Currently, the trending phrase is ‘fed is best’, which is understandable if one cannot breastfeed due to illness, a mastectomy or other infections. However, these types of sayings tend to equate the nutrition of breastmilk to formula. Research has shown that children who have been breastfed verses formula fed have lower mortality rates, protection against obesity and higher intelligence (Victora, et al, 2016). Increasing numbers of hospitals are supporting breastfeeding mothers: however, supportive information needs to be disseminated beyond the hospital about the benefits of breastfeeding, especially to follow-up pediatricians, nurses, and grandparents, who are the first line of support to new mothers.
Successful breastfeeding happens when a baby is able to maintain a proper supply and demand model. When a baby is hungry, they suckle and drain the milk from the mother’s breast, which signals her breasts to produce more milk to replace the deficit. When this process is interrupted, typically by scheduling, stress, or supplementing with breastmilk alternatives, the mother’s supply of milk will dwindle.
History behind the creation of infant formula
From ancient times (first documented in 2000 B.C.) to the 19th century, women who were unable to or chose not to breastfeed had to rely on the services of wet nurses, which were other lactating women (Wargo, 2016). Alternatives to human breastmilk were also used, such as cow’s or goat’s milk, however this was found to have detrimental effects due to folate deficiency and sometimes led to early-onset hypocalcemic seizures (due to lack of Vitamin D) and kidney disease, as well as disease from microscopic organisms (Wargo, 2016). With the boom of the Industrial Revolution of the 18th and 19th century, came a surge in scientific food achievements. Achievements, such as the discovery of pathogenic microorganisms, led to the invention of pasteurization to eliminate harmful bacterium. As well, the ability to increase the longevity of foods through refrigeration and canning techniques were also discovered. Then in 1838, a German scientist, Johann Franz Simon, published the chemical differences between cow’s milk and human milk, noting the high protein levels and low carbohydrate levels in cow’s milk verses human milk (Wargo, 2016). This then led to the development of the first commercial liquid infant formula by a German chemist, Justus von Liebig to, consisting of bovine milk, wheat and malt flour, and potassium bicarbonate in 1867. Within a year it made its way to the United States (Levenstein, 1988). Around the same time, Swiss chemist and inventor, Henri Nestlé developed the first artificial infant formula, Farine Lactée (Wargo, 2016). This led to the development of powdered infant formulas and a boom in infant formula creations which are constantly changing in an attempt to imitate human milk. It wasn’t until 1980, when the Infant Formula Act was created, that companies were held to a certain standard to ensure the safety and nutrition of infant formulas, including minimum and, in some cases, maximum levels of specified nutrients (Wargo, 2016).
As of 2016, the introduction of infant formula to infants less than 6 months of age is roughly 40% and the introduction of infant formula to infants within the first 2 days is at 20% (CDC, 2019).
So, what is in infant formula? And how does it compare to breastmilk?
Based on the American Academy of Pediatrics (AAP)’s recommendations, the FDA requires the following nutrients be present in all infant formulas: protein; fat; vitamins C, A, D, E, K, B1, B2, B6, and B12; niacin; folic acid; pantothenic acid; calcium; phosphorus; magnesium; iron; zinc; manganese; copper; iodine; sodium; potassium; and chloride (Stevens et al, 2009). Along with the above nutrients, infant formula typically has soy and vegetable oils included. Studies have shown that soy contains phytoestrogens, which may act as endocrine disruptors and interfere with hormonal homeostasis in children (Harlid et al, 2017).
As you can see from this chart, although the above seems identical to the main proponents of breastmilk, there are a plethora of other ingredients in breastmilk that are not included in formula. As well, the nutrients in breastmilk are specifically created for the baby. For example, 50% of iron produced in breastmilk is absorbed and digested in comparison to 7% in infant formula and 10 % in cow’s milk. Mothers create breastmilk specifically made for their child at their specific age with their specific needs.
