?

Colwell RR. Cholera: The Biography. Am J Epidemiol

2010;171:1246-7"

RC replied to me with comments about water treatment, but supplied no reference for spread through ingestion of treated or untreated water.

Am I missing something with the water transmission theory? If contaminated excreta enter a river system, there is an obvious mechanism for anyone downstream to come into contact with dirty water and catch the disease. But how does cholera spread upstream?

I apologise for my lack of links, but as an independent I am having problems getting access to libraries and electronic versions of articles. Anyway, I have just been looking at an excellent report by Jose Leao of a cholera outbreak on the volcanic Cape Verde island, Fogo (see Trans Epidemiol Soc Lond 1857;41), started when a ship with sick passengers stopped there. One thing for sure is that the epidemic was not transmitted by rivers or the water supply.

Hi Anthony,

I work for a not-for-profit NGO health agency, and I don't have institutional access to journals either. This doesn't inhibit me from using search engines to track down abstracts of relevant articles. And I usually find that if you ask one of the principal authors they will happily send you a PDF of the full text, gratis.

You just apologised for not providing links, while referring me to an article published in 1857?

Earlier you stated that >,

yet it seems you are not inclined to believe her when she makes a statement that contradicts your belief?

You write; >

It's pretty simple Anthony. People pump water in pipes and transport it in tanker trucks from place to place, and (most significantly) any infected people who travel up stream or across watersheds can spread the virus up stream or into different river systemns.

It was the fact that all of the initial cases took place in the town the Nepalese Peace Keepers were quartered in, or down stream of this town, combined with the timing, that suggested the Nepalese as an accidental transmission vector...

Here's Dr. Renaud Piarroux. He >

>>

http://www.ph.ucla.edu/epi/snow/cholera_haiti_newdev34.html

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Paul.

To return to your original question, Anthony, re: the protective effects of maternal antibodies in breast milk, I just spent

http://www.ncbi.nlm.nih.gov/pubmed/6798576

.

>

http://www.ncbi.nlm.nih.gov/pubmed/12850343

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2 weeks, indicating that breast milk antibodies mediate this effect. >>>

http://www.ncbi.nlm.nih.gov/pubmed/17473095

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And here's one about Cholera antibodies and breastfeeding;

>

http://europepmc.org/abstract/MED/6843632/reload=0;jsessionid=3b261Xn6f3P22QUGZcTT.4

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E Coli gastroenteritis;

I have had a look at the above antibody studies:

1. Hanson and Soderstom (1981) is a theoretical review article.

2. The second one deals with HIV, where we know the virus is present in breast milk and can transfer to the baby, so is not relevant to the main fatal respiratory and gastrointestinal infections where organisms come from outside, not from the mother.

3. Enterovirus infection are often mild or asymtomatic, so of doubtful relevance in the overall picture

4. I spent half an hour reading the original NEJM cholera article, but gave up because there were so many problems with it, including: small numbers; conflicting statistical tests; odds ratios without confidence limits; no correlation between cholera colonization and milk antibodies, nor in milk total IgA between those with and without diarrhea; missing points (infants) from all four graphs in Fig 1; figures on graphs and table do not agree.

5. Would not download on my computer. Again, very low subject numbers.

Rita Colwell is an expert on environmental aquatic habitats of cholera vibrios, not on its epidemiology. Nevertheless, I would have expected her to know of water-borne outbreaks had they existed. However, I have just been at an international conference in London, where I asked an international expert on cholera spread if he could give me any reference for a water-borne epidemic, or for any replication of Snow's investigation. He could not, but will think about it. I will email him asking him to contribute to this RG question, if indeed he does find any such study.

Hi Anthony,

I'm not sure how you would get ethics approval for a RCT on human cholera transmission...

:-)

In the interview with Renaud Piarroux he asserts that the only way to account for the rapid spread of the outbreak in Haiti is that a common water source was contaminated. He states that person-to-person transmission can't account for how rapidly the cholera spread.

Hopefully the fellow you have consulted can provide some clear evidence either way, (or can at least confirm that such evidence doesn't appear to exist).

There does appear to be abundant evidence that maternal antibodies in breast milk are protective against a number of infectious diseases. I would again suggest that in terms of simple nutritional requirements, fresh human milk must be a better food for a human infant than preserved, dried, and/or non-human milk.

Paul.

Since people won't read the old literature, an RCT might be a quick way to resolve the cholera matter. In my opinion, this would be quite ethical, provided of course participation was entirely voluntary. It seems, nowadays, that altruism is deemed unethical by committees.

