Amningens betydning i et sundhedsfremmende og forebyggende perspektiv

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1 Amningens betydning i et sundhedsfremmende og forebyggende perspektiv Region Syddanmark Maj 2012 Kim Fleischer Michaelsen Institut for Ernæring og Idræt Københavns Universitet Pædiatrisk Ernæringsenhed, Juliane Marie Centret, Rigshospitalet Percent with full and partial breastfeeding SKOT 2010 Proportion of infants being breastfed at 3 months % Percentage of women partially breastfeeding Age in months 3 Uzbekistan Sweden Tajikistan Norway Poland Armenia Germany Ukraine Switzerland Russian Federation Ireland Latvia United Kingdom % 50% 150 Statens Institut for Folkesundhed august

2 Composition Per 100 ml Human milk Cow s milk Energy kj Fat g Protein g Whey/casein % 60:40 20:80 Lactose g Human Milk 15 2 Oligosaccharides Sodium Effects Focus on term, healthy infants in industrialised countries Relative Risk of Death from ARI and Diarrhea Among Non-Breastfed Children in Two Studies, Compared to Breastfed Infants (set at ARO of 1) WHO Collaborative Team on the Role of Breastfeeding in the Prevention of Infant Mortality, Lancet 2000;55:451-5 Rutstein,S. International Journal of Gyn/Obstet. 2005; 89:S7-S Adjusted Relative Odds of Mortality <2 mo 2-3 mo 4-5 mo 6-8 mo 9-11 mo mo Methodological problems Observational studies unethical to randomize Confounding Breastfeeding mothers higher social class and better educated Definitions of breastfeeding Never BF versus any BF Exclusively, fully, partial Duration of any breastfeeding Alternative to breastfeeding less optimal decades ago Lene Schack-Nielsen og Kim Fleischer Michaelsen Ugeskrift for Læger 2007; 169: 985 2

3 2007 Main conclusions from WHO systematic review and metaanalysis U.S. Department of Health and Human Services Agency of Health and Human Services, 2007 Outcome Effect Comparison Blood pressure Systolic - mmhg Total s-cholesterol mmol/l Overweight or obesity Odds ratio Type II diabetes Odds ratio (-1.7 to -0.7) Smaller effect than other intervention (-0.3 to -0.06) Larger than other interventions 0.78 (0.72 to 0.84) Other interventions no significant effect 0.63 (0.45 to 0.89) Similar to other interventions Intelligence IQ points 4.9 ( ) Other interventions? Warning: 415 pages 3

4 US Department of Health Evidence report BF associated with reduced risk of Acute otitis media Non-specific gastroenteritis Severe lower respiratory tract infections Atopic dermatitis Astma (young children) Obesity Type 1 and 2 diabetes Childhood leukemia SIDS NEC US Department of Health Evidence report 2007 Maternal outcomes BF associated with reduced risk of type II diabetes and breast and ovarian cancer Early cessation or no BF associated with increased risk of postpartum depression No effect on osteoporosis Effect of BF on postpartum weight loss unclear Studies examining BF and later obesity in the offspring What about obese mothers and breastfeeding? children from Czech Republic Followed until age of 6-14 y Controlled for maternal BMI and other confounders Duration of BF: Never < 1mo 1-3 mo 3-6 mo > 6 mo % Overweight : 12.4% 9.7% 9.1% 9.0% 9.0% AJCN 2007 Toschke et al, J Pediatr

5 Better sateity regulation Breastmilk composition and taste changes during a feeding This provides satiety signals for the infant to stop suckling Breastfeeding and the immune system The BF infant plays a more active role in the feeding process Immune systems in Human Milk Secretory IgA antibodies Leucocytes B lymphocytes Macrophages Neutrofiles T lymphocytes* Secretory immunoglobulin A (SIgA) Oligosacharides Bifidus factor Lysozyme Lactoferrin Interferon-gamma* Nucleotides* Cytokines* Thymic size at 4 mo and mode of feeding Hasselbalch et al Acta Paediatr

