Amning og amningens effekter - Dialog

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
90
80
70
60
50
40
30
20
10
Age in months
3
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Percentage of women partially breastfeeding
%
100
4
100 %
50%
150
Statens Institut for Folkesundhed august 2011
6
1
Composition
Per 100 ml
Human milk
Energy kJ
310
Fat g
4.0
Protein g
0.9
Whey/casein %
60:40
Lactose g
60
Human Milk 15
Oligosaccharides
Sodium
15
Cow’s milk
290
3.8
3.1
20:80
40
2
58
7
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-S24..
Focus on term, healthy infants in
industrialised countries
Adjusted Relative Odds of Mortality
Effects
7
6
5
4
3
2
1
0
<2 mo
2-3 mo
4-5 mo
6-8 mo
9-11 mo
12-24 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
2007
Main conclusions from
WHO systematic review and metaanalysis
Outcome
Effect
Comparison
Blood pressure
Systolic - mmHg
-1.21 (-1.7 to -0.7)
Smaller effect than
other intervention
Total s-cholesterol
mmol/l
-0.18 (-0.3 to -0.06)
Larger than other
interventions
Overweight or
obesity
Odds ratio
0.78 (0.72 to 0.84)
Other interventions
no significant effect
Type II diabetes
Odds ratio
0.63 (0.45 to 0.89)
Similar to other
interventions
Intelligence IQ points 4.9 (3.0-6.9)
U.S. Department of Health and Human Services
Agency of Health and Human Services, 2007
Other interventions?
http://www.ahrq.gov/clinic/tp/brfouttp.htm Warning: 415 pages
3
US Department of Health
Evidence report - 2007
• 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
Studies examining
BF and later obesity
in the offspring
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
What about
obese mothers
and
breastfeeding?
• 33.768 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 2002
4
Better sateity
regulation
Breastmilk composition
and taste changes
during a feeding
Breastfeeding and
the immune system
This provides satiety
signals for the infant
to stop suckling
The BF infant plays
a more active role in
the feeding process
Secretory IgA antibodies
Immune systems in Human Milk
• 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 1996
5
Stimulation of the child’s own
immune system
• Thymic size at 4 mo is double the size in BF
infants compared to FF
Breastfeeding and atopic manifestations
Multidisciplinary review of the litterature (1966-2001)
Odijk et al. Allergy 2003
– 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
• Breastfeeding seems to protect from the
development of atopic disease
• The effect appears even stronger in families with
atopic disease
• Kidney transplants from a maternal donor is
surviving better if the recipient has been BF
– Campbell et al. Transplantation 1984, 37,340
Results
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 2004
• 15,430 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
• Overall, BF was not associated with atopic
dermatitis
– (IRR=0.91, 0.80-1.04).
• The risk differed according to family history
• No allergic parents
– IRR=1.29, 1.06-1.55
• One allergic parent
– IRR=1.11, 0.94-1.31
• Two allergic parents
– IRR=0.88, 0.69-1.13
• Two parents and one sibling
– IRR=0.69, 0.47-1.00
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 (4.5-6.1) IQ
6
US Department of Health
Evidence report - 2007
• 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
BF and IQ – Meta-analysis
BF and IQ – Meta-analysis
Anderson JW et al. AJCN 1999
Anderson JW et al. AJCN 1999; 70:525
Effet of duration of Breastfeeding
BF
4-7 w 8-11 w 12-19 w 20-27 w > 27 w
IQ
-.02
1.68
2.15
2.78
2.91
JAMA 2002
• The effect of BF in children according to
birthweight
– Low birthweight
– Normal birthweight
5.18 IQ points
2.66 IQ points
• The effect seemed to be independent of
age at IQ test (6 mo- 17 y)
Results adjusted for these
co-variates
• Parental social status
• Parental education
• Single mother status
• 9125 individuals born 1959-61
– 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
• Mother’s height
•
•
•
•
•
Parity
Gestational age
Birth weight
Birth length
Sex
• Mother’s age
• Pregnancy weight gain
• Smoking during 3rd trimester
7
108
973 males and females (27.7 y)
IQ by WAIS
2280 males (18.7 y)
IQ by BPP
41
106
104
40
102
39
100
38
98
96
37
<1 mo
2-3 mo
4-6 mo
7-9 mo
>9 mo
What is the cause of
the better IQ?
Residual confounding
Unregistered factors that correlate
with both duration of breastfeeding
and offspring intellectual
development
Maternal IQ?
Caring ability?
<1 mo
2-3 mo
4-6 mo
7-9 mo
>9 mo
Factors in human
milk?
• DHA incorporation in cell
membranes in CNS
–A plausible biological
mechanism
Factors associated with
the feeding situation?
Physical and psychological
contact during breastfeeding?
- also a cause effect
8
Behavioral
pattern of
the mother
Temporal peri-partal impairment in
memory and attention and its possible
relation to oxytocin concentration
Support and
stimulation
of child
Breast
feeding
Silber at al. Life Sci 1990;47:57-65
LCPUFA
Oxytocin
Prolactin
Bonding
Behavioral
pattern of
the mother
Cognitive
development
Focus more on infant
Affectionate touch
Less depression
Selective effects of oxytocin on
human memory
Heinrichs et al 2004, Physiology and behaviour 2004
• 38 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
• 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)
Oxytoxin
• Guastella AJ et al. Biol Psychiatry. 2008;64:256-8.
– 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 2005 435:673-6.
– 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
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
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
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…
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Mean Z-scores of healthy breastfed infants
relative to the NCHS/WHO reference
WHO curves 0-5 years
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
Comparison of WHO with Danish reference - boys
Adoption of WHO Child Growth Standards1
(December 2010)
97th
WHO
Danish
90th
20
75th
! !
!
25th
10th
3rd
10
Weight (kg)
!
15
!
50th
Comparison of WHO with Danish reference
weight-for-age percentiles for boys
Adoption Status
5
Adopted
Adoption being discussed
Not adopted
More than 140 countries have adopted the standards2
Status unknown
1. Zorlu G. Bull World Health Organ. 2011;89:250-251.
2. WHO. http://www,who.int/global_health_histories/seminars/presentation48b.pdf.
Accessed November 11, 2011.
Comparison of WHO with Danish BMI-for-age percentiles for boys
8
12
16
20
24
28
32
36
40
44
48
52
56
60
64
Age (months)
79
312 healthy term infants from Copenhagen
54 % breastfed at 9 months
WHO
Danish
18
20
4
SKOT Cohort
60 months reference - boys
Comparison of WHOBirth
withto Danish
97th
90th
16
75th
50th
14
25th
10th
3rd
12
BMI (kg/m²)
0
0
4
8
12
16
20
24
28
32
36
40
44
48
52
56
60
64
Age (months)
Kim F Michaelsen - kfm@kvl.dk Obergurgl January 2005
83
Kim F Michaelsen - kfm@kvl.dk Obergurgl January 2005
84
14
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
• Holistisk
• Ayurveda
• Psykoneuroimmunologi
Politiken
31.Maj 2008
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
Det samme gælder fisk. Man har vist at de udskiller adrenalin og noradrenalin
I blodet straks de bliver fanget
Mælk giver øget slim i svælg og luftveje – positivt fordi det renser ud
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. i Ecology of Food and Nutrition 16
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