Breast-Feeding: Second Thoughts

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Breast-Feeding:

Second

Thoughts

PEDIATRICS Vol. 54 No. 6 December 1974 757

John W. Gerrard, D.M., F.R.C.P.

From the University of Saskatchewan, Saskatoon, Saskatchewan

ABSTRACT. A number of studies have shown that

breast-feeding not only supplies the infant with nourishment

but gives him immunologic protection against infection as well. Breast-fed infants are less likely to develop respira-tory and gastrointestinal infections and allergic reactions. Infants slowly develop their own immunologic defenses in the months after birth, and breast-feeding is a hygienic, gradual method of protection during the transition to immunologic independence. Best protection is achieved

when the infant receives breast milk alone for, at least, the first six months of life. Pediatricians should be aware that this is particularly important in areas where

contamina-tion of cow’s milk and other foods is likely and where medical facilities are inadequate. Pediatrics, 54:757, 1974, BREAST-FEEDING, 1MM UNOLOGIC DEFENSES, COLOSTRUM.

A recent report from the World Health

Organi-zation’ has drawn attention to the rise in the infant

mortality rate in rural Chile, the rise coinciding

with the fall in the prevalence of breast-feeding.

An editorial in the Larwet commenting on this

report emphasized the dangers of starting solids

early and making the baby obese, and of

hyperna-tremia and water deficiency, but omitted any

ref-erence to what is probably one of the most

impor-tant functions of breast-feeding, namely

protec-tion against infection.’

It has been taught traditionally that the main

value of breast-feeding is that it provides protein,

calories, salts, vitamins, and fluid in the

propor-tions best suited to meet the baby’s needs and that,

where surroundings are not hygienic, it is less

like-ly than cow’s milk to be contaminated.

Breast-feeding also fosters happy mother and child

rela-tionships and promotes involution of the uterus. If

these are the only valid reasons for breast-feeding,

artificial substitutes derived from modified cow’s

milk should be adequate, but the data recently

de-rived from Chile suggests that they are not.

A review of the passage of immunogbobulins

from mother to fetus, written before the recent

ex-pbosion of information on the structure and

func-tion of immunogbobulins, stated that the fetus

de-rived all of his immunologic protection

transpla-centally and that, though some immunogbobulin

was present in cobostrum, this was of no clinical

consequence.’ This was reaffirmed in a

well-known veterinary text6; man is said to receive all

his antibodies transpbacentably, being contrasted

in this respect with the calf, piglet, and foal who

receive theirs in cobostrum. These statemehts are

only partially trUe, for the human breast-fed infant

receives, in addition to his transpbacental infusion

of IgG, an initial bobus of IgA in cobostrum.7 The

main function of cobostralby acquired IgA is the

protection of the gastrointestinal tract.8 However,

some IgA, together with IgG and IgM is absorbed,

for immunogbobulmn levels of colostrally fed babies

are significantly higher on the fifth day of life than

at birth.9 Breast milk itself provides a continuing

supply of antibody, documented particularly in

respect to Escherichia ‘#{176}and polio virus.”

The human breast-fed baby therefore receives

sys-temic protection transplacentally and local

pro-tection of the gastrointestinal tract orally. That

systemic protection is important is now

self-evi-dent, for babies with hypogammagbobulinemia

and X-linked agammagbobulmnemia begin to

suf-fer infections as soon as but usually not before

ma-ternally acquired antibody levels fall. Is there

good evidence that breast-feeding provides

addi-tional protection?

(Received March 18, 1974; revision accepted for publication May 8, 1974.)

ADDRESS FOR REPRINTS: Department of Pediatrics, University Hospital, Saskatoon, Saskatchewan, S7N 0W8, Canada.

at Viet Nam:AAP Sponsored on September 8, 2020 www.aappublications.org/news

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TABLE I

PREVALENCE OF INFECTIONS IN BREAsT-FED, PARTIALLY

BREAST-FED AND ARTIFICIALLY FEn INFANTS#{176}

Groups No.

