Long breast feeding and heart disease
Long breast feeding and heart disease Janak Upadhyay 16.03.2001
Re: long breast feeding and heart disease André Briend 16.03.2001
Re: long breast feeding and heart disease David Morley 16.03.2001
Re: long breast feeding and heart disease S.K Roy 17.03.2001
Re: long breast feeding and heart disease Genevieve Becker 17.03.2001
'long' breastfeeding Barbara Elaine Golden 17.03.2001
Re: long breast feeding and heart disease Gulnara Semenova 19.03.2001
Re: severely malnourished infants under 6 months Gulnara Semenova 21.03.2001
severely malnourished infants under 6 months André Briend 26.03.2001

Date: Fri, 16 Mar 2001 07:55:32 +0100
From: Janak Upadhyay <
Subject: long breast feeding and heart disease

dear colleagues,
to-day morning in the sky news it was reported that long breast feeding (more than 6 months) is associated with higher risk of heart disease. this finding, although not conclusive, will have serious implication on the work of many nutritional professional.
my e-mail is to raise this issue and have guidance on our position as a professional.

Date: Fri, 16 Mar 2001 09:43:45 +0100
From: "Andre' Briend" <
Subject: Re: long breast feeding and heart disease

Dear Janak,

The term "long breast feeding" to describe breast feeding more than 6 months is not appropriate. For the last 3 - 6 millions years of evolution of our species, breastfeeding lasted 3 to 5 years. Whatever may the predominent view on this, breast feeding below 2 years should be regarded as "short breast feeding".

I do not know these papers about breastefeeding after 6 months and CVD. I would be interested to see the evidence. Having said that, it may be relevant to remind that in developing countries breast feeding is associated with improved survival well after 6 months of age, especially in case of high prevalence of malnutrition. I worked on this topic a few years ago (see refs below), but this was also shown by others.

Unfortunately, the benefits of breast feeding now must be balanced with the risk of HIV transmission in high prevalence area.

Best regards,


André Briend, MD, PhD
5 rue du Vertbois,
75003 Paris, France
tel : 33-1-53 01 80 36 U 557 , fax : 33-1 53 01 80 05 ISTNA/CNAM

From: "David Morley" <Davidatmorleydc.demon.co.uk>
Subject: Re: long breast feeding and heart disease
Date: Fri, 16 Mar 2001 10:09:07 -0000

Dear Janak, There was a study I think Ann burgess was involved in Uganda, this showed that in the second year of life Breast milk was responible for half the calores. I reproduced the study in a diagram in my book My Name is Toaday page 326 { Mc Millans}

Date: Sat, 17 Mar 2001 10:42:15 +0600
From: "Dr.S.K Roy" <
Subject: Re: : long breast feeding and heart disease

We must know in detrails and examine it seriously.


GPO Box 128
fax 880-2-8823116
email:swapanaticddrb.org, skroyaticddrb.org

From: "Becker" <beckeratiol.ie>
Subject: Re: long breast feeding and heart disease
Date: Sat, 17 Mar 2001 13:03:13 -0000

The research study is in the British Medical Journal of March 17, 2001 available at www.bmj.com The research paper is by Lesson CP, Kattenhorn M, Deanfield JE and Lucas A. The BMJ also has an editorial on the article.

If you read the whole research article, the authors clearly state "We emphasise that our observational data do not establish a causal relationship between length of breastfeeding and cardiovascular disease. " This emphasis is not in the abstract. However the abstract does conclude "These data should not alter current recommendations in favour of breastfeeding, which has several benefits for infant health."

The 'long' breastfeeding mentioned is over four months! Hardly long!

A colleague of mine spoke to Alan Lucas by telephone and Alan Lucas was shocked at the way the study was being reported by the media. Alan was to be interviewed on BBC yesterday (Friday) to say the results were just an observation and breastfeeding over 4 months should continue widely.

On a side thought - both the research unit and the editorial writer disclose funding support from infant formula companies.

