Breastfeeding

A nutritional journey: from breast milk to infant nutrition

März 2020

As mammals, bre­ast­feeding has always been fun­da­mental practice for sur­vival and deve­lo­pment. Through years the value of this practice changed a lot fol­lowing cul­tural values and society deve­lo­pment. During stone age, bre­ast­feeding was the only optional. No bre­ast­feeding at that period was equal to death (1). For Egyp­tians and Hebrews, children were con­si­dered a “divine gift”. Hebrews and Egyp­tians sought wet nurses to gua­rantee the sur­vival of children sepa­rated from their mothers (2). When wet nurses were not available cow milk was given (1). Walking from Hip­po­crate to Soranus and Galenus arriving to Avicenna a concept was deve­loped: “cha­rac­te­ristics of the nursing mother influence the health of the baby”. Avicenna for the first time said that bre­astfed is the most appro­priate food for growth and deve­lo­pment (1). Aris­totle was the first that dis­cussed milk pro­perties and he under­lined that the healt­hiest milk for children is the one with the lowest quantity of curds (1). In term of solid food intro­duction Hip­po­crates was quite spe­cific. He indi­cated that solid food should be intro­duced as soon as children cut their first teeth, while Soranus sug­gested for weaning the period around 18–24 months and Galen even 3 years (1).

During the 17th and the 18th century two con­cepts were quite clear, the role of colostrum in the pre­vention of gastro­in­tes­tinal infection and high sur­vival rate of children bre­astfed versus children fed by animal milk (3), and to hire wet nurses became a common practice. During the Indus­trial Revo­lution, families moved to cities and due to monetary power, no wet nurses were available and bre­ast­feeding decrease once again. Mothers had no time to bre­astfeed and the use of animal milk increased with sub­se­quent incre­asing level of mal­nut­rition and alter­native foods were intro­duced even within the first week with tragic results and almost 100% mor­tality (4). Several alter­na­tives were pro­posed, firstly diluted animal milk also with sugar and cream addiction, and con­densed milk was dis­co­vered. In 1867 the first com­mercial infant formula from J. Von Liebig was deve­loped  with flour, malt and pot­assium bicar­bonate mixed with pre-​heated milk and in 1874 the first arti­ficial formula milk for feeding infants was deve­loped by Nestlè (5). Alt­hough the very high price of this new formula made it inac­ces­sibly for the majority of popu­lation. The pre­va­lence of bre­ast­feeding reached its low point in 1972, only 22% of newborn infant in USA were bre­astfeed (6), then the rate gra­dually increase, 34% in 1975 and 59.7% in 1985. Actually due to the baby Friendly Hop­sital Initiative launched by WHO and UNICEF in 1991 a support for breast feeding is strong and in a long run (6).

It is quite clear how fun­da­mental is human milk and bre­ast­feeding per se. Spe­ci­fi­cally, human milk has immu­no­lo­gical and nut­ri­tional pro­perties and it is con­si­dered the best available option which gua­rantees an ade­quate growth and an optimal deve­lo­pment of a child. Dif­fe­rences in term of mediators and hor­mones have been shown between infants who were bre­astfed and ones who were not. A key point is repre­sented by unmea­surable envi­ron­mental and psycho-​affective factors. So, it may be sim­plistic to con­sider human milk only as a nut­rient; since it encom­passes much more (7).

Complimentary Feeding

Com­pli­mentary foods are necessary for both nut­ri­tional and deve­lo­p­mental reasons, and are important stages in the tran­sition from milk feeding to family foods (8). The com­pli­mentary feeding period is one of rapid growth and deve­lo­pment when infants are sus­cep­tible to nut­rient defi­ci­encies and excess, and during which there are marked changes in the diet with exposure to new foods, tastes, and feeding expe­ri­ences (8).

Timing of intro­duction is crucial and is fun­da­mental related to phy­sio­lo­gical and neu­ro­lo­gical matu­ration and four to six months of age is the optimal window to introduce com­pli­mentary feeding (9). Renal and gastro­in­tes­tinal func­tions are suf­fi­ci­ently mature to meta­bolize com­pli­mentary food in this spe­cific period of time (9). An early intro­duction of solid food (< 4 months of age) may result in an increase in childhood Body Mass Index (BMI) (10), while iron status of healthy infants could be altered by an earlier intro­duction of com­pli­mentary foods leading to alte­ration of infant iron stores (11). Among other issues, it is crucial to establish pre­fe­rences of fruit and vege­tables when infants are “learning to eat” (8). Fruit and vege­tables are important sources of a wide range of vital micro­nut­rients, and increased con­sumption of these foods can reduce the risks of a number of chronic diseases, including car­dio­vascular diseases (10, 12).