6 Stimulation of the child s own immune system Thymic size at 4 mo is double the size in BF infants compared to FF Hasselbalch et al Acta Paediatr 1996, 85, 1029 The immune respons after some vaccines is better in BF infants Hahn-Zoric et al. Acta Paed Scand 1990;79:1137 Tuberculin reactivity is transmitted with breast milk Schlesinger et al. Lancet 1977; 2: 529 SIgA content in urine is higher in BF infants Goldblum et al. Saunders 1996, 159 Kidney transplants from a maternal donor is surviving better if the recipient has been BF Campbell et al. Transplantation 1984, 37,340 Breastfeeding and atopic manifestations Multidisciplinary review of the litterature ( ) Odijk et al. Allergy 2003 Breastfeeding seems to protect from the development of atopic disease The effect appears even stronger in families with atopic disease BF and risk of atopic dermatitis during the first 18 mo of life by parental history of allergy Christine S Benn et al. Am J Epidemiol ,430 mother-child pairs enrolled in The Danish National Birth Cohort Data on BF, atopic dermatitis, and potential confounders from telephone interviews Diagnostic algoritm evaluated against clinical examination Cumulative incidence of atopic dermatitis was 11.5 % at 18 mo of age Results Overall, BF was not associated with atopic dermatitis (IRR=0.91, ). The risk differed according to family history No allergic parents IRR=1.29, One allergic parent IRR=1.11, Two allergic parents IRR=0.88, Two parents and one sibling IRR=0.69, AJCN 1999; 70:525 DOES BREASTFEEDING INCREASE INTELLIGENCE LATER IN LIFE? 20 studies meeting initial inclusion criteria 11 studies controlled for 5 covariates BF infants compared to formula-fed infants: Unadjusted benefit of 5.3 ( ) IQ 6

7 US Department of Health Evidence report No relationship between BF in term infants and cognitive performance Relationship between BF and cardiovascular disease unclear Unclear relationship between BF and infant mortality in developed countries Anderson JW et al. AJCN 1999; 70:525 Effet of duration of Breastfeeding BF BF and IQ Meta-analysis Anderson JW et al. AJCN 1999; 70: w 8-11 w w w > 27 w IQ BF and IQ Meta-analysis Anderson JW et al. AJCN 1999 The effect of BF in children according to birthweight Low birthweight 5.18 IQ points Normal birthweight 2.66 IQ points The effect seemed to be independent of age at IQ test (6 mo- 17 y) JAMA individuals born Information on breastfeeding collected at 12 mo 973 men and women examined at 27.2y Wechsler Adult Intelligens Scale (WAIS) 2280 men examined at draft board at 18.7y Børge Prien Prøve Results adjusted for these co-variates Parental social status Parity Parental education Gestational age Birth weight Single mother status Birth length Mother s height Sex Mother s age Pregnancy weight gain Smoking during 3rd trimester 7

8 males and females (27.7 y) IQ by WAIS <1 mo 2-3 mo 4-6 mo 7-9 mo >9 mo males (18.7 y) IQ by BPP <1 mo 2-3 mo 4-6 mo 7-9 mo >9 mo What is the cause of the better IQ? Factors in human milk? DHA incorporation in cell membranes in CNS A plausible biological mechanism Residual confounding Unregistered factors that correlate with both duration of breastfeeding and offspring intellectual development Maternal IQ? Caring ability? Factors associated with the feeding situation? Physical and psychological contact during breastfeeding? - also a cause effect 8

