Breastmilk and Breastmilk Substitutes

1. Why breastmilk?1

Human milk is for human babies.2

In ‘The 10 facts on breastfeeding,’ the WHO states that a lack of exclusive breastfeeding during the first six months of life contributes to over a million avoidable child deaths each year. As the ‘10 Steps to Successful Breastfeeding’ states: “everyone has the right to information about the benefit of breastfeeding and the risks of artificial feeding. Governments have a responsibility to provide this information. Communities as well as media and other channels of communication can play a key role in promoting breastfeeding.”

In ‘Why it is important to share and act on this information,’ Facts for Life states: “Breastfeeding is the natural and recommended way of feeding all infants, even when artificial feeding is affordable, clean water is available, and good hygienic conditions for preparing and feeding infant formula exist.”

In ‘The Risks of Not Breastfeeding for Mothers and Infants’, Dr. Alison Stuebe writes: “Given the compelling evidence for differences in health outcomes, breastfeeding should be acknowledged as the biologic norm for infant feeding.”

In ‘Breastfeeding and the Risk of Postneonatal Death in the United States,’ the authors conclude: “Breastfeeding is associated with a reduction in risk for postneonatal death. This large data set allowed robust estimates and control of confounding [external variables that can obscure or exaggerate an outcome –ed.], but the effects of breast milk and breastfeeding cannot be separated completely from other characteristics of the mother and child. Assuming causality, however, promoting breastfeeding has the potential to save or delay 720 postneonatal deaths in the United States each year.”

The title of this Lamaze position paper reads ‘Breastfeeding is priceless: No Substitute for Human Milk.’ Lamaze goes on to say that “the World Health Organization (WHO), health care associations, and government health agencies affirm the scientific evidence of the clear superiority of human milk and of the hazards of artificial milk products.”

Protective factors of breastmilk

Human milk provides protection against many infectious agents through repeated exposure and the total antimicrobial protection provided by human milk appears to be far more than can be explained by examining protective factors individually.

In Necrotizing Enterocolitis: Protective Role of Breastmilk,’ the authors write that “Breastmilk feedings are associated with a decrease in NEC [Necrotizing Enterocolitis –ed.] in premature infants” and they attribute this to the unique immunologic properties of breastmilk.

This study on the ‘Storage of human milk and the influence of procedures on immunological components of human milk’ shows that breastmilk “can be stored for 8 hours at room temperature (25 degrees C), for three days in the fridge (4 degrees C) and for up to a year in the freezer (-20 degrees C) without any increase in the levels of pathogens (harmful bacteria) it contains.”

In ‘Antimicrobial Activity of Breastmilk Against Common Pediatric Pathogens,’ the authors state: “It can be said that in any part of the world, no single pediatric measure has such widespread and dramatic potential for child health as a return to breastfeeding.”

In this previous but valuable study on the effect of routine screening of raw breastmilk and donor milk for premature babies, the authors discuss that while the data clearly document that premature infants fed raw expressed human milk are frequently exposed to large numbers of bacteria, no adverse events directly related to consuming this milk were documented.

According to Richard J. Schanler, et al., in this study, “advantages to an exclusive diet of MM [mother’s milk] were observed in terms of fewer infection-related events and shorter hospital stays.”

For more information on the disease killing properties of breastmilk, see these La Trobe Tables for antibacterial, antiviral and antiparasite factors of breastmilk.

Physical benefits of breastfeeding3

Other important benefits of breastfeeding include proper jaw and facial development which reduces both ear infections and bite issues, by preventing malocclusion.4 The skin to skin contact that breastfeeding provides helps babies acquire the beneficial bacteria that protects them from diseases and builds their immune system.5 Skin to skin contact also provides relaxation for both parent and child due to the effects of oxytocin. Long term benefits are laid out in this WHO publication. Breastfeeding also has its economical benefits.

For additional information on the physical benefits associated with breastfeeding for both parent and baby, see Lamaze’s ‘Healthy Birth Practice #6: Keep Mother and Baby Together – It’s Best for Mother, Baby, and Breastfeeding’. Lastly, this in-depth study by Brian Palmer, DDS, discusses the benefits of breastfeeding and overall health.

Healing properties of breastmilk

In addition to its biological and physiological benefits, breastmilk has also been shown to have some amazing healing properties. More and more research is showing the healing and disease killing properties of breastmilk. Researchers conclude that multipotent stem cells, isolated from human breast milk could potentially be ‘reprogrammed’ to form many types of human tissues. The presence of these cells in human milk suggests that breastmilk could be an alternative source of stem cells for a patient’s own stem cell therapy.