Respiratory

Infections

Gastro-intestinal Infections

Unclassified infections

No. % No. % No. %

Breast-Fed -9 months Breast-Fed

-partially Artificially

Fed

9,749

8,605

1,707

2,730 28.0

2,926 34.0

666 39.0

505 5.2

1,101 12.8

273 16.0

322 3.3

516 6.0

139 8.2

Total 20,061 6,322 31.5 1,879 9.0 977 4.9

#{176}Dataderived from Grulee et al.”

TABLE II

DEATHS DURING THE FIRST 9 Morrrus OF LIFE IN BABIES

BREAST-FED, PARTIALLY BREAST-FED ANI) ARTIFICIALLY

FED#{176}

Un-Res-

class-piratory Gastro- ified

infec- intestinal infec- Other

Groups No. tions infections tions Causes

Breast-Fed

-9 months 9,749 4 2 7 2

Breast-Fed

-partially 8,605 44 6 25

Artificially

Fed 1,707 82 14 33

Total 130 22 65 2

#{176}Dataderived from Grulee et al.12

TABLE III

RELATIONSHIP BETWEEN DuiiTIoN OF BREAST-FEEDING

AND AGE AT WHICH IMMUNOGLOBULIN LEVELS REACH THEIR

NADIR

Age When Maternally Age

Acquired immunoglobulins at

are at Their Lowest Weaning

Levels (Weeks) (Weeks)

Man 12 36

Horse” 16 20

Cow’4 8 12

Pig” 5 8

The most convincing evidence was provided

many years ago by a study carried out in Chicago

in the 1930’s on 20,061 babies.’2”3 These babies

re-mained under the care of the Infant Welfare

Soci-ety for at least 9 months. There were three groups:

9,749 were breast-fed for at least 9 months; 8,605

were partially breast-fed, and 1,707 were brought

up on diluted, boiled cow’s milk with added sugar.

The three groups of babies were also given orange

juice from the age of 4 weeks and cod liver oil

from the age of 6 weeks. A cereal was added at 5, a

vegetable at 6, and a second cereal at 8 months.

These studies were carried out at a time when

lit-tle was known about the management of fluid and

electrolyte disturbances, and when antibiotic

agents were not available. Any increase in the

morbidity and mortality of the babies brought up

on cow’s milk therefore was due either to harmful

factors derived from cow’s milk, or to the

depriva-tion of beneficial factors present in breast milk, or

to both. The results are summarized in Tables I and

II.

Infections, particularly gastrointestinal, but

also respiratory and unclassified, were

signffi-cantly more common in babies not given breast

milk (p <0.001), and so were deaths (p <0.001).

The overall mortality rate rose from 1.5/1,000 live

births in babies breast-fed for 9 months, to 84.7/

1,000 live births in babies brought up entirely on

boiled cow’s milk. What is also of interest is that,

though deaths from gastrointestinal tract

infec-tions increased from 0.2/1,000 live births in the

breast-fed group to 8/ 1,000 live births in those

brought up on cow’s milk, deaths resulting from

respiratory tract infections rose to an even greater

degree, from 0.4/ 1,000 live births in the breast-fed

group to 48/1,000 live births in those brought up

on cow’s milk. Breast milk appeared to provide

al-most complete protection against gastrointestinal

“infections”, and though it did not provide such

complete protection against respiratory and other

“infections,” it probably provided the babies with

a milieu in which they could develop their own

protective mechanisms because, after the age of 5

months, breast-fed babies had far fewer

respirato-ry infections than did babies brought up on cow’s

milk. At the age of 9 months, only 3.6% of the

breast-fed babies, compared with 9% of the babies

brought up on diluted cow’s milk, were having

respiratory problems.