9 Behavioral pattern of the mother Support and stimulation of child Temporal peri-partal impairment in memory and attention and its possible relation to oxytocin concentration Silber at al. Life Sci 1990;47:57-65 Breast feeding Oxytocin Prolactin Bonding LCPUFA Behavioral pattern of the mother Cognitive development Focus more on infant Affectionate touch Less depression 20 pregnant women and controls Cognitive tests of memory and attention Cases improved their performance significantly 6-12 months after delivery compared to late pregnancy and lactatioon (at 3 months) Selective effects of oxytocin on human memory Heinrichs et al 2004, Physiology and behaviour healthy men Intranasal oxytocin or placebo 50 min before tests Oxytocin significantly impaired recall performance From discussion Other studies show impaired cognitive performance in the presence of improved social memory or social behaviour Isolate the mother from distracting stimuli during lactation Focus maternal attention on the interaction between mother and infant Oxytoxin Guastella AJ et al. Biol Psychiatry. 2008;64: Administration of oxytocin to male humans enhances the encoding of positive social information to make it more memorable. Results suggest that oxytocin could enhance social approach, intimacy, and bonding in male humans Kosfeld M et al, Nature : Oxytocin increases trust in humans. These results concur with animal research suggesting an essential role for oxytocin as a biological basis of prosocial approach behaviour. Negative effects on long term health Breastfeeding Brain (maternal) HIV Pollutants 9

10 Breast feeding and HIV 1/3 of pregnant mothers HIV positive 33 out of 100 1/3 of those transmit HIV to the infant 11 out of 100 1/3 of these infants are infected through breast milk 3 out of 100 Pollutants Metylmercury, dioxines, organocloride compounds levels are higher in breastmilk than in infant formula In mothers with high levels the intrauterine exposure is more likely to have negative effects than exposure through breastmilk There is consensus than any potential negative effects through breastmilk is outweighed by the positive effects of breastfeeding Hypernatiemic dehydration during the 2. week Maternal effects 10

11 Breast cancer and BF Collaborative group on Hormonal Factors in Breast Cancer Lancet 2002 Reanalysis of individual data from 47 studies in 30 countries with 50,302 women RR risk of breast cancer decreases by 4.3% for every 12 mo of breastfeeding (p<0.0001) 7% for each birth Maternal body composition Fat stores build up during pregnancy Used as energy stores during lactation Transfer of fat from mother to infant through milk with high milk content Especially fat stores at lower abdomen and thighs are released during lactation Can explain most of the difference between breast cancer in developed and developing countries Sundhedsstyrelsen anbefalinger er: Fuld amning til barnet er omkring 6 måneder, idet de fleste børn kan trives på modermælk i 6 måneder Delvis amning til 12 måneder evt. længere For danske forhold er det ikke relevant at skelne mellem eksklusiv amning, hvor barnet kun får modermælk, og fuld amning hvor barnet evt. får lidt vand ved siden af, men ernæres af modermælk. 4-6 mo 6 mo Population based recommendation 6 (4) 11

12 Information Eksperters indlæg til Flaskebarn,dk Vi har været i dialog med højtplacerede eksperter og erfarne fagfolk, der forholder sig kritisk til den herskende ammepolitik, praksis i sundhedsvæsenet og befolkningens forståelse for mor og barns trivsel når det gælder ernæring. Læs deres indsendte indlæg her. Sigrid Riise, Sundhedsplejersker i 38 år og radiorådgiver på DR Jeg er ikke modstander af amning. Tværtimod. Men det er relevant med kritik af den danske ammepolitik for nybagte mødre føler, at de spiller fallit, fordi de ikke kan amme deres barn. Kvinder skal give bryst for deres egen skyld, og ikke fordi den officielle danske ammepolitik lægger op til, at flest mulige kvinder skal amme... Phillip Granjean, Miljømediciner, Professor, Doktor Forurening af modermælk er i mange år blevet negligeret. WHO forsøger at sætte amningen i så gunstigt et lys som muligt ved bevidst at holde diskussionen af forureningsstoffer ude. Men de positive effekter ved amning bør afvejes over for de negative ved forurening... Joan Bentzen, Cand. scient. og phd. i Sundhedsvidenskab Sundhedsstyrelsen har slet ikke videnskabeligt belæg for sine anbefalinger i»håndbog i vellykket amning«men er præget af manipulering og mangel på videnskabelige dokumentation... Hanne Munch, psykolog på Center for spædbørn Det Spædbarnsvenlige Initiativ er den "ultimative krænkelse". I dag ville det være mere tidssvarende at foreslå, at der skal vises omsorg over for moderen, tages hensyn til moderens ønsker, og at moderen skal spørges, om hun vil amme om hun vil have, at hendes barn skal have en sut etc. Hele stilen og sprogbrugen i WHO s ti bud er krænkende set fra denne synsvinkel... Svend Aage Madsen, chefpsykolog ved Rigshospitalet Sundhedsvæsnet bør ikke fremstille amning som afgørende for en god mor-barn-relation. Dels er det ikke sandt. Dels vil det kunne lægge et pres på mødrene, som kan belaste et sårbart forhold unødigt Han mener, at der er tendenser i både retningslinjer og praksis i sundhedsvæsenet i dag til at lægge et unødigt pres på nybagte mødre... Kim Fleischer Michaelsen, professor i børneernæring Det er ikke farligt ikke at amme, men der god videnskabelig dokumentation for at amning har positive effekter for barnets udvikling, trivsel og risiko for sygdomme. For det enkelte barn er der ikke tale om store fordele og det er bestemt ikke risikabelt eller farligt ikke at blive ammet. Men fordelene er værd at tage med 12

