Breastfeeding: New Horizons

1. Breastfeeding: New Horizons Caroline Steele, MS, RD, CSP, IBCLC Manager, Clinical Nutrition & Lactation csteele@choc.org Children’s Hospital of Orange County Orange, CA

2. Areas of Breastfeeding Research • Breastfeeding & Orofacial Development and Reduction of Risk of Obstructive Sleep Apnea (OSA) • Role of Breastfeeding in Reducing Maternal Risk of Type II Diabetes • Breastfeeding and Maternal and Infant Response to Stress • The Role of Breastfeeding in Fighting Obesity • Breastfeeding and Long Term Health

3. Importance of Breastfeeding to Orofacial Development and Reduction of Risk for OSA

4. BF and Airway Development • Relationship between soft palate and epiglottis is different in infants than adults • When infant’s mouth is closed, epiglottis and soft palate touch • During BF, epiglottis rises and divides the isthmus faucium into two canals • Allows the infant to breathe and swallow at same time • Adults cannot do this • At this time period, infants have airway more similar to other mammals than adult humans

5. Risk Factors for Obstructive Sleep Apnea (OSA) • Large BMI • Large neck • High palate • Narrow dental arches • Overjet • Abnormal tongue activity • Genetic • Result of habits • Bottle feeding • Pacifier use • Thumb/finger sucking

6. Historical Look at Orofacial Structures • Weston Price, MD—1930s • Evaluated nonindustrialized islands/cultures • Evaluated teeth facial contour and mouths of natives and skulls • Nearly all exhibited: • Ideal occlusions • Normal palate height • Wide dental arches • Minimal decay • Common feature: BF was only method of feeding

7. Craniofacial Development • Occurs primarily during first 4 years • 90% is complete by age 12 • Suggests that features that put adults at risk for OSA were likely present at age 12

8. Importance of Breastfeeding “Breastfeeding is important for palate and dental arch shape, alignment of the teeth, as well as the development of a correct swallow and orofacial musculature.” “Breastfed infants have the best chance of developing an ideal occlusion, normal palates, and wide dental arches.” Palmer B. J Hum Lact 1998;14:93-98.

9. Why?? • At birth, natural position for tongue is pushed forward • Protects breast from trauma • Helps compress the lactiferous sinuses • Coordinated effort of mouth, jaw, and facial muscles that occurs during BF ensures proper development of these muscles • Infant’s palate is soft and malleable • BF infants with normal swallow have better chance of developing normal palate height and a dental arch that has a rounded U shape

10. BF and Palate Development • Tongue contributes to shaping of palate • Bottle or pacifier inserted between tongue and palate • Tongue cannot reach palate • Physical contact of bottle nipple or pacifier can actually elevate the height of the palate • Vacuum created by strong sucking can also increase height of palate

11. Swallowing Patterns • Swallowing pattern is developed in infancy • Adult swallowing pattern: • Tip of tongue just behind front teeth • Tongue continues across hard palate in peristaltic motion • During end of swallow, tensor palatini muscles fire and open the eustachian tubes • Muscles elevate and tense so that food/fluid does not escape theough the nose • Tongue does not exert any pressure on the teeth during a correct swallow

12. Bottle Feeding and Swallowing • Less muscle coordination needed • Perioral, facial, and TMJ musculature development may be suboptimal • Artificial nipples vary (size of hole, compression needed, etc.)

13. Bottle Feeding/Swallowing Cont’d • Excessive flow may cause tongue to be placed at back of throat to protect airway • Inadequate flow results in excessive sucking • Potential for collapse of oral cavity • Bottle nipples firmer than breast • Tongue gets drawn inside mouth to protect bottom side of tongue from trauma from gum pad • Tongue thrust often develops

14. Concerns Regarding OSA “Excessive vacuum that may be needed during bottle-feeding and the development of a tongue-thrust are the main contributing factors to the malocclusions that put an individual at risk for OSA.” www.brianpalmerdds.com

15. Relationship During Childhood • Davis and Bell • Strong association between exclusive bottle feeding and malocclusion • Relationship did NOT diminish with change from primary to permanent teeth • Labbok and Hendershot • Longer duration of BF, lower incidence of malocclusion • Bottle feeding leads to habit of tongue-thrusting • Significant decrease in tongue-thrusting with increased duration of BF

