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Blackwell Science, LtdOxford, UKNBUNutrition Bulletin1471-98272004 British Nutrition Foundation

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Facts Behind the Headings

Dispelling popular myths that discourage breastfeedingS. Hyman and S. Stanner

Correspondence:

Stephanie Hyman, British Nutrition Foundation, High Holborn House, 52-54 High Holborn, London, WC1V 6RQ, UK. E-mail: s.hyman@nutrition.org.uk

FACTS BEHIND THE HEADLINES

Dispelling popular myths that discourage breastfeeding

S. Hyman and S. Stanner

British Nutrition Foundation, London, UK

Several recent headlines have yet again extolled the vir-tues of breastfeeding (Derbyshire 2004; Hope 2004;Rozenberg 2004). Some of these were initiated by a pro-spective study published in the

Lancet

which supportedlong-term benefits of breastmilk feeding for cardiovas-cular health (Singhal

et al

. 2004). Twenty years ago, 926preterm infants were randomly assigned into two par-allel trials, one group receiving donated banked breast-milk or preterm formula (trial 1) and the second groupreceiving standard term or preterm formula milk (trial2) as sole diet or as supplements to mother’s milk. Twohundred and sixteen of these babies were followed up atthe age of 13–16 years and screened for cardiovascularrisk factors including blood pressure, plasma lipopro-tein concentrations, endothelial function and 32,33 splitproinsulin levels (an indicator of insulin resistance). Thispaper focused on the lipoprotein levels, which includedmeasures of triglyceride concentration, the ratio of lowdensity lipoprotein (LDL) to high density lipoprotein(HDL) cholesterol, the ratio of apolipoprotein B (apoB)to apolipoprotein A-1 (apoA-1) (a measure of the num-ber of atherogenic particles vs. the number of anti-atherogenic particles) and C-reactive protein (CRP)concentration, a marker of low grade inflammationassociated with cardiovascular disease. The investiga-tors reported a 14% reduction in the ratio of LDL toHDL cholesterol in the adolescents randomised tobanked breastmilk in trial 1 compared with those receiv-ing preterm formula. This difference remained signifi-cant after adjusting for possible confounding factors(

e.g.

age, sex, body mass index). In addition, those in thebreastmilk group had significantly lower CRP concen-trations as well as lower apoB concentrations followingadjustment for confounders. There were, however, nodifferences in apoA-1 or triglyceride concentrations

between the two groups. The investigators also foundno difference in lipoprotein profile or CRP concentra-tions between the infants randomised to term formulaor preterm formula in trial 2.

The researchers demonstrated that a greater propor-tion of breastmilk intake in infancy was significantlyassociated with lower ratios of LDL to HDL and apoBto apoA-1 and with lower CRP concentration at age 13–16 years (Singhal

et al

. 2004). These findings supportprevious reports by the same group demonstratingbreastmilk consumption to reduce later blood pressure(Singhal

et al

. 2001), insulin resistance (Singhal

et al

.2003) and leptin resistance (Singhal

et al

. 2002) in thesame cohort, as well as considerable epidemiologicalevidence from other researchers supporting beneficialeffects of breastmilk on cardiovascular risk factors inlater life.

Despite the well publicised benefits for short- andlong-term health, strong support for breastfeeding fromhealth professionals and the media and various UK pro-grammes, including the Baby Friendly Hospital Initia-tive, it has been difficult to persuade women to initiateand then continue to breastfeed. The UK has one of thelowest breastfeeding rates in Europe and the situationdoes not appear to be improving substantially. Forexample, 31% of women in the UK do not try to breast-feed (Department of Health 2000) compared to only2% in Sweden (World Health Organization 2003).

Under the age of 24 years this figure is considerablyhigher, with 40% of mothers not attempting to breast-feed (Hamlyn

et al

. 2002) (Fig. 1). By 2 weeks only 52%of mothers in the UK continue to breastfeed and by4 months this figure has dropped to 28%. A number ofreasons are cited as to why mothers give up breastfeed-ing; in the early stages painful nipples and the babyrejecting the breast are the most common causes, insuf-ficient milk is the most common factor causing mothersto give up feeding between 1 week and 4 months,returning to work appears to be the main factor in latermonths (Hamlyn

et al.

2002). Socio-economic class isan important factor in breastfeeding, the Infant Feeding

Dispelling popular myths that discourage breastfeeding

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Survey (2000) found that 43% of mothers in social classV were not breastfeeding compared with 9% of those insocial class I. White mothers are less likely to breastfeedat birth compared with mothers from ethnic minoritygroups.

