The Immunological Secrets of Breastfeeding: Implications for Policy and Practice Prepared by Miriam Labbok, MD, MPH, FACPM, FABM UNICEF NYHQ

The Immunological Secrets of Breastfeeding:

Implications for Policy and Practice

Prepared byMiriam Labbok, MD, MPH, FACPM, FABM

UNICEF NYHQ

Primary reference for presentation:

Labbok M, Goldman A, Clark D. Breastfeeding: Maintaining an irreplaceable immunological resource. Nature Reviews/Immunology, July 2004, 4: 565 – 573.

Also:LANCET Child Survival Series. July 2003.Heinig MJ. Host defense benefits of breastfeeding

of the infant: Effect of breastfeeding duration and exclusivity, In Pediatrics Clinics of North America, February 2001, 48(1):105-123.

Breastfeeding -- the major source of active and passive immunity in the vulnerable early months and years of life -- is considered to be the single most effective preventive means of reducing death rates of children under five years of age.

Of the estimated 10 million children who die each year in the developing world, about 60% are preventable.

LANCET collaborative report published in 2003 proposed that a single preventive measure, increased “optimal breastfeeding behaviours” could prevent 13% of deaths, or save 1.3 million children annually.

When compared with the other interventions* it becomes even clearer that meaningful intervention to support increased breastfeeding must be a priority.

*Determined using data from the 42 countries that had 90% of the child deaths worldwide in 2000, by estimating the impact of universal coverage with each individual intervention.

Preventive Estimated deaths prevented*

Intervention (thousands) (% of all deaths)

Breastfeeding 1,301 13Insecticide-treated materials 691 7Complementary feeding 587 6Clean delivery (efforts to ensure that childbirth is free of

unnecessary contamination) 411 4Nevirapine and replacement feeding 150 2H. influenzae type b vaccination 403 4Zinc supplementation 351 4Clean water, sanitation, hygiene 326 3Vitamin A supplementation 176 2Newborn Temperature Management 227 2Tetanus toxoid vaccination 161 2

Malaria7% ARI

29%

Measles8%

Diarrhea25%

Other31%

Good nutrition in the early years of life save lives

Malnutrition is responsible about 56% of mortality among children 6 months to 5 years

of age

Current levels of breastfeeding cannot be allowed to diminish; by some estimates, current advances in breastfeeding practice are already saving millions of lives annually.

In the United States, it is estimated that 20% of postneonatal mortality, and a significant percentage of neonatal mortality could be prevented by improved breastfeeding. (Chen and Rogan, 2004)

But saving lives is not the only benefit of breastfeeding. Breastfeeding makes important contributions to growth, and to cognitive and psychosocial development, and thus leads to a healthier population, capable of greater achievement, and longer life.

Breastfeeding provides economic benefits to families compared with buying breastmilk substitutes, which translates into national economic gains.

Given all this, why have breastfeeding and related complementary feeding not gained the highest levels of support among the priorities of the global health and development agendas and related funding?

While attention to breastfeeding may be increasing in at the national level in the United States today, breastfeeding seems to be given modest and perhaps declining importance in today’s global health and development agendas and donor support.

Why is such a clear winner being left at the post in the race for the cure for untimely infant and child mortality? Is this a result of: concerns over the transmission of HIV? pressure from the infant feeding industry? Or is breastfeeding merely no longer “fashionable”

among those working in international development?

In this era of public–private partnerships, can breastfeeding’s role as an irreplaceable immunological resource help keep it at the top of global agendas?

This presentation will examine: 1. the immunological basis for the positive impact of

breastfeeding on health and survival, and its implication for practice

2. the past recognition of the importance of breastfeeding in international public health and development agendas,

3. why the messages seem to be missing today

4. how the “irreplaceability” of human milk, due mainly to its immunological components, may be a vital message in re-establishing and maintaining global as well as clinical attention to protection, promotion and support for breastfeeding.

Nutritional Components of Breastmilk at Six Months:

Exclusivity Yields An Important Balance

Protein 0.67 kcal/g SufficientEnergy 8g/L SufficientVitamins A B6 D

1.7mol/L0.13 mg/L645 ng/L

Depends on MaternalSunlight

Minerals Ca Fe Zn

234 mg/L0.3 mg/L1 mg/L

OKPrenatal Stores

Non-breastfed human infants experience an immunodeficiency that increases the risk of infections and other diseases.

The antimicrobial, anti-inflammatory, and immunomodulating agents in human milk are multi-functional, act synergistically, and compensate for developmental delays in the infant.