Pettenkofer, who knew far more about water-borne disease and cholera than I do, was so exasperated by the uncritical acceptance of water-borne transmission for cholera that he drank a cholera cocktail, without giving himself the disease.

To revert to the original question, I agree that breast milk contains anti-infective antibodies, and that nutritionally and evolutionally it would be expected to be best for babies. The problem with self-evident "truths" is that no one bothers to test them. I still maintain there is no evidence that the better health of breastfed infants is due to the extra maternal antibodies they have had, and much that contradicts this.

G'day Anthony,

>

Are you referring to me not being able to find an online copy of the case-history published in 1857?

Can you perhaps provide a link, or some quotes from the article?

Could you also explain why this single case history, written at a time when infectious diseases were very poorly understood, outweighs the conclusions of a wealth of research published in the subsequent 156 years, and the overwhelming consensus of epidemiologists and public health researchers and physicians?

Max Joseph von Pettenkofer did indeed drink a cocktail containing cholera, (because he believed in a version of the miasma ("bad air") theory), and subsequently did not develop any serious symptoms.

All this really proves is that the you cannot draw meaningful conclusions from a study with a sample where n = 1.

I would suggest that the most likely explanation is that Pettenkoffer was a healthy, well nourished fellow from a country where the population had been under selection pressure from sporadic outbreaks of cholera for many generations, and that he either did not ingest a sufficient quantity of the bacteria to show any symptoms of diarrhea, or who was one of that percentage of any population who are immune asymptomatic carriers of cholera.

>

Cholera

The Lancet, Volume 363, Issue 9404, Pages 223-233

David A Sack, R Bradley Sack, G Balakrish Nair, AK Siddique

People with lowered immunity, and people who are malnourished, are much more susceptible.

http://www.who.int/cholera/technical/prevention/control/en/

.

As cholera had not been seen in Haiti for over a hundred years, the population were immunologically naive to the disease. I would expect a much lower percentage of their population would have had any natural resistance than the population of late 19thC Bavaria. I also suspect there is a much higher rate of malnutrition (and of HIV) in modern Haiti than amongst ennobled chemists/hygienists living in 19C Europe, Ist dieses nicht die meisten wahrscheinlich?

Regards,

Paul.

There is another possible benefit of breastfeeding, specific to the poorer developing nations, that we have not yet mentioned; on-demand nursing, as was practiced in many traditional cultures, makes conception much less likely. In cultures where children are breastfed on demand, (often for two or three years), subsequent pregnancies are much further apart.

If people are regularly experiencing problems with obtaining an adequate supply of food, a larger interval between births decreases infant mortality rates.

Paul.

to the child yes to other do not try without consent of milk giver

Thank Rajiv- that's very good advice!

:-)

Hi Anthony,

You wrote;

>

I don't believe anyone has ever done a RCT on the benefits of parachutes when exiting a plane at high altitude, but there is ample evidence of them.

Similarly, we know that draining a pneumo-thorax works anatomically and physiologically — there is no reason to test it experimentally.

If cholera is not water borne, why does improving hygiene, sanitation, and fresh water supplies work?

If the antibodies found in breastmilk do not provide immunity to some disease, why do infants fed breast milk get less of these infections?

Paul.

The question to ask is "Why do non-breastfed infants get more infections?" I maintain it is because they are much more likely to be fed on their back, especially from propped bottles as in old institutions. Food or drink can then get into the middle ear down the short and wide Eustachian tubes of infants, providing an ideal protected culture medium for bugs lurking in the nose or throat. When held upright, this toxic gunge can then run down into lungs and stomach. Only infections consistent with this mechanism (eg, not colds) are commoner in the non-breastfed.

Hi Paul,

The comment re not reading the old literature was not directed at you, but at experts in the field. For example, in the Lancet 2004 definitive review you gave a link to, only 2 of the 150 references were from before 1950.

I quoted the Cape Verde cholera outbreak as I happened to have the print journal to hand, and it was clearly not a water-borne epidemic. I have read hundreds of reports of outbreaks in the 19th C. None as far as I know clearly implicated the water supply, and some authors definitely ruled this out.

The prime reference for cholera being water-borne in the above Lancet review was Snow. It did also cite 4 other studies to support the claim that cholera was the classic water-borne disease, but these are far from convincing;

1. Lancet 1991 was a review article.

2. A J Trop Med 1999 claimed Lake Victoria was a source of cholera. However, sharing food with a person with diarrhea, or drinking from streams had higher risk factors, and eating washed fruit/veg was protective (!).