13 WHO curves 0-5 years Mean Z-scores of healthy breastfed infants relative to the NCHS/WHO reference 1 year 2 years 3 years 4 years 5 years Source: An Evaluation of Infant Growth, WHO, 1994 Source: An Evaluation of Infant Growth, WHO, 1994 Eligibility criteria of individuals No health, environmental or economic constraints on growth Mother willing to follow feeding recommendations Full BF 4-6 mo and continued breastfeeding for at least 9-12 mo Term birth Single birth Lack of significant perinatal morbidity No smoking mothers (before and after delivery) 13

14 !!!!! Adoption of WHO Child Growth Standards 1 (December 2010) Comparison of WHO with Danish reference - boys WHO Danish 97th 90th Adoption Status Adopted Weight (kg) Comparison of WHO with Danish reference weight-for-age percentiles for boys 75th 50th 25th 10th 3rd Adoption being discussed Not adopted Status unknown More than 140 countries have adopted the standards 2 1. Zorlu G. Bull World Health Organ. 2011;89: WHO. Accessed November 11, Age (months) BMI (kg/m²) Comparison of WHO with Danish BMI-for-age percentiles for boys Birth to 60 months Comparison of WHO with Danish reference - boys WHO Danish 97th 90th 75th 50th 25th 10th 3rd SKOT Cohort 312 healthy term infants from Copenhagen 54 % breastfed at 9 months Age (months) Kim F Michaelsen - kfm@kvl.dk - Obergurgl January Kim F Michaelsen - kfm@kvl.dk - Obergurgl January

15 Det farlige Det underlige B12 mangel hos ammende mødre!!! 1 ½ år gl. pige på fedtfattig kost næsten uden kød og med rismælk 400 ml sødmælk Rapsolie i maden 15

16 Politiken 31.Maj 2008 Holistisk Ayurveda Psykoneuroimmunologi Dyr fyldes med fortvivlelse og desperation og danner stress hormoner når det skal slagtes. Når man spiser kød spiser man samtidig disse negative Kemiske stoffer Mælk giver øget slim i svælg og luftveje positivt fordi det renser ud Det samme gælder fisk. Man har vist at de udskiller adrenalin og noradrenalin I blodet straks de bliver fanget Current research issues Body composition in infants I en pressemeddelelse peger den ene af forskerne, Mark Kristal, professor i neurovidenskab og psykologi ved University of Buffalo, USA, på, at der i moderkagen findes komponenter, som kan dæmpe fødselsdepression og vanskeligheder ved at skabe en nær tilknytning til barnet. iecology of Food and Nutrition 16

17 Difference in fat mass percentage between breastfed and formula fed infants Gale et al. AJCN 2012 Systematic review with 15 studies included Methods: TBK4, TOBEC, isotope dilution, Pea-Pod, DXA, MRI, or computerized tomography Fat-free mass growth from birth to 6 months of age Fat mass growth from birth to 6 months of age 8 times increase! 2000 g 250 g Department of Human Nutrition and JUCAN Gregers S Andersen Unpublished Department of Human Nutrition and JUCAN Gregers S Andersen Unpublished kfm@life.ku.dk 17