16. Conclusions “Breastfeeding reduces the risk of bite relationships the can put an individual at risk for OSA. Since OSA can lead to many health problems, it can be concluded that breastfeeding is critical for the future health of our children.” www.brianpalmerdds.com

17. Role of Breastfeeding In Reducing Maternal Risk of Type II Diabetes

18. Nursing for Good Health • Study of 157,003 women • 2 separate cohorts (83,585 and 73,418) • For each year of lactation, women with a birth in the prior 15 years had a decrease in risk of DM by 15% • Independent of other DM risk factors (BMI, diet, exercise, smoking) • Benefit appears to accrue after 6 months of lactation

19. Nursing and Risk of Type II DM • BF mothers have lower glucose and insulin levels • Hormonal changes of a long period of nursing translate into lower DM risk

20. Maternal and Infant Response to Stress—Benefits of Breastfeeding

21. BF & Infant Stress Response • Leptin (protein produced in adipose tissue and present in human milk) • Reduces responses to stress in infant • Acts on both central (hypothalamus and hippocampus) and peripheral (pituitary and adrenal gland) targets • Reduces exposure to glucocorticoids and enhances brain (hippocampal) development

22. BF & Maternal Stress Response • Reduced cortisol and epinephrine response to physical stress (running on treadmill) • Autonomic response to psychologic stressor (Trier Social Stress Test) blunted compared to bottle feeding mothers • Blunted reactivity to irrelevant stress • Enhanced reactivity to stress threatening mother-infant dyad • Plasma ACTH and cortisol secretion are reduced by infant suckling (lower after nursing than before nursing)

23. Conclusions • Good for babies! • Reduces stress response • Enhances brain development • Good for moms! • Reduces stress response • Assists in filtering irrelevant stress vs. that which poses a “threat” to the infant

24. Breastfeeding & Obesity

25. Obesity in the United States • 65% of adults are overweight or obese • 17% of children 2-19 yrs are overweight • Statistics are on the rise • Causes are multifactoral • BF may play a key role

26. Obesity Theory • Obesity in bottle fed infants historically blamed on overfeeding • Research suggests there may be other physiologic factors at work

27. Role of Hormones in Breastfeeding

28. Prolactin • Released from anterior pituitary gland • Nipple stimulation causes hypothalamus to signal anterior pituitary to release prolactin • Binds to receptor sites on the alveoli • Stimulates the alveoli to secrete milk

29. Oxytocin • CRITICAL in breastmilk production • Released from the posterior pituitary • Released with nipple stimulation or by visual, auditory, or psychological stimuli • Also causes the cells surrounding alveoli in the breast to contract causing milk “let down” (milk ejection reflex or MER)

30. Oxytocin and the GI Hormones • Stimulates the release of GI hormones (insulin,CCK, somatostatin, and gastrin) in both mother and baby. • GI hormones stimulate intestinal villi, increasing surface area for absorption of nutrients in both mother and baby. • CCK also helps regulate caloric intake by inducing satiety, post-feeding sedation, and sleep.

31. Infant Benefits • DARLING study • Infants receiving breastmilk as only milk during first yr were lighter than formula fed infants with similar length and OFC • Energy intake of breastfed infants lower than formula fed infants • Even after introduction of solids • Authors suggest this is a function of self- regulation in breastfed infants

32. Infant Benefits • Grummer-Strawn, et al • Duration of BF (up to 2 years of age) showed a dose-response, protective relationship regarding being overweight at age 4 • Those BF >1 yr had a 51% reduction in risk for overweight than those never BF • No protection against being overweight among those BF for <3 months • ? BF infants tend to adapt more readily to new foods such as vegetables which may influence future food choices

33. Von Kries, et al. • Exclusive BF for 3-5 months associated with 35% reduction in obesity at age 5-6 yrs • Not accounted for by other lifestyle factors • Evidence for a programming effect of BF in preventing obesity later in life

34. Gilman, et al. • Infants fed breastmilk more than formula or BF for longer periods • Lower risk of being overweight during older childhood and adolescence

35. Maternal Benefits • BF mothers lose weight more effectively than bottle feeding mothers • Advantage is seen during at least the first 12 months of BF • May promote awareness of their own nutrition among breastfeeding mothers