3. J Inf Dis 1992 found by far the highest risks were from food or iced drinks from street traders in Peru.

4. Bull Who 1982 . Surface waters in Bangladesh were contaminated with cholera, but those who drank from at least one culture-positive source were not more likely to be infected than those who drank only from negative sources. Commenting on data from Bangladesh, Sir Richard Feachem asked "Is cholera primarily water-borne?" (Lancet 1976;2:957). This does not seem to have done his career any harm, as he went on to found the UCSF Global Health Group.

The recent cholera expert I spoke to also mentioned that a large enough dose could not spread via the air. However, only one vibrio may be enough if it found its way into the middle ear of an infant, more likely if it had been bottle fed.

Hi everyone,

Is it ethical to design a case-control study which compares two groups bottle-fed babies? Cases are fed with "synthetic/cow milk" and the controls are fed with "mother's milk". (In my country, it is not uncommon when mothers are busy and either pump or squeeze their milk into bottles.) We can then compare the infection rates of these two groups. I would be very glad to know your opinion about this idea.

Regards,

Emran

Hi Emran,

Breastfeeding and feeding bottled breast-milk are different things in terms of infection risk, because you have to control for the sterility (or lack there-of) of the bottles used.

And as Anthony's hypotheses is that it is the feeding position, not the quality of the milk, that increases infection risk, two groups of bottle-fed babies would not be a valid way of testing the hypotheses. You need to redesign that experiment!

You could do a similar study without any ethical problems, simply by recruiting a very large sample of new mothers, matching them for factors such as socio-economic status, education etc, and then letting them feed their babies however they wanted or needed to. Then you could look for any significant differences between the breast-fed infants and the bottle-fed or formula fed babies.

Anthony- what about hormonal benefits- breastfeeding greatly promotes the mother-infant bond and lowers the incidence of post-natal depression.

Regards,

Paul.

Hi Paul,

I think I previously get Anthony's hypothesis. If it is the position and not the milk itself which makes the babies susceptible to infection, then we can compare the two groups when they are perfectly matched, fed in the same bottles and the same position (i.e. while they are in their back). If the "position theory" is true, then we should not have any significant difference in the infection rate between two groups (This is the cohort version of what I said previously). As you said, sterility is also a confounding factor which should be taken into account in the study design.

Paul, in your last paragraph I assume your emphasis is about breastfeeding and not the mother's milk itself but I think the initial question Anthony asked was about "breast milk vs. synthetic/cow milk" [If you consider these two milks as equivalents, then you can change the question to: "to be fed in the supine position vs. not the supine position".]

Regards,

Emran

Thanks Emran. To check if there are any intrinsic benefits to breast milk, double blind feeding of breast milk or alternative would to my mind be perfectly ethical, though I doubt many ethical committes would agree.

I don't think any trial is neded to show that supine feeding is a bad idea and can lead to ear, lung or stomach infections. Independent observers, starting with Soranus, have noted this. The crucial question is, Is this a rare unimportant quirk, or far commoner than suspected and the reason infections are commoner in the non-breastfed (at least for most of the first year of life)?

There are plenty of old studies of infections by feeding mode (eg Howarth in Derby, Lancet 1905 (?)). Note the very high mortality rates with condensed milk from a sterilised tin. I suspect bugs in the respiratory tract and middle ear like condensed milk as much as I do!

Have just happened across an article in Ped Infect Dis J 2002;21:888 Expressed milk as a source of Neonatal Sepsis. The authors note that human milk is a good culture medium, and contamination leading to sepsis has been reported from 8 different organisms. This makes me wonder if it is even ethical to feed expressed breast milk to infants.

Have just read Arch Ped 2012;166:431 and 483, which found that bottle feeding was associated with rapid weight gain, and hence risk of future obesity. This was true even when comparing breast milk fed at the breast or in a bottle. This confirms the basis of my question, that what matters is how the infant is fed, not what it is fed.

What was surprising was just how many US mothers were choosing to bottle-feed breast milk, which is difficult and time-consuming. However, this shows that it might now be quite possible to experimentally study mode of feeding independently of type of milk for other outcomes.

Anthony- hot off the presses...

This study demonstrates a protective effect of human breast milk which is not conveyed to human infants by non-human milk. In-vitro, the inactivation of HCV, influenza, herpes-simplex and vaccinia was demonstrated with human breast milk that had been frozen, (in fact the protective effect was actually stronger with milk that had been stored at low temperature, so bottle-fed breast milk might convey more protection than breast feeding!).