Twelve years before Grulee’s study,

Wood-bury’4 analyzed infant mortality rates in

breast-fed and artificially fed infants. He obtained his

data from 22,422 live born infants in eight

Amen-can cities. The number of babies being breast-fed

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70

Fic. 1.Percentages of babies breast-fed, partially breast-fed, and artificially fed. Data derived from \Voodbury.’

z 4

U-z

0

0 0

a,

0.

C,’

I-4

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ARTICLES 759

possible to compare mortality rates in babies

breast-fed for 12 months with others breast-fed for

shorten periods of time. The analysis revealed that

the probability of any baby dying during each

month of the first year of life was closely related to

method of feeding, (Fig. 2) breast-fed babies fared

better than those partially breast-fed, and both

groups fared better than those artificially fed.

After the age of 8 months, there was no additional

advantage in being exclusively breast-fed.

It might not be possible, for more reasons than

one, to demonstrate today in North America or in

Europe that the mortality of exclusively

breast-fed babies is less than that of bottle-fed babies,

be-cause the investigation and treatment of enteral

infections has improved greatly. Nevertheless, in

areas where standards of hygiene are bow and

hos-pital facilities are poor, the protective value of

breast-feeding is beyond dispute and has been

con-firmed by the experience in rural Chile. ‘ In Chile,

at 4 weeks, 3, and 6 months, mortality rates in

bot-tle-fed babies were twice those in babies receiving

breast milk only. Breast-fed babies who were also

given cow’s milk fared no better than those given

cow’s milk alone, indicating that if a baby is to

benefit from breast-feeding he must be given

breast milk alone. The Chilean study also showed

clearly that, as income rose, mothers tended to

switch from breast-feeding to bottle-feeding; it

was for this reason that mortality rates rose in the

families with higher incomes.

The protective value of breast-feeding has also

been demonstrated in a study in Guatemala.”

There, a series of breast-fed babies, reared in an

isolated community with poor standards of

hy-giene, were followed carefully. Stools were

cub-tuned at weekly intervals, more frequently during

the first week of life. Although aerobic organisms

and E. coli were cultured transiently from stools

during the first few days of life-probably a sequel

of fecal contamination during

delivery-thereaft-en, as long as the baby was exclusively breast-fed,

the predominant organism in the stool was

lacto-bacillus. It was not until mothers began to wean

their babies that E. coli began to appear in

appre-ciable amounts; at this time, babies often had

diar-rhea. Gastroentenitis resulting from infections,

unknown in exclusively breast-fed babies, was

common in bottle-fed babies in nearby towns. The

Pan American Health Organization study”’ also

demonstrated that breast-feeding protected

babies against gastrointestinal tract and

nutrition-al diseases, but for the baby to be fully protected,

breast milk had to be given alone, i.e., without

ad-ditional cow’s milk.

The effectiveness with which breast-feeding

MONTHLY MORTALITY RATE BY

TYPE OF FEEDING PER 1000 INFANTS

BREAST FED EXCLUSIVELY L.JJ

PARTIALLY BREAST FEDZ’%%

ARTIFICIAL FEEDINGS[

AGE IN MONTHS

Fic. 2. Monthly mortality rate by type of feeding per 1,(X)0 infants. Data derived from bu’

can remove pathogens from the gastrointestinal

tract has been demonstrated in two

well-docu-mented outbreaks of gastroentenitis in

nun-17, 18 Both outbreaks were attributed to E.

coli 0.111. In both instances, traditional methods

of control, isolation of patients and carriers, and

treatment with appropriate antibiotic drugs, had

proved ineffective. Tassovatz and Kotsich’s’8

ex-penience in Belgrade was more instructive. All

babies in the nursery in which the epidemic

oc-curred were actually being given breast milk,

though babies who had neonatal problems such as

episodes of apnea or jaundice, or who were very

premature and so could not be put to the breast,

were given breast milk which had been boiled.

Seven babies died of gastroenteritis. Although the

epidemic was contained, it was not possible to

eradicate the organism, and babies continued to

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be affected by gastroenteritis spasmodically.