36. Conclusions • Good for babies! • May help teach infant to recognize internal hunger cues extending beyond infancy • Eliminates the “clean your plate” mentality • May also be related to something in breastmilk as benefits were seen with breastmilk via bottle as well • Good for moms! • Assists in weight loss post partum • May help promote nutrition awareness

37. Breastfeeding & Long Term Health

38. Immunologic Benefits of Breastfeeding Immunologic Benefits of Breastfeeding

39. VITAMINS NK Cells Mast cells PROTEIN A, C, E Eicosanoids T-cells B-cells Cytokines Macrophages Immunoglobulins Neutrophils Epithelial cells TRACE ELEMENTS FATTY ACIDS Zinc, Iron, Selenium n-3 LCPUFA n-6 LCPUFA The Role of Nutrients in Supporting the Immune System Host Defense Against Infections and Allergy Field CJ et al. J Leukoc Biol. 2002;71:16-32; Kelly DS. Nutrition. 2001;17:669-673.

40. Protective Aspects of Breastfeeding • “Every time a baby breastfeeds, he is immunized.” • Babies who BF utilize immunizations better than those who are formula fed. • Most significant against bacterial infections, infections of the gut (NEC), and respiratory infections. • BF decreases risk of RSV and if they do get RSV there are fewer hospitalizations

41. Immune Response The Breastmilk Army Secretory IgA (Synthesized and stored in the breast) • Secretory component keeps the baby’s gut from digesting the IgA antibody • Binds to pathogens preventing attachment to infant’s cells • Protects the gut mucosa • Prepares the gut for future feeds Leukocytes • Primarily macrophages and neutrophils • Phagocytosis of microbial pathogens Nonspecific factors with antimicrobial effects • Lysozyme (inhibits bacterial growth by disrupting cell wall) • Lactoferrin (limits bacterial growth by removing essential Fe) • Nucleotides (enhance immune function in infants)

42. “Is this the whole story, or are there effects that reach beyond infancy? Do immunologic factors in breast milk influence the development of the infant’s immune system to the extent that they influence the pathogenesis of chronic disease later in life?” Jackson KM, et al. JAOA. 2006;106(4):203-207.

43. BF & Immune System Development • Hasselbach, et al • Confirmed in 2 separate studies • Infants at 4 months had larger thymus glands than those who were partially BF or formula fed • Thymus is central organ in immune system • Responsible for proper development of T lymphocytes • Clinical significance of size of thymus not known; however, role of thymus in T-cell development suggests potential for direct effect of BF

44. Allergy, Autoimmunity, and BF • Meta-analysis of 6 studies showed BF for first 3 months was protective against allergic rhinitis • Review of 56 published articles suggested BF was protective for atopic allergies • Research suggests BF may decrease future risk of autoimmune disorders • May be due to the fact that BF facilitates increased immunologic tolerance

45. Autoimmune Disorders • Crohn’s Disease and Ulcerative Colitis • Higher risk in formula fed vs. BF infants • Type I DM (IDDM) • Largely a result of genetic factors and disregulation of the immune system • Countries with lowest prevalence of BF at 3 months had highest incidence of IDDM • Patients with IDDM were more likely to have been BF < 3 months • Formula feeding in place of BF independently associated with IDDM after adjusting for other variables

46. “Could early consumption of breast milk also provide long-term benefits by protecting individuals from chronic diseases later in life? While the evidence is not conclusive, there is enough evidence to suggest that breastfeeding may significantly alter the immune system of the infant.” Jackson KM, et al. JAOA. 2006;106(4):203-207.

47. Blood Pressure • Meta-analysis by Martin, et al • 15 studies; 17,503 subjects • Small reduction in diastolic blood pressure associated with BF • Reducing Na intake during infancy • Increasing intake of long chain polyunsaturated fatty acids • Protecting against hyperinsulinemia in infancy and insulin resistance throughout life • Could confer important benefits on cardiovascular health at the population level

48. Summary: “What We Eat Can Determine Who We Can Be!*” • Research continues to support that breastmilk is the optimal nutrition. • Research also supports numerous maternal health benefits to breastfeeding. • The best thing healthcare professionals can do is to continue to encourage breastfeeding and support the breastfeeding mother. *Oski FA. Nutrition. 1997;13:220-221.