In order to try to identify some of the factors thatmay be responsible, a telephone survey amongst 1000women was carried out by NOP World on behalf ofthe Department of Health to support this year’sBreastfeeding Awareness Week (11–17th May 2004)(http://www.dh.gov.uk/PublicationsAndStatistics/Press-Releases). This survey identified a number of commonmyths that must be tackled if national breastfeedingrates are to improve. It seems that the ‘breast is best’message is not getting across to all women; over a thirdof those interviewed thought that modern infant for-mula milks were similar or the same as breastmilk andwere unaware that breastmilk contains a number ofantibodies, growth factors, enzymes and hormones thatare not present in formula milk. Breastmilk also con-tains natural prebiotics that stimulate growth of non-pathogenic, beneficial, bacteria such as lactobaccilliand bifidobacteria in the gut. This, in turn, helpsinhibit the growth of pathogenic organisms such as

Escherichia coli

(

E. coli

) and encourages the establish-ment of a healthy gut microflora, which may help toprotect them from the risk of gastro-intestinal infec-tions (see Bye 2004 in this issue of

Nutrition Bulletin

).At present, prebiotics are not added to most formula

milks. Breastmilk provides perfectly balanced, tempera-ture-controlled nourishment that adapts to meet all thenutritional and energy requirements of the growingchild.

Nearly all women interviewed believed that breast-feeding comes naturally to some but not to all and thatsome women are unable to produce enough milk tobreastfeed successfully (95% and 87% of respondents,respectively). In fact, nearly all women are able tobreastfeed provided they are given sufficient informa-tion and support. Sadly over two-thirds of those inter-viewed (67%) felt that breastfeeding in public isconsidered to be socially unacceptable. Despite this per-ception, more and more establishments are welcomingbreastfeeding mothers and providing suitable facilitiesand an NOP survey conducted in 2003 suggested thatmost people do think that it is acceptable to breastfeeddiscreetly in public.

Twenty per cent of those aged 16–24 years mistakenlybelieved that breastfeeding would have detrimentaleffects on their breast and body shape. Health profes-sionals need to ensure that young people in particularare reassured that this is not the case and are informedabout the potential benefits of breastfeeding in terms ofhelping to promote the loss of excess weight gained inpregnancy (as it uses up around 500 kcals per day) andin helping the womb to return to normal.

The government has set a target to increase breast-feeding initiation rates by two percentage points peryear through the NHS Priorities and Planning Frame-work, with a specific focus on women from disadvan-taged groups. An improved understanding of thesocial factors undermining breastfeeding will helpthose involved in its promotion to develop anddeliver more effective programmes and may also helpto address the socio-economic bias and reduce healthinequalities.

References

Bye

N (2004) Protecting the infant through nutrition – are prebiotics the answer?

Nutrition Bulletin

29

: 213–22.Derbyshire

D (2004) Breastfeeding Cuts Heart Risks in Adult Life.

Telegraph

, May 14th, 2004.Hamlyn

B, Brooker

S, Oleinikova

K

et al.

(2002) Infant feeding 2000. The Stationery Office, London.

Hope

J (2004) Breast Milk Protects against Heart Attacks.

Daily Mail

, May 14th, 2004.

Rozenberg

G (2004) Myths that Harm Breastfeeding.

The Times

, May 10th, 2004.

Singhal

A, Cole

TJ, Fewtrell

M

et al.

(2004) Breastmilk feeding and lipoprotein profile in adolescents born preterm: follow-up of a pro-spective randomised study.

Lancet

363

: 1571–8.

Figure 1

Incidence of breastfeeding by mothers age (1995 and 2000). Source: Hamlyn

et al

. (2002).Material reproduced from Hamlyn

et al

. (2002), is Crown copyright and is reproduced with the permission of the controller of HMSO.

0

10

2030

40

50

6070

80

90

Under20

20–24 25–29 30 orover

Allbirths

Age of mother

Per

cen

tag

e w

ho

bre

astf

edin

itia

lly

1995

2000

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S. Hyman and S. Stanner

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Singhal

A, Cole

TJ & Lucas

A (2001) Early nutrition in preterm infants and later blood pressure: two cohorts after randomised tri-als.

Lancet.

357

: 413–19.Singhal

A, Fewtrell

MS, Cole

TJ

et al.

(2003) Low nutrient intake and early growth for later insulin resistance in adolescents born preterm.

Lancet

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: 1089–97.

Singhal

A, O’Rahilly

S, Cole

TJ

et al.

(2002) Early nutrition and leptin concentrations in later life.

American Journal of Clinical Nutrition

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: 993–9.World Health Organization (2003) http://www.who.International/

nut/db_bfd.htm (accessed 4 June 2004).