31 The advantages of breastfeeding versus the risks of maternal medication

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No discussion of the risks of maternal medications can be undertaken without an understanding of the benefits of being breastfed for the child. Advantages to breastfeeding have been recognized in general terms for decades. However, new information and evidence-based studies following breastfed infants for months and even years have identified many additional advantages and protections provided by human milk and the process of breastfeeding.

The nutrient advantages can be simply stated by "species specificity" (see Table 3.1). The nutrient needs of the human infant are specifically met by the nutrient content of human milk. The most dramatic cvidcnce of this is demonstrated by the comparative advantages to brain growth, visual acuity, auditory acuity, and scores on

Table 3.1 Composition of human breast milk and of cow's milk

Cow's milk

Colostrum

Mature milk

Total protein (g/l)

33

23

11

Casein (g/l)

25

12

3.7

Lactalbumin (g/l)

2.4

-

3.6

Lactoglobulin (g/l)

1.7

35

-

Secretory IgA (g/l)

0.03

6

1

Lactose (g/l)

47

57

71

fat (g/l)

38

30

45

Polyunsaturated fatty acids (%)

20

70

80

Calories (kcal/t)

701

671

747

Mean values; adopted from Behrman (2000).

Mean values; adopted from Behrman (2000).

developmental tests related to infants who are exclusively breastfed, compared to infants who receive traditional formulas. These data are substantiated by multiple studies in both prematures and full-term infants. Along with the ideal nutrients, such as omega-3 fatty acids, whey protein, and high levels of lactose, the energy for the brain, are the presence of enzymes and ligands that facilitate the digestion and absorption of nutrients, including the micronutrients.

The other well-documented advantages of human milk are the infection-protection qualities that protect the breastfed infant from respiratory infections, otitis media, gastrointestinal infections, and even urinary tract and meningeal infections (Hanson 2004). The study of the immunologic properties of human milk has shown that infants who are exclusively breastfed for at least 4 months have a reduced risk of childhood onset diabetes, Crohn's disease, celiac disease, and childhood-onset cancers - especially leukemia. Hundreds of articles testing the allergy protection of human milk have shown a clear advantage in being breastfed for potentially allergic children.

There are many advantages to breastfeeding for the mother herself The process facilitates the rapid recovery postpartum, with a reduccd loss of blood and the prompt involution of the uterus to its pre-pregnant state (Labbok 2001). Further breastfeeding prevents post-partal depression (Groer 2005), and reduces the long-term risk of obesity and osteoporosis for the nursing mother. Studies of specific diseases show that there is a reduced risk of breast cancer and ovarian cancer for women who breastfeed (Lawrence 2005, Collaborative Group 2002). Finally, the special relationship between mother and infant that develops while the infant suckles at the breast has always been a prime reason to breastfeed.

Determining the risk-benefit ratio, for a given infant, of maternal medication requires taking all of the tremendous advantages under consideration and understanding the specific risk of the medication to a given child. For example, if the child is in a developing country where the risk of dying of an infectious disease in the first year of life is 50% for those infants who receive formula, then the risk of a maternal medication is relatively insignificant by comparison.

The World Health Organization (WHO) and the Innocenti Declaration state clearly the importance of infants being breastfed. The Innocenti Declaration was reaffirmed in 2006 at its fifteenth-year anniversaty, once again urging exclusive breastfeeding for the first 6 months of life followed by continued breastfeeding with the addition of solid foods through to 12 months of age, and for as long thereafter as mother and child wish.

The incidence of breastfeeding decreased significantly throughout the 1970s and 1980s and is now slowly increasing worldwide because of a vigorous effort on the part of many supportive organizations to reverse the trend of bottle feeding. The most extensive program is the Baby Friendly Hospital Initiative (BFHI), which was begun by the United Nations International Children's Emergency Fund (UNICEF). The Baby Friendly Hospital Initiative has spread throughout most of the developing world, but is only slowly being accepted in Western cultures. BFHI requires that all hospitals have a breastfeeding policy and that all staff be thoroughly trained in the introduction and management of breastfeeding. In addition to adequate training of the staff, all infants should be put to breast within the first hour of life. It is also required that dummies or pacifiers not be provided to breastfeeding infants, and that BFHI hospitals pay for any formula utilized, accept no free samples, and distribute no free samples to their patients.

White encouraging mothers and babies to breastfeed in the hospital, support needs to be provided at home as well by the mother's physician, the pediatrician, the nurse midwife, and office staff, as well as licensed, board-certified lactation consultants. With respect to medications, however, proper information is essential. Many mothers are told to wean because of the medication that they must take. This is actually very rarely necessary. The information available to the practitioner, however, is often incorrect. Package inserts and the physician's desk reference, for instance, almost always suggests that the drug is not recommended during lactation, not because there is negative information but because the manufacturer has not provided any studies or information that would permit them to say it is safe. This may also lead to poor compliance - that is. the mothers do not follow medical advice. In a prospective study carried out at a counseling center among 203 breastfeeding mothers who were prescribed

3.2 The passage of medications into the mother's milk an antibiotic compatible with breastfeeding, 15% of the women did not take the medication prescribed and 7% stopped breastfeeding (Ito 1993A). It therefore becomes the responsibility of the practitioner to adequately inform the breastfeeding mother using relevant medical literature, and to determine the probability that the drug will enter the milk in a relevant quantity and present any problem for the child.

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