Agents that are “developmentally delayed” in infancy and that are provided by human milk

Antimicrobial

• Lactoferrin

• Lysozyme

• Secretory IgA

• Memory T cells

• Antibodies to T-cell-independent antigens

Anti-inflammatory• Lactoferrin• Lysozyme• Secretory IgA• IL-10• PAF-acetylhydrolase

Immunomodulatory• Secretory IgA• Interferon-g• IL-8• IL-10

Relationships between immune functions of the mammary gland and the nursing infant -

Effects Agents in MilkDirectly compensate for

developmental delays in the infant immune system:

Indirectly compensate for developmental delays in the infant immune system

Enhance poorly expressed functions

Adapt the gastrointestinal tract to extrauterine life

Prevent inflammation

Enhanced survival of defense agents

Establish commensal bacterial flora

Secretory IgA, lactoferrin, lysozyme, interferon-g, PAF-acetylhydrolase

Oligosaccharides and nucleotides

Cytokines, anti-idiotypic antibodies

Epithelial growth factors

PAF-acetylhydrolase, antioxidants, IL-10, TGF-b

Secretory IgA, lactoferrin, lysozyme

Growth factors for commensals.

Anatomy of Breastmilk: a living colloidal suspension produced by the mother’s body

to address the changing needs of the child in the environment

Cellular T- and B-Lymphocytes Neutrophils Macrophages Epithelial cell activity

Non-cellular Immunoglobulins Enzymes Inhibitors of metabolism, e.g.,

lactoferrin Carrier Proteins Oligosaccharides. Hormones and hormone-like

substances, e.g., Human milk growth factors

Anti-inflammatory factors Glycosylated proteins Nonspecific Factors Immunomodulating agents Additional Viral Fighting

Factors, such as Antiviral lipids

Practice implications:Breastfeeding is rarely contraindicated by maternal

infectious disease or by treatment modalities Bacterial Infections

Most bacteria blocked by milk components

Treat and continue breastfeeding

Viral Infections Rare passage via breastfeeding Generally asymptomatic Avoid lesions Hepatitis: Give HBIG and

vaccinate. C not passed. Spirochetes

Avoid lesions

Parasites Treat and continue breastfeeding

Retroviruses Difficult to isolate but passage

confirmed by epidemiological study

If adequate replacement and health care acceptable, feasible, affordable, sustainable and safe, avoid breastfeeding, or...

Is exclusive breastfeeding a possibility?

“New” Data on EBF Show...

HIV and Breastfeeding

CD8 cells selectively Passage limited by

EBF and high CD4

Costs New Studies -

consistent findings

Therefore – New Policies:

Global Strategy on Infant and Young Child Feeding

Framework for Action on HIV/Infant Feeding endorsed and implemented by WHO/UNICEF

Neonatal Health:Colostrum and Transitional milk

Reduced necrotizing enterocolitis (NEC) Breastfeeding can reduce the incidence of NEC by up to 20 fold

Lucas A, Cole T. LANCET 1990, 336:1519-23.

Reduced sepsis WHY?

Passive immune factors, Active production and absorption of maternal cells

for improved immune protection, Improved gut and brain tissue maturation Reduced challenge to systems

This presentation examines: 1. the immunological basis for the positive impact of

breastfeeding on health and survival,




Major international health and development documents supporting breastfeeding• WHO/UNICEF International Code of Marketing of Breastmilk Substitutes (1981) :

passed to limit commercial marketing influence on women’s infant feeding decisions.• The Convention on the Rights of the Child (1989): adopted by the General

Assembly of the United Nations, this obliges governments to take appropriate measures to ensure that the advantages of breastfeeding can be put into practice.

• The Innocenti Declaration (1990): pronounced that all women should be enabled to practice exclusive and continued breastfeeding.

• The Plan of Action adopted at the World Summit for Children (1990): advocated the "empowerment of all women to breastfeed their children exclusively for four to six months and to continue breast-feeding, with complementary food, well into the second year."

• The World Declaration and Plan of Action for Nutrition (1992): pledged "to reduce substantially within this decade … social and other impediments to optimal breast-feeding."

• The International Conference on Population and Development in Cairo (1994): recognized breastfeeding as an important child survival strategy.

• The Beijing Platform for Action (1995): called for the promotion of breastfeeding, implementation of the International Code and the facilitation of breastfeeding by working women.

• The World Fit for Children report from the UN General Assembly Special Session on Children (2000)

• The WHO/UNICEF Global Strategy for Infant and Young Child Feeding (2002)

The Millennium Development Goals (2000), which address the major single international development consensus, does not mention breastfeeding, per se.

Nonetheless, it is clear that optimal breastfeed would help achieve all of the goals.






Social and commercial pressures. Family income pressures and early return of

mothers to the workplace - maternity leave- social support

Conflicting pressures may lead to cognitive dissonance: - difficulty in accepting that alternative approaches may be better than the existing ones

Commercial marketing - public sector funding does not match or exceed that of the commercial sector- the vast weight of marketing remains in support of formula use, in spite of the vast weight of scientific evidence for breastfeeding.