Therefore, after 6 months, charts of the babies

(1,008) who had passed through the unit were

re-viewed. Of 883 babies who had been put to the

breast, none had gastroenteritis, and none had had

stool cultures positive for E. coli 0. 1 1 1. The

re-mainder had been given boiled breast milk. The

16 babies in whom gastroenteritis had developed,

and all those with positive stool cultures, had been

in this group. It was therefore decided to give all

the babies fresh breast milk. There were no

fur-ther cases of gastroenteritis. Within two months,

E. coli 0. 1 1 1 had disappeared from the nursery.

This suggests that at least part of the value of

breast milk lies in a component which is heat

la-bile, possibly an immunogbobulmn.

The value of natural milk and the importance of

local, gastrointestinal immunologic protection has

been highlighted by recent work on calves and

piglets. Both calves and piglets, unlike the human

infant, are normally agammagbobulinemic at

birth, both derive all their immunologic

protec-tion postnatally orally, in colostrum.6 Their

gas-trointestinal tracts are permeable to protein for

only the first day or two of life, and their cobostral

immunogbobulmns are therefore absorbed only if

taken at this time.’9’2#{176}Calves that do not obtain

their fair share of colostrum within 24 hours of

de-livery remain hypogammagbobulmnemic.2’ Such

calves generally develop colibacilbosis and may

die of gastroenteritis or septicemia.2’ Penhale and

his colleagues”” have shown that appropriate

cow 1gM given intravenously protects market

calves against colisepticemia, but not against

cob-ienteritis, and that appropriate colostral whey

given daily protects against colienteritis, but not

against colisepticemia. Adequate protection

re-quires both systemic IgM, derived normally from

colostrum on the first day of life, and daily

cobs-tral whey by mouth.

It might be thought that it would rarely be

necessary to provide calves with artificial feeds,

but this is not the case, since farmers with dairy

herds often prefer to dispose of their calves in

order to market the milk. Other farmers, anxious

to build up herds, prefer to buy young calves.

When this is so, calves have to be provided with

milk replacers. The basis for milk replacers is

nat-urally cow’s milk. There are obvious advantages in

having a ready supply of dried powdered milk that

can be reconstituted as and when necessary.

Studies by Shillam and his colleagues,2628

howev-er, have shown that calves brought up on ultrahigh

temperature-treated milks (heated to 135C for 1

to 3 seconds) or on synthetic diets based on dried

skimmed milk powders, do not gain weight as well

as calves brought up on whole cow’s milk;

enteri-tis often develops. The enteritis causes a

signifi-cant mortality rate. The most effective treatment

for the enteritis is whole cow’s milk, it is much to

be preferred to antibiotic therapy,

chlortetracyc-line, for example.” The available evidence

mdi-cates that colienteritis develops in calves when

they are brought up on dried skimmed and

heat-treated milks because heating denatures the whey

protein containing the immunoglobulmns.

Cohen-teritis is less likely to occur when calves are

brought up on ordinary whole cow’s milk because

the whey and immunogbobulins have not been

de-natured.’9 The analogy with Tassovatz and

Kots-ich’s18 experience is noteworthy. Different

sero-logic types of E. coli usually cause gastroenteritis

in calves, piglets, and human beings, although 026

and 055 have caused scours in calves as well as

gas-troenteritis in human beings30’31; all resemble each

other in that cobostrum followed by breast-feeding

affords protection.