Breastmilk compounds kill warts: “Compound in breast milk has been found to destroy many skin warts, raising hopes it might also prove effective against cervical cancer and other lethal diseases caused by the same virus.” A cancer killing substance, named HAMLET has also been found in breasmtilk.

The importance of the act of breastfeeding

Lastly, the benefits of breastfeeding are more than its product, the milk. They are beyond providing food and drink to one’s child for superior growth and development. There is more to breastfeeding than just the nutritional component of the milk itself. The time spent between a parent and a child is also vital to the development of a strong relationship. It provides an opportunity to interact and connect. Therefore, it is no surprise that parents who breastfeed their children are less likely to abuse their children.

Newborn humans are born in a helpless state and continue their development after birth. The nurturing embraces of breastfeeding mimic the embrace of the womb that the baby experienced in utero. In light of this, the method a caregiver uses to provide donor milk to a baby is thus also very important. Please also see ‘How do I feed the milk to my baby.’

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2. WHO guidelines for exercising feeding options

In ‘The Global Strategy for Infant and Young Child Feeding’, the recommendations for feeding infants and young children are:6

  • Milk from own parent by breastfeeding,
  • Milk from own parent, expressed,
  • Milk from another parent by wet-nursing, or
  • Milk from a milk bank, or
  • Breastmilk substitute fed by cup,

depending on individual circumstances and as discussed with a health care provider. [Ed.]

To enable parents to establish and sustain exclusive breastfeeding for six months, WHO and UNICEF recommend:

  • Initiation of breastfeeding within the first hour of life;
  • Exclusive breastfeeding –that is, the infant only receives breastmilk (including milk expressed or from a wet nurse) without any additional food or drink or water;
  • Breastfeeding on demand –that is, as often as the child wants, day and night;
  • No use of bottles, teats or pacifiers.

In this document, EOF uses the WHO definition of exclusive breastfeeding, which includes expressed milk and milk from another parent (i.e. wet-nurse). In support of exclusive breastfeeding, in circumstances where wet-nursing is not feasible, informed milk sharing can be a viable option for families. Milk sharing can be seen as an extension of wet-nursing, and as a safe alternative for infant feeding and successful exclusive breastfeeding.

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3. Why breastmilk substitutes?

For certain rare genetic diseases, such as galactosemia, (identified through the early newborn metabolic screening)7 the use of non-milk based breastmilk substitutes is the suggested feeding option.

Please see this WHO publication (section 1:89) for other medical reasons for the use of breastmilk substitutes. The Codex Alimentarius provides information on the standard of practice for use of infant formula for special circumstances.

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4. Risks and ethics of breastmilk substitutes

“Infants who are not breastfed, for whatever reason, should receive special attention from the health and social welfare system since they constitute a risk group,” says the WHO.8

When parents do not breastfeed, they generally turn to infant breastmilk substitutes. The World Health Organization (WHO) and UNICEF recommend that health care providers inform parents about the health risks of artificial feeding and the benefits associated with breastmilk.9 The risks are numerous, but rarely is proper handling and preparation taken into consideration, “[…] Formula must be refrigerated and discarded after the first feeding attempt because it contains no antibodies or infection protection factors.”10

Unlike breastmilk, breastmilk substitutes need to be carefully measured out based on its caloric content to ensure that your baby is getting the suggested portion. Caregivers need to be warned against diluting or over-mixing, as doing so may begin a child on a path of battling with obesity or malnourishment. Infact Canada outlines a list of the risks associated with artificial feeding to help make a more informed decision about feeding babies.

The WHO writes: “Powdered infant formula (PIF) has been associated with serious illness and death in infants due to infections with Enterobacter sakazakii. During production, PIF can become contaminated with harmful bacteria, such as Enterobacter sakazakii andSalmonella enterica. This is because, using current manufacturing technology, it is not feasible to produce sterile PIF. During the preparation of PIF, inappropriate handling practices can exacerbate the problem.”11 Please see this WHO document for proper guidelines.

Susan Orlando, RNC, NS writes that “the protective properties of breast milk are unique and cannot be duplicated in the laboratory. The components identified in breast milk are multifunctional and interactive. The composition of breast milk complements the developing host defense system in the newborn infant. Since breastfeeding is the biological norm for infants, this means that there are risks to using any and all other artificial breastmilk substitutes for infant feeding purposes.” For more information on how breastmilk substitutes affect the bacterial colonization in the gastrointestinal (GI) tract, see the article, ‘“Just One Bottle Won’t Hurt” –or Will it?’ by Marsha Walker, RN, IBCLC.