Com­ple­mentary foods must embrace all food cate­gories with an emphasis on vege­tables and fruits. Daily variety, diversity in a meal, and repeated exposure up to eight times are effi­cient stra­tegies to increase accep­tance to foods not initially accepted (9, 13). Pro­moting healthy foods as part of usual meals during com­ple­mentary feeding is important, as eating habits learned in childhood are likely to con­tinue through life (9). There is no need to add sugar or salt to foods and sugar swee­tened beverages. According with Faith et al, fruit juice intake was posi­tively related with adi­posity gain (14). Parental use of food as a reward leads to children’s dimi­nished ability to regulate intake, which then leads to increased emo­tional over eating (15). A high-​protein intake in early childhood may increase the levels of insulin-​releasing amino acids with may sti­mulate insulin and insulin-​like growth factor secretion that could be related to obesity risk later in life (16). Also fun­da­mental is an ade­quate fat intake. Early life stages can be seen as cri­tical periods for fat cell deve­lo­pment and adipose tissue growth in humans, thus the intake of ade­quate fat-​containing essential fatty acids should be pro­moted (9, 17). We need to keep in mind that fat confer a greater energy density to the food for which, for equal volume ingested, the amount of available energy is greater (17). Also the lipid com­ponent of the diet is more quickly con­verted and stored in the form of body fat, with a minimum con­version energy cost com­pared to pro­teins or carbohydrates.

Conclusion

We could con­clude that we need to know whether there are optimum times during the life span when expe­rience pro­motes healthy food con­sumption for a healthy life, and con­versely, when depri­vation of such foods has the greatest con­se­quences on health for generation to come (18).

 

Refe­rences:

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  5. Schuman AJ. A concise history of infant formula (twist and turns included). Contemp Pediatr 2003, 20:91–103.
  6. Eck­hardt KW, Hen­dershot GE. Ana­lysis of the reversal in breast feeding trends in the early 1970s. Public Health Rep 1984, 99:410–15.
  7. Pecoraro L, Agostoni C, Pepaj O, Pie­tro­belli A. Behind human milk and bre­ast­feeding: not only food. Int J Food Sci Nutr. 2018, 69(6):641–646.
  8. Fewtrell M, Bonsky J, Campoy C, et al. Com­ple­mentary feeding. A position paper by the European Society for Paediatric Gas­tro­en­te­rology, Hepa­tology, and Nut­rition ESPGHAN) Com­mittee on Nut­rition. JPGN 2017, 64:119–132.
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  13. Johnson CM, Hen­derson MS, Tri­picchio G, Rozin P, Heo M, Pie­tro­belli A, Ber­kowitz RI, Keller KL, Faith MS Observed parent-​child feeding dynamics in relation to child body mass index and adi­posity. Pediatr Obes. 2018, 13(4):222–231.
  14. Faith MS, Den­nison BA, Edmunds LS, Stratton HH. Fruit juice intake pre­dicts increased adi­posity gain in children from low-​income families: weight status-​by-​environment inter­action. Pediatrics. 2006, 118(5):2066–75.
  15. Faith MS, Rose E, Matz PE, Pie­tro­belli A, Epstein LH. Co-​twin control designs for testing beha­vioral eco­nomic theories of child nut­rition: metho­do­lo­gical note. Int J Obes 2006, 30(10):1501–5.
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  17. Rudolph MC, Young BE, Lemas DJ, Palmer CE, Her­nandez TL, Barbour LA, Friedman JE, Krebs NF, MacLean PS. Early infant adipose depo­sition is posi­tively asso­ciated with the n‑6 to n‑3 fatty acid ratio in human milk inde­pendent of maternal BMI. Int J Obes 2017, 41(4):510–517.
  18. Larquè E, Labayen I, Flodmark C‑E, Lissau I, Czernin S, Moreno LA, Pie­tro­belli a, Widhalm K. From con­ception to infancy – early risk factors for childhood obesity. Nature Rev Endocrinol 2019, 15(8):456–478.

 

Thomas Zoller1, Maria Clemente1, Luca Pecoraro1, Angelo Pietrobelli1,2

1Department of Sur­gical Sci­ences, Den­tistry, Gyne­cology and Pediatrics, Pediatric Clinic, Verona Uni­versity Medical School, Verona, Italy

2Pennington Bio­me­dical Research Center, Baton Rouge, LA, USA.

 

Cor­re­spon­dence:

Prof. Angelo Pie­tro­belli, MD, Pediatric Unit, Department of Sur­gical Science, Den­tistry, Gyne­cology and Pediatrics, Pediatric Clinic, P.le A. Stefani, 1, 37139 Verona, Italy; E‑mail: angelo.pietrobelli@univr.it

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