Farmers specializing in raising hogs would

nat-urally like their sows to produce as many litters as

possible in a minimum period of time. They have

therefore wondered if it might not be possible to

bring piglets up, like their human counterparts, on

the “bottle. “ This would enable the sow to be

reinseminated as soon as the piglets had been

de-bivered. Owen and his colleagues at the University

of Saskatchewan have turned their attention to

this problem.3234 They first substituted

intraperi-toneal gammagbobulmn (from pigs) for cobostrum,

and found that though this raised the

immuno-globulins in the serum-if not to normal, to near

normal levels-it did not provide protection

against cohibacibbosis. Daily injections of

immuno-globulins were likewise ineffective. They

con-cluded that systemic protection alone provided no

protection. Cobostrum fed for 24 hours, not

fol-bowed by suckling was also ineffective, even

though serum immunoglobuhins rose to normal

levels, since such piglets brought up on cow’s milk

contracted colibacilbosis and often died. Cobostral

feeding followed by suckling for 4 to 6 weeks

pro-vided complete protection. If the duration of

suckling was reduced, troublesome, but not

neces-sarily lethal, colibacibbosis followed. Having found

that gammagbobulin given systemically afforded

no protection, Owen and his co-workers34

proceed-ed to give gammagbobuhmn orally, the natural

route. When the gammagbobulmn was given orally

for one day, the piglet’s serum immunoglobulmns

rose to near normal levels, but the piglets still died

of colibacilbosis. When, however, they were given

gammagbobulin orally for a minimum of ten days,

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co-ARTICLES 761

hibacilbosis did not develop. Such piglets fared as

well as those brought up on cobostrum and sow’s

milk. These findings are in keeping with the

obser-vations that orally administered type-specific E.

coli antisera protects the gastrointestinal tract

from colonization by the same serological type of

E. coli.”’7 Piglets, like calves, for optimum

growth and freedom from cohibacibbosis, need both

local and systemic protection.’3

It would seem that the human baby, like the

piglet and calf, also requires both. Systemic

pro-tection in the form of transpbacental IgG is not

enough. Only if the baby is given cobostral

anti-body and breast milk will he be spared

gastrointes-tinal infections. 12. 5. 17, 18 The protection afforded

by breast milk is probably only partially

immu-nologic in origin, for the high-lactose,

low-phos-phate, and low-protein content of breast milk

pro-vide a medium in the gastrointestinal tract which

has a low pH, and which is inimical to the growth

of pathogenic E. coli, shigellae and

salmonel-lae.3839 This latter protection is entirely

depend-ent on the baby being given breast milk alone,

be-cause the introduction of cow’s milk, or of other

foods, leads to rapid elevation of the pH of the

stool and colonization of the gastrointestinal tract

with E. coli. If breast-feeding is to be really

pro-tective it must be given alone. Additional

protec-tion is provided by lactoferrin, which has a

power-ful bacteriostatic effect on E. coli.#{176}

Grulee and his co-workers” found that

breast-feeding insured almost complete freedom from

gastrointestinal infections. In light of modern

knowledge this is not surprising. He also found

that it reduced the prevalence of respiratory tract

infections by about a quarter, and reduced the

deaths resulting from respiratory infections by a

factor of more than 100.12 It is a little difficult to

ascribe all these changes to local protection, since

IgA antibodies in cobostrum are not absorbed to

any appreciable extent.7 It would therefore seem

likely that the fall in the prevalence of respiratory

infections is due in part to the exclusion from the

diet of cow’s milk and other food antigens. These

foods can, and not uncommonly do, precipitate

respiratory symptoms, such as rhinorrhea,

bron-chiohitis and “bronchopneumonia,” which are

in-distinguishable clinically from those symptoms

caused by infections.4’4’ The relationship

be-tween food antigens and respiratory disease is easy

to demonstrate because symptoms can be relieved

and reintroduced simply by the exclusion and

reintroduction of the food in question.

In view of these findings, we should ask what,

apart from the provision of calories and

nourish-ment, is the function of breast-feeding.