Breastmilk changes depending on the age and needs of the baby. There are three distinct stages – Colostrum, Transitional Milk and Mature Milk. Colostrum is the first fluid that is produced by the breast after delivery for roughly 7 days. It is a condensed yellow fluid that contains a higher amount of protein, vitamins, immune factors and minerals than mature breastmilk. It also has a laxative effect that helps the baby excrete the dark, tar-like stool produced in the womb (Smolin, 2013, p.605). Transition milk is the milk produced for the following 2 weeks which is creamier than mature milk. Then mature milk is produced from 20 days after birth, onwards. Mature milk can vary in fat levels and immune factors depending on the infant’s need and age.
What are the proteins, lipids, and carbohydrates in human milk?
Lactalbumin is the main protein in breastmilk. It develops into a soft curd that is easily digested and has lower amino acids methionine and phenylalanine than cow’s milk. Amino acids in cow’s milk have been shown to be difficult for infants to digest (Smolin, 2013, p.605). As well, results from the European Childhood Obesity Project supports the ‘early protein hypothesis’, meaning higher levels of protein found in standard infant formulas lead to the body becoming fatter in later years (Petherick, 2010). Breastmilk contains the amino acid, taurine, which is needed for bile salt formation and eye and brain function (Smolin, 2013, p.605). The lipids in breastmilk are high in cholesterol, fatty acids such as linoleic acid, arachidonic acid, and DHA. DHA is essential for proper fetal development including neuronal, retinal and immune function (Horrocks, 1999). The primary carbohydrate in breastmilk is lactose, which is digested slowly to allow the growth of acid-producing bacteria.
A large difference between human breastmilk and infant formula are human milk oligosaccharides (HMO). HMO’s are a group of complex sugars and over a hundred different HMOs have been identified. They vary depending on the women and more studies are being done on the function of each HMO. HMOs are important in that they seed the gut and shape the infant’s gut microbiome by helping it to colonize beneficial bacteria such as Bifidobacterium. It helps the infant to block the attachment of viral, bacterial or parasitic pathogens to epithelial cells and may prevent infectious diseases (Bode, 2015). Human breastmilk also contains enzymes and hormonal growth factors. The enzymes are digestive and antioxidative enzymes such as amylase, lipase, lactoperoxidase, and superoxide dismutase. Some of the hormonal growth factors are epidermal growth factor and insulin-like growth factor. Breastmilk also has immunity factors such as lysozyme, secretory IgA, cytokines, and leukocytes (Bode, 2015). This is a quick summary of the additional ingredients in human breastmilk and the benefits of each.
Studies have shown that breastfeeding can lead to disease prevention by enhancing immune protection. Breastmilk has been shown to decrease ear infections, respiratory illnesses, asthma, and chronic digestive diseases. It also lowers risk for obesity, type 1 and type 2 diabetes, heart disease, hypertension, high blood cholesterol, and childhood leukemia (Victoria et al, 2016).
Along with the nutritional and health factors, breastfeeding also helps create a physical bond between the mother and infant. It helps to decrease postpartum depression in the mother and aids in the development of the facial muscles, speech development, and correct formation of teeth in the infant (Smolin, 2013, p.605). When an infant suckles at the mother’s breast, it also sends signals to the uterus to continue uterine contractions to help the uterus return to normal size.
With the proper amount of support and diet, most women should be able to properly breastfeed. There are however contraindications of breastfeeding, meaning circumstances or cases where breastfeeding should not occur. One of them is a rare genetic condition called Galactosemia, where the infant cannot process galactose and can be life-threatening if untreated. These babies would be given soy-based formulas or if they cannot digest soy, there are some formulas with very little galactose (Berry, 2017). Other reasons to avoid breastfeeding are if the mother is HIV or HTLV positive, uses an illicit street drug or has the Ebola virus (Davanzo, 2018). Human milk banks are possibly available for mothers in these situations, so the infant can still benefit from human milk, especially infants that are born prematurely. Human milk banks are places where women can either donate or obtain human milk for consumption. These banks typically pasteurize the human milk before distribution and have screening tests to determine the safety of the donor’s milk. There are also online forums where women can donate directly to other mothers in need, however these forums are likely not regulated or screened.