Message burn-out. There are many examples of reports of ‘burn-out’

due to duration of a concern or due to conflicting messages. - The Deputy director of the CDC's National Center for HIV, STD and TB Prevention on the resurgence of sexually transmitted diseases in the United States: “Some of these people have been hearing these [public health] messages for three decades now and are suffering from prevention burnout and skepticism."

Message burnout is a real possibility in breastfeeding support:

- The Code is nearly 25 years old, and the Baby-friendly concept is more than a decade old. So it is conceivable that both public health planners, and the general public, have heard the message so many times so that they are “burned out” on the established breastfeeding support messages.

Competing Issues. The HIV/AIDS pandemic

- Initial reaction - Now clear agreement across UN agencies that this issue must be viewed in perspective for the first six months, is a vital, timely public health priority.

Increased availability of treatments to decrease transmission - Ensuring that the role of breastfeeding remains central

Support for exclusive breastfeeding will increase child survival even where HIV is endemic - by increasing survival among HIV-negative infants, reducing complicating infections among HIV-infected children and, if current findings are confirmed, decreasing transmission from mother-to-child among HIV-infected women.

Cumulative probability of HIV among 549 children born to HIV+ women

Coutsoudis et al. AIDS 2001, 15:379-87 Exclusively

breastfed group ( ) is statistically significantly different from mixed fed ( ), but is not statistically significantly different from never breastfed ( )group until 15 months, controlling for 15 variables.

0

5

10

15

20

25

30

35

40

45

Birth

6 wks

3 m

o6

mo

12 m

o

15 m

o

Ross J et al. 2004, AJPH

Cumulative HIV-free Survival

600.0

650.0

700.0

750.0

800.0

850.0

900.0

0 6 12 18 24

Age (months)

HIV-

free

surv

ivor

s/10

00 liv

e bi

rths

No postnatalintervention/Status Quo BFpatterns (B24)

No BF by HIV-infected mothers(B0)

Short duration (6 months) BFby HIV-infected mothers (B6)

Short duration "safer" BF (6months) by HIV-infectedmothers (SB6)

"Safer" BF (24 months) by HIV-infected mothers (SB24)

Model for Per 1000 HIV-Positive Mothers(IMR 96)

Ross J and M Labbok. AJPH, 2004

WHO/UNAIDS/UNICEF Basic Guidelines on HIV&IF

If status unknown, or if tested and HIV- Exclusive breastfeeding (EBF) for 6 months and continued

breastfeeding for 2 years and beyond for HIV negative women and women of unknown status.

If tested and HIV+ For HIV positive women if replacement feeding is affordable,

feasible, acceptable, safe and sustainable, avoidance of all breastfeeding is recommended. Otherwise EBF is recommended for the first months of life.

Women should have access to relevant infant feeding information, follow up care and support including family planning and nutritional support.

More Competing Issues.

Increased availability of treatments for illnesses- Sometimes comes at the cost of attention to prevention.

- Example: oral rehydration programming, respiratory infections

Scientists and programme planners who address epidemics often see exogenous immune system complements (such as antibiotics) as the first line of defence. - incidence of antibiotic-resistant microbial pathogens has rapidly increased.






Revitalizing Interest: Call attention to its unique qualitiesBreastfeeding has an irreplaceable immunological role

in child health and survival.

Breastfeeding provides immunological agents - our best defence against a host of common infections, - infectious agents are unable to rapidly become resistant to these natural defence agents.

Plans and strategies for development in industrialized and less-developed settings, alike, would benefit from the inclusion of breastfeeding support - concomitant improvements in survival, growth and development- improvements in development overall.

This may be a new “message” to build upon to include breastfeeding more actively in current development planning mechanisms.

Issues that remain: Breastfeeding has no significant commercial advocate.

In today’s world of public-private partnership, there is nowhere that we can seek unbiased private sector support for each mother to succeed in breastfeeding.

We must look to professional, government, and non-governmental organizations to send the message and to support breastfeeding programmes.

The biologically irreplaceable immunological and immunomodulating components of human milk may be the key to stimulating support for breastfeeding. If we do not support it, breastfeeding may diminish due

to commercial bias, competing interests, misunderstandings, and societal pressures on women. We will have lost vital, naturally developed, immunological protection for us all that can extend far past the period of breastfeeding.

Conclusions Practice

Early and Exclusive Breastfeeding, with continued breastfeeding for 2 years or longer!

Especially if there are other children or an immune-compromised individual in the household.

Policy If we do not support breastfeeding, levels and interest

may further diminish due to commercial bias, competing interests, misunderstandings, and societal pressures on women.

If we allow this to occur, we will have lost vital, naturally developed, immunological protection for us all that can extend far past the period of breastfeeding.

Can we afford this loss?

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Documents

The Immunological Secrets of Breastfeeding: Implications for Policy and Practice Prepared by Miriam Labbok, MD, MPH, FACPM, FABM UNICEF NYHQ