Inactivation of Hepatitis C Virus Infectivity by Human Breast Milk.

J Infectious Diseases 2013 Pfaender et al.

>

http://jid.oxfordjournals.org/content/early/2013/09/24/infdis.jit519.abstract

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Full text;

http://jid.oxfordjournals.org/content/early/2013/09/24/infdis.jit519.full.pdf+html

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Discussion;

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http://jid.oxfordjournals.org/content/early/2013/09/24/infdis.jit521.full.pdf+html

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http://www.medscape.com/viewarticle/812331?src=wnl_edit_medn_wir&uac=77067MJ&spon=34

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Regards,

Paul.

"Therefore, nursing by HCV-positive mothers is unlikely to play a major role in vertical transmission"

But this was already known from epidemiological observations. According to the CDC, breastfeeding is not contraindicated in Hepatitis C infected mothers. In other words, breastfed babies are no less likely to get HCV than those fed with other milks or formulae not containing antibodies.

It is also known that breastmilk has anti-infective properties, at least in vitro, and that nevertheless many different viruses are spread via breastfeeding.

I watched the programme Health Freaks on Channel 4 (UK) last night where members of the public put forward a large number of supposed health remedies. The idea chosen for testing was that breast milk when taken or applied in adults protected against skin and other infections. Breast milk was applied to cultures of about a dozen harmful bacteria. My first thought was that it might inhibit growth for some of these bugs, as it does contain anti-infective substances. I then wondered if bug growth might rather be increased, bearing in mind that milk is a good culture medium, and there has been a recent paper showing that many harmful bugs can get into expressed human milk supplied on the internet. As it turned out, breast milk had no effect in vitro. This increases the onus on those who believe breast feeding is valuable because of the properties of the milk to produce some evidence for this.

Breastfeeding involves far more than just supplying breast milk to a baby.

I recently heard the following comment on BBC Radio 4 Today:

"Breastfeeding is natural, but does not come naturally".

See also Daily Telegraph letter, Nov 14 2013, p.29:

"I thought that women made a choice whether to breast- or bottle-feed, and that breastfeeding would come naturally. Now, as a new mother, I have realised that breastfeeding can be incredibly difficult..." Elizabeth Ramsden.

So it is not self evident that the adverse effects of non-breastfeeding must be due to the absence of breast milk.

" In addition to containing all the vitamins and nutrients your baby needs in the first six months of life, breast milk is packed with disease-fighting substances" 

This is not in dispute.  What I am asking is if anything in breast milk makes any difference in practice?  Did the greatly increased morbidity and mortality previously seen in bottlefed infants in the UK, for example, have anything at all to do with the constituents of breast milk or alternatives, rather than the way the baby was fed?

This recent study seems to be the most definitive available.   It confirms my main thesis, that breast milk does not have any special or magic properties.

******************************************************************

"Effect of Supplemental Donor Human Milk Compared With Preterm Formula on Neurodevelopment of Very Low-Birth-Weight Infants at 18 Months

A Randomized Clinical Trial

Deborah L. O’Connor...

Editorial

Donor Human Milk for Very Low-Birth-Weight Infants

Tarah T. Colaizy, MD, MPH

 Key Points

Question  Does use of nutrient-enriched donor milk compared with preterm formula, as a supplement to mother’s milk during hospitalization, improve cognitive development of very low-birth-weight infants at 18 months’ corrected age?

Findings  In this randomized clinical trial of 363 infants, no statistically significant differences in cognitive composite scores on the Bayley Scales of Infant and Toddler Development, Third Edition were found between feeding groups after adjustment for recruitment center, birth weight group, percentage of total enteral feeds for each infant consumed as mother’s milk, and maternal education.

Meaning  If donor milk is used in a setting with high provision of mother’s milk, improved neurocognitive development should not be considered a treatment goal.

Abstract

Importance  For many very low-birth-weight (VLBW) infants, there is insufficient mother’s milk, and a supplement of pasteurized donor human milk or preterm formula is required. Awareness of the benefits of mother’s milk has led to an increase in use of donor milk, despite limited data evaluating its efficacy.

Objective  To determine if nutrient-enriched donor milk compared with formula, as a supplement to mother’s milk, reduces neonatal morbidity, supports growth, and improves neurodevelopment in VLBW infants.