The gastrointestinal tracts of babies, calves, and

piglets at a time when they are normally being

supplied with breast milk or its equivalent, are singularly susceptible to certain pathogenic strains of E. coli.234344 The human baby is

suscep-tible because antibodies to these organisms, often

present in maternal serum, do not usually cross the

placenta, and are therefore absent or present only

in very low titer in placental serum.45’46 Once,

however, the period of breast-feeding is over,

these same organisms are relatively harmless. This

is strange, for one might have anticipated that

when the child had been weaned he would

be-come susceptible, but being, in some respects at

least, bigger and stronger, he might be better abbe

to withstand the infection. In point of fact, by the age of 12 months, half the infants, whether or not

they have previously had attacks of

gastroenteri-tis, are not only relatively immune to these orga-nisms, but they also have demonstrable antibodies to them in their sera.46 The calf and piglet are

sim-ilarly prone to infection by certain pathogenic E.

coli. If they do not obtain protection in the form of

appropriate antibody,” mainly IgA in the pig,47 in

their respective colostrum and milk, cohibacillosis

develops and they frequently die. They, like the

human baby, have lost their susceptibility to the

same E. coli by the time they are weaned. The

value of secretory IgA probably lies in its ability to

prevent E. coli from adhering to mucosal surfaces

where they liberate the enterotoxins that are

re-sponsible for the severe diarrhea and subsequent

dehydration.48

The same mechanism is operative with regard

to poliomyelitis. Antibodies to the polio virus are

present in colostrum and breast milk.4’ Polio

anti-gens given with breast milk in the neonatal period

do not provoke an antibody response,’#{176}”

never-theless babies given poliovirus vaccine orally

later, while still on the breast, develop antibody

responses indistinguishable from those in babies

brought up on formulas.” If these observations can

be extrapolated to cover other pathogens, we may

assume that breast-feeding, while providing at

least some protection against bacterial and viral

infections, also permits the infant’s immune

sys-tem gradually to assume responsibility for his own

defense. At birth, the infant is entirely dependent

on antibody acquired transplacentally and

pro-vided in colostrum and breast milk, but by the age

of 9 to 12 months he is self-supporting. While he

has been gradually losing maternally derived

pro-tection he has been gradually acquiring his own.

His own immunologic armamentarium is

deter-mined by the organisms and food antigens to

which he has been exposed. Antibodies to foods

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may, by cross reacting with organisms, provide

some degree of protection against organisms not

yet encountered. That this is so is suggested by the

gradual increase in serum immunoglobulmns in the

latter half of the first year of life.

An important function of breast-feeding is

therefore to insure a smooth transition from

de-pendence to independence. In the absence of

breast-feeding, the transition may be difficult,

with a significant increase in infant morbidity and

mortality. The evidence indicates beyond all

question that until the eighth month breast-fed

babies have fewer gastrointestinal and respiratory

tract infections and a greater chance of survival

than have artificially fed babies. This suggests that

the baby should be maintained on the breast and

on the breast alone for 6 months. This will insure

maximum protection and a minimum of exposure

to foreign food antigens during the period in

which his passively acquired transplacental

pro-tection is being replaced by his own antibody

pro-duction. In this context it should be noted that the

human baby, foal, calf, and piglet, in the natural

course of events, remain on their respective milks

until they have lost their passively acquired

im-munity and are beginning to make their own anti-bodies (Table III).

