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LACTATION

promotion of artificial feedings and advertisement of these feedings to the public. The United States did not sign until 1994. The Institute of Medicine, through the Subcommittee on Nutrition during Lactation, con- firmed the position that all women, under ordinary cir- cumstances, should breast-feed their infants and further stated that breast-feeding was ideal, even if the mother’s diet was not perfect. The American Academy of Pedi- atrics, joined by the American College of Obstetrics and Gynecology, stated in 1997 that infants should be ex- clusively breast-fed for five to six months. They further stated that breast-feeding should continue as weaning foods are added through the first year of life and then for as long thereafter as the mother and the infant choose

Significance of Breast-Feeding to Health

Why have all of these important groups spoken out so strongly in favor of breast-feeding? The knowledge that human milk is for the human infant has been accepted for centuries. In the late twentieth century, however, con- siderable scientific investigation established unequivo- cally that breast-feeding is associated with a reduced incidence of infection in the infant, including reduced in- cidences of gastrointestinal, upper and lower respiratory, ear, and urinary tract infections. Immunologic data have shown reduced incidences of childhood-onset cancers, es- pecially lymphoma and acute lymphocytic leukemia. Crohn’s disease, celiac disease, and childhood-onset dia- betes also are reduced when infants are breast-fed for at least four months. Probably the most dramatic informa- tion published in multiple articles is the relationship be- tween breast-feeding and infant development. A study by Niles Newton compared the developmental progress of breast-fed and bottle-fed three-year-olds. Alan Lucas, Ruth Morley, T. J. Cole, and others reported a multisite study that compared premature babies given their mother’s milk by feeding tube with infants given premature-infant formula. The group studied them at eighteen months and followed them until seven and a half to eight years of age. The study showed an 8.5-point difference when the data were adjusted for socioeconomic status and education of the mother. The eighteen-year study by L. John Horwood and David M. Fergusson in New Zealand showed a mea- surable difference at eighteen years of age in school out- comes and behaviors related to whether or not the children were breast-fed in infancy. Although these studies have been criticized for design flaws, many scientists accept their findings. These results are in addition to the compelling psychologic benefit to the mother and the infant in their relationship during breast-feeding.

Facilitating the Decision to Breast-Feed

A mother needs an opportunity to make an informed de- cision about how to feed her infant. If a mother comes to pregnancy without any information on this process, it is the health care provider’s responsibility to see that she is well informed about the benefits of breast-feeding for

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her baby, for herself, and for society so she can make a decision that will be optimal.

The economic benefit of breast-feeding. A simple cal-

culation of the cost of buying formula does not reflect completely the monetary benefits of breast-feeding. It costs between $60 and $80 a month to purchase infant formula, $700 to $1,000 for the first year of life. Careful studies in controlled populations, such as in health main- tenance organizations, have demonstrated in multiple re- ports that infants who are not breast-fed have an increased number of illnesses, visits to the doctor, prescription med- ications, and hospitalizations compared with their breast- fed counterparts. The estimate per infant of the health care costs not to breast-feed is between $600 and $1,000 per year. This estimate does not include the reduction in the onset of chronic illnesses that may last a lifetime, such as diabetes, Crohn’s disease, and allergies.

Benefits to the mother. The benefits of breast-feeding

to the mother are often ignored. Women who breast- feed return to their prepregnant, physiologic states more rapidly. The uterus involutes, the postpartum blood loss is reduced, and the woman returns to her physiologic weight as well. Among other possible benefits are reduced incidences of long-term obesity, breast cancer, ovarian cancer, and most remarkably long-term osteoporosis. Al- though breast-feeding is not a contraceptive, it signifi- cantly affects the fertility in the childbearing years by suppressing ovulation.

Establishing lactation. Critical information about the mother’s potential for a good milk supply is obtained dur- ing pregnancy. When the obstetrician does the early ex- amination of the breasts in the first trimester, the breasts should be evaluated with respect to their potential for producing milk. Unusually small, unusually large, asym- metric, or tubular-shaped breasts may pose a problem. Prior surgery of the breast should be discussed. Lumpec- tomies and augmentation mammoplasty are not con- traindications. Reduction mammoplasty, however, may pose a problem if the integrity of the ducts was inter- rupted. The obstetrician should also evaluate the breasts’ responses to the hormones of pregnancy, the degree of increase in size of the breasts, and changes in the areola and nipple. The obstetrician should discuss with the mother her intentions to breast-feed and address any questions she may have. The mother should be encour- aged to attend breast-feeding preparation classes, which are commonly available at hospitals with maternity ser- vices and at local mothers’ groups.

The breast prepares for lactation during pregnancy by enhancing the ductal system and developing lacteal cells that will produce the milk. From about sixteen weeks in gestation on, the breast is capable of making milk if the fetus is delivered. During pregnancy the placenta pro- duces a prolactin-inhibiting hormone (PIH) that blocks the breast from responding to the abundant prolactin of pregnancy. Once the placenta is delivered, the PIH drops,

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