Design, Setting, and Participants  In this pragmatic, double-blind, randomized trial, VLBW infants were recruited from 4 neonatal units in Ontario, Canada, within 96 hours of birth between October 2010 and December 2012. Follow-up was completed in July 2015.

Interventions  Infants were fed either donor milk or formula for 90 days or to discharge when mother’s milk was unavailable.

Main Outcomes and Measures  The primary outcome was the cognitive composite score on the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) at 18 months’ corrected age (standardized mean, 100 [SD, 15]; minimal clinically important difference, 5 points). Secondary outcomes included Bayley-III language and motor composite scores, growth, and a dichotomous mortality and morbidity index.

Results  Of 840 eligible infants, 363 (43.2%) were randomized (181 to donor milk and 182 to preterm formula); of survivors, 299 (92%) had neurodevelopment assessed. Mean birth weight and gestational age of infants was 996 (SD, 272) g and 27.7 (2.6) weeks, respectively, and 195 (53.7%) were male. No statistically significant differences in mean Bayley-III cognitive composite score (adjusted scores, 92.9 in donor milk group vs 94.5 in formula group; fully adjusted mean difference, −2.0 [95% CI, −5.8 to 1.8]), language composite score (adjusted scores, 87.3 in donor milk group vs 90.3 in formula group; fully adjusted mean difference, −3.1 [95% CI, −7.5 to 1.3]), or motor composite score (adjusted scores, 91.8 in donor milk group vs 94.0 in formula group; fully adjusted mean difference, −3.7 [95% CI, −7.4 to 0.09]) were observed between groups. There was no statistically significant difference in infants positive for the mortality and morbidity index (43% in donor milk group, 40% in formula group) or changes in growth z scores.

Conclusions and Relevance  Among VLBW infants, use of supplemental donor milk compared with formula did not improve neurodevelopment at 18 months’ corrected age. If donor milk is used in settings with high provision of mother’s milk, this outcome should not be considered a treatment goal."

"THE TYRANNY OF ‘BREAST IS BEST’

ELLA WHELAN

ASSISTANT EDITOR

The breastfeeding crusade undermines mothers’ autonomy.

22 FEBRUARY 2017

Formula milk is now regularly demonised, as are the mothers who opt for it over breastfeeding...

There is nothing wrong with feeding a child solely on formula milk – this is a proven, well-known fact. Breastfeeding has its advantages, yes – but a child raised on formula will do no better or worse than a child who is breastfed. "

Comment

• I do not think that breast milk has any benefit in practice over formula.  However, this misses the point, as it is a clear fact as known for well over a century that bottle or formula fed babies have greater morbidity and mortality, whatever the exact reason for this.   It is easy to show this nowadays in developing countries.
• Yes, breastfeeding promotion undermines maternal autonomy. This is the whole point of it.  Society has to take a position when the interests of the child conflict with the interests of the mother.   Which is why we campaign against genital mutilation, smoking in pregnancy, corporal punishment, etc, etc.
• I don't know how much influence Spiked has, but surely some stand has to be taken against its alternative facts.

Goldman Sachs' new initiative will courier working mums' breast milk to their babies across the world

Goldman is working on a new initiative to retain working parents, says Lucy Tobin [Evening Standard Aug 20 2018]

Goldman Sachs is the investment bank with a hardcore reputation. It’s the employer which, it used to be said, gave staff only four hours off for bereavements — and two weeks for giving birth. Get a job at Goldman and your life belongs to Goldman. 

But now it’s 2018, and even Goldman Sachs has gone family-friendly. The bank that once told staff their weekend ended on Sunday morning and they’d better be logging in again by then, and which is known for offering graduates six-figure salaries to compensate for 100-plus hour weeks, has changed.

The latest evidence? The US bank has become what’s thought to be the first company in the UK to pay for its breastfeeding working mums to courier their expressed milk back to their babies if travelling for work.

In an internal memo to staff, the bank said: “Parenting and work can sometimes feel at odds. Goldman Sachs aim[s] to make the balancing act a little easier,” before explaining that its US offices will deliver freezing kits to nursing bankers’ hotel rooms and then courier expressed milk back to the baby for feeding...

For bankers in London, where Goldman employs 6,000 people, new mums will be reimbursed for breast milk delivery costs on work trips."

Comment

Before setting up such a complicated and expensive scheme, it would be a good idea to find or sponsor research to see if this made any difference. This question has been up here on RG for 5y and I still know of nothing to suggest that it is the milk itself rather than breastfeeding per se that is the crucial factor.