In ‘The Risks of Not Breastfeeding for Mothers and Infants,’ Dr. Alison Stuebe concludes that “Formula feeding is associated with adverse health outcomes for both mothers and infants, ranging from infectious morbidity to chronic disease.”

La Trobe Table # 6 summarizes a list of contaminants in infant formula that have caused infections. Other risks and/or contaminants that have been found in breastmilk substitutes include phthalates, bisphenol A (BPA), melamine, genetic engineering, and microbiological risks. For more information on safe practices, sterilization and the microbacterial content in powdered formula see the Codex Alimentarius.

When it comes to premature babies, Necrotizing Enterocolitis (NEC) is a very dangerous complication of feeding with breastmilk substitutes. Breastmilk has been associated with a decrease in NEC in premature babies and should be widely available to all infants in hospitals. Please see ‘What about premature babies?’ for more information.

Another concern regarding artificial feeding is the ethics behind formula companies’ marketing and distribution of their products. Formula companies have misinformed consumers by making false statements about their products and by neglecting to provide key information. This has widespread health and economical implications in many countries, but is devastating to developing nations in particular. Please view these 6 episodes of ‘Formula for Disaster’ on YouTube for a closer look at the ethics of formula companies in the Philippines.

There is an overall lack of support for people who struggle with breastfeeding. Parents are exposed to clinical or hospital environments filled with formula advertisements which gives a strong message to new moms, one that undermines any form of ‘lip-service’ paid to breastfeeding. This type of marketing and distribution goes directly against the ‘International Code of Marketing Breast Milk Substitutes.’

When using formula, education about the risks associated with artificial infant feeding is important. Follow the ‘Alerts & Safety Information and Reporting Illnesses, Injuries and Problems’ for the latest recalls in formula.

Please see ‘HIV and the global context of infant feeding’ for the WHO’s position on breastmilk substitutes.

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  1. In this document EOF utilizes the WHO definition of exclusive breastfeeding which includes milk from another lactating parent (see ‘WHO guidelines for exercising feeding options’). In support of exclusive breastfeeding, in circumstances where wet-nursing is not feasible, informed milk sharing can be a viable option for families. Milk sharing can be seen as an extension of wet-nursing, and as a safe alternative for infant feeding and successful exclusive breastfeeding. EOF recognizes the benefits that direct breastfeeding from the breast bestows as well as the value of the milk itself. We may therefore use the words breastfeeding and breastmilk interchangeably. []
  2. Breastfeeding, and especially early breastfeeding, is one of the most critical factors for improving child survival. Breastfeeding also has many benefits other than reducing the risk of child mortality. HIV has created great confusion among health workers about the relative merits of breastfeeding for the parent who is known to be HIV-infected. Tragically this has also resulted in lactating parents who are known to be HIV uninfected or whose HIV status is unknown, adopting feeding practices that are inappropriate for their circumstances with detrimental effects for their infants.

    In ‘Guidelines on HIV and infant feeding. 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence’, the research group also noted how infant feeding, even in settings where HIV is not highly prevalent, has been complicated by messaging from the food industry and other groups with the result that parents, who have every reason to breastfeed, choose not to do so based on unfounded fears. In these settings, application of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant Health Assembly Resolutions has particular importance. []

  3. When nursing directly from the breast is not possible, feeding with an at-the-breast system mimics as much of the natural mechanisms of nursing as possible and provides the same skin-to-skin contact. Please see ‘How do I feed the milk to my baby?’ for more information. []
  4. Page, David C. Your Jaws Your Life: Alternative Medicine. Baltimore, MD: SmilePage Pub., 2003. Print. []
  5. As cited in Healthy Birth Practice #6: Keep Mother and Baby Together –It’s Best for Mother, Baby, and Breastfeeding []
  6. ‘The Global Strategy for Infant and Young Child Feeding’, bullet 18 states: “The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother’s milk be considered unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative –expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat –depends on individual circumstances.” []
  7. Commonly referred to by parents as the ‘heel prick’ or ‘PKU test.’ []
  8. ‘Global Strategy for Infant and Young Child Feeding’bullet 19. []
  9. International Code of Marketing of Breast-milk Substitutes.’ bullet 4.2 []
  10. Lawrence, Ruth. Breastfeeding, A Guide for the Medical Profession. P. 438. 2005. Print. []
  11. http://www.who.int/foodsafety/publications/micro/pif2007/en/ []

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