There are times when mothers should temporarily stop breastfeeding. These are mothers with untreated brucellosis or mothers taking certain medications. Hotlines such as the Infant Risk center can help with determining which medications pass through the breastmilk and which ones are safe while breastfeeding). Other examples are mothers undergoing diagnostic imaging with radiopharmaceuticals, and mothers who have herpes simplex virus (HSV) lesions present on the breast (although mothers can breastfeed directly from the unaffected breast) (Davanzo, 2018). Pumping and dumping through these times are needed in order to maintain milk supply.
Another possibility is relactation, which is when suckling of the infant, even after a stretch of not breastfeeding, can stimulate the hormone prolactin, which signals the mammary glands to produce milk again. An example of this is when a mother is going through cancer treatments and has to stop breastfeeding due to the medications. Once the medications have cleared her system, she can put her baby to her breast for a couple of weeks to see if milk reappears.
With the current breastfeeding trends having been addressed, as well as the benefits and contraindications of breastfeeding, we will explore foods that are beneficial for lactating mothers. A big myth is that a mother’s diet does not change the composition of her breastmilk. Studies show that fatty acids such as Arachidonic acid (AA) and docosahexaenoic acid (DHA) are greatly influenced by the mother’s diet (Bravi et al, 2016). AA and DHA can be found in duck, poultry liver, eggs, and fatty fish like salmon. As discussed, DHA is essential for brain and nervous system development. Other studies have also shown the breastmilk of vegan mothers are typically lower in Vitamin B12, Iron and Zinc and may need to increase these nutrients either through food or supplements to provide adequate levels (Pistollato et al, 2015).
A nutrient-dense whole foods diet is beneficial for a lactating mother. The mother should increase her caloric intake to compensate for the energy needed during lactation. Average increase in daily amount should be around 500 calories for the first six months and 400 calories for the next six months. This would help to ensure appropriate nutrients are not being depleted from her needed stores. With regards to the actual foods, suggestions would be to eat organic, grass-fed sources of proteins, complex carbohydrates from whole grains and complex vegetables, a balanced ratio of omega-3 and omega-6 fats, and fruits and seeds. Some mothers seek out galactagogues, which are supplements or pharmaceuticals that promote lactation in mothers. The efficacy of the herbal supplements like Shatavari, fenugreek, silymarin, garlic, and malunggay are mixed and more studies are needed (Bazzano et al, 2016). Overall, as long as the lactating mother is eating a nutrient dense, whole food varied diet, she should be successful in creating breastmilk.
The largest deterrent to breastfeeding is dwindling milk supply. This is typically due to lack of feeding on cue, the mother returning to work and not having proper support in the workplace to pump and maintain her supply, or the cultural difficulty of breastfeeding in public. Thankfully, there are resources and associations to help empower mothers to breastfeed. La Leche League is an international nonprofit breastfeeding advocacy group. Local chapters hold meetings to provide breastfeeding information and support. The World Health Organization is a great resource for parents to find the latest breastfeeding statistics and guidelines. If the breastfeeding mother is having problems with either latch or milk supply, another resource is an International Board Certified Lactation Consultant (IBCLC). An IBCLC is a healthcare professional who specializes in the clinical management of breastfeeding. They are certified and work in a wide variety of settings, providing leadership, advocacy, professional development, and research in the lactation field.
In summary, infant formula should only be introduced on rare occasions and only after breastfeeding is no longer a viable option. The pros of breastfeeding outweigh the cons and with proper support from hospital staff, family members and the community, along with a nutrient-dense diet, a breastfeeding mother should have more success in feeding her infant, human breastmilk.
Stephanie Buck is a certified birth and postpartum doula, CD(DONA). Stephanie graduated Summa Cum Laude this past July from Hawthorn University’s Master of Science in Holistic Nutrition program. Stephanie also holds a MA in International Policy and Commerce from George Mason University. After overcoming pregnancy difficulties and a rare trachea cancer, she switched from a career in the defense industry to focus on women’s wellness. Stephanie’s focus is on fertility, prenatal and lactation nutrition. When she’s not working, Stephanie can be found tending to her bees, hiking along the trails in Maryland with her boys or talking about ways to detox from environmental toxins.
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