It may, however, be suggested that, in countries

where standards of hygiene are high and facilities

for treating infections are adequate,

breast-feed-ing need no longer be recommended. Babies who

acquire gastrointestinal tract infections can

readi-ly be treated effectively. This is true but, in areas

where hygiene is lacking, as on Indian

Reserva-tions in Saskatchewan, even though nearby

treat-ment facilities are excellent, gastrointestinal

in-fections are only too common. These infections

not infrequently give rise to feeding problems,

secondary disaccharidase deficiencies,

malnutri-tion, and failure to thrive, and the consequent

need for prolonged hospitalization and

hyper-alimentation. Most if not all these problems could

so easily be avoided were all babies, or at least

those at risk, breast-fed. In areas where hygiene is

satisfactory, the administration of cow’s milk and

an ever-increasing number of other foods to babies

at an early age has spawned a new set of problems,

namely recurrent diarrhea, rhinorrhea,

bronchioli-tis, bronchopneumonia and eczema, precipitated

by food antigens.’6 Respiratory illnesses in this age

group can also be caused by respiratory

synci-ytial, parainfluenza, and adenovirus and other

viruses.’7”8 Gastrointestinal tract illnesses can be,

and often are, caused by enteropathogenic

orga-nisms. The elucidation of the cause of these

ill-nesses in any one child is therefore not always

straightforward. The diseases precipitated by

foods are usually associated with negative

re-sponses to skin tests,” they can also occur early in

infancy when serum IgE levels are negligible or

low0 and, on these grounds, are probably not

IgE-mediated. The gastrointestinal disorders are

asso-ciated with an increase in IgA and 1gM

immuno-cytes in the jejunal mucosa, an increase in IgA and

IgM antibodies in the stool, and of IgA

hemagglu-tinating antibodies in the serum.6’ It is not known

whether these reactions are productive of

symp-toms or are protective. In either instance, they

probably indicate an attempt on the part of the

gastrointestinal tract to ward off foreign antigens. Such babies appear to be on the horns of a dilem-ma since, in the absence of a brisk IgA response,

food antigens may be more readily absorbed and

the stage set for priming the IgE antibody system

and the development of atopic disease.62 In

Sas-katchewan we have become very much aware of

the double hazard to which the formula-fed baby

is exposed-on the one hand an increased

suscepti-bility to gastrointestinal infections, as Grulee’s

study’3 indicated, and on the other to an increased

prevalence of gastrointestinal and respiratory

dis-ease resulting from the ingestion of food

anti-gens.6’

The scientist usually endeavors to make sure

that a projected new form of treatment is tried out

initially on an experimental animal. In the matter

of infant feeding, the experiment, which is

artifi-cial feeding, was carried out first in human beings.

It was thought to have been successful. Its

unsuc-cessful application in the pig and calf suggests that

it was not. We are now beginning to realize, hope-fully before it is too late, that there is no adequate

substitute for breast milk.

Fifty years ago, according to Woodbury,’4 90%

of all American babies were put to the breast, and

a little more than 10% were still being breast-fed

at 12 months. Today, at least in Saskatchewan, less

than 50% are put to the breast, and most of these

receive supplements of cow’s milk before they are

2 months old. The majority thrive, so often that

many physicians no longer encourage or

recom-mend breast-feeding; a number even decry it,

be-hieving that the combined efforts of the cow and

the ingenuity of man have produced a perfectly

acceptable substitute. Customs initiated in the

more developed countries are frequently copied

in the less developed countries. It would be a

tragedy of the first order were physicians to

en-courage mothers, living in countries, or in parts of

countries, where standards of hygiene are low, to

abandon the breast for the bottle. The evidence is

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North-ARTICLES 763

em Canada,64 that breast-feeding plays a unique

role in protecting the infant from both

gastrointes-tinal and respiratory disease. It is for this reason

that efforts spent in encouraging breast-feeding

can be expected to pay greater dividends in

re-spect to child health than efforts spent in

engi-neering substitute formulas.

Most of us in the practice of pediatrics, as in so

many other areas, have taken a permissive

atti-tude toward breast-feeding. This attitude is

under-standable, since we presumed that the function of

breast milk was little more than the provision of

nourishment. We now know that breast milk also

provides effective protection, more effective than

antibiotics, against certain common enteric

pathogens, and that it can also be expected to

pro-vide relative freedom in infancy from allergic

dis-ease, a growing problem of modern feeding habits.

Whenever there is a history of troublesome

aller-gies, mothers should be strongly encouraged to

breast-feed their children. And, whether

condi-tions are hygienic or not, we now know that

breast-feeding insures a smooth transition for the

baby from being entirely dependent on his mother

for both his nutritional and immunologic

require-ments to being completely independent. It is this

new awareness of the limitations of formula

feed-ing-now unexpectedly reenforced by animal

models-that makes us have second thoughts on

breast-feeding.

REFERENCES

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ACKNOWLEDGMENT

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1974;54;757

Pediatrics

John W. Gerrard