Genevieve Becker
Breastfeeding Researcher
Galway, Ireland

From: Barbara Elaine Golden <chl037atabdn.ac.uk>
Subject: 'long' breastfeeding
Date: Sat, 17 Mar 2001 17:20:45 +0000 (GMT)

Alan Lucas has long been a proponent of breastfeeding and has carried out several sentinel studies on the advantages wrt mental development in preterm infants. He did this study because of the mounting evidence of effects of early feeding on the development of CV disease and the reports in other primates. It was opportunistic and observational. The association found is not necessarily sound - it may or may not be able to be repeated prospectively - nor does it show cause and effect. However, it is strong enough to have to be reported. I only think it's a pity that they chose to give it to the BMJ as this ensured lay coverage with distortion of the facts. What he has signalled is the need for further studies, critical review and prospective research and, if shown to be sound, hypotheses to explain it. I asked him, in passing, whether the rates of weight gain (from 4 months on) had been taken into account and, having read the article, must ask him again as this isn't satisfactorily answered

.Barbara G

Barbara E Golden BSc MD FRCPI FRCPCH DCH RNutr
Dept Child Health, University of Aberdeen
Medical School, Foresterhill, Aberdeen AB25 2ZD
Phone: (44) 01224 553894
Fax: (44) 01224 663658

Date: Mon, 19 Mar 2001 13:51:21 +1100
From: Gulnara Semenova <
Subject: Re: long breast feeding and heart disease
Cc: Ted Greiner <


Dear all,

Sorry for my late reply

If you have not already seen, please have a look at the articles at the BMJ and responses, they are very good.

- Ted Greiner made a good point , that it is ethically impossible to randomize breastfed and bottlefed infants groups for research purposes, therefore we would never know for sure does breastfeeding or not have a definite protective effect. But looking at the number of epidemiological studies from all around the world we see that breastfeeding advantages outweigh any hypothetical disadvantages, even for HIV.

- The study has been funded by formula companies and it was reported in the article.

- I have email from UK and it says that Lucas himself was deeply shocked by the interpretation of his study by the media and by the reported conclusions. I'd like to believe.

- The response rate in the study was only 28%, is it enough to make any conclusion from? Certainly enough for the media

- I found several articles at the LRC which might help. I will write a small resume and send it to you, if I have a time. Shortly, once again further studies are necessary, confoundings made the results from different studies inconclusive, however:

1) the study in Dundee( by A. Wilson), 1998 BMJ vol 316, found that systolic blood pressure was raised significantly in children who were exclusively bottle-fed compared with children who received breast milk. Breastfeeding was studied for about 15 weeks, so it is shorter than in the Lucas article.

2) There are couple of articles about breastfeeding protects against obesity. and the obesity is a known risk factor for the heart diseases. By Von Kries et al, 1999, Breastfeeding and obesity, cross sectional study, BMJ ,319. Conclusion: 9357 children aged 5 and 6 have been studied. The prevalence of obesity in children who have never been breastfed as 4.5% compared with 2.8% in breastfed children. A clear dose response effect was identified for the duration of breastfeeding on the prevalence of obesity: the prevalence was 3.8% for 2 months exclusive breastfeeding, 2.3% for 3-5 months, 1.7% for 6-12 months, and 0.8% for more than 12 months. Similar relationships were found with the prevalence of being overweight. After adjusting to potential confounding factors, breast feeding remained a significant protective factor against development of obesity( odds ratio 0.75,95%CI0.57 to0.98) and being overweight(0.79, 068 to 0.93).

- in article by Rolland-Cachera et al, 1999,Acta pediatr 98, increasing prevalence of obesity among 18 year old males in Sweden; evidence for early determinants, they speculate:. That increased prevalence of obesity, might be related to the high protein intake early in infancy, which affects hormonal status. Altered hormonal status in obese children( high IGF-1 and reduced GH) could be a mirror image of protein deprivation, and then the consequence of an excess of protein intake. Then they speculate further about protein and android body fat distribution and a role of excessive protein intake in the development of metabolic complications of obesity, such as insulin resistance and cardiovascular disease.

Breastfeeding and obesity studies results are also non conclusive as some studies did not find any correlations. But why we cannot be biased too?

3) by Prof Davies University of Whales college of medicine, BMJ 1995(310)" IN some early studies the low birth weight infants have been linked with later risks of high blood pressure and IHD. The typical pattern of early weigh gain is to catch up- to reach a higher centile than they were at birth. This phenomenon is also found in some infants of appropriate weight for gestation. Some heavier children at one year will therefore probably be those who have caught up from intrauterine growth retardation. On the other hand, these are considered to be at risk of later cardiovascular disease, yet we now hear that they seem to be advantaged in being less vulnerable to alter coronary artery disease. It is an intriguing possibility that early growth may somehow be related to programming of later disease. But the literature on the subject contains contradictions that need to be explained."

4) there is a number of articles by Baur from Sydney( 1998, Metabolism, 47, vol 1) on investigating interrelationships between type of feeding and skeletal muscles phospholipid fatty acids composition and glucoregulation in young children.

Low levels of DHA and LCPUFAs in skeletal muscles membrane phospholipid are associated with insulin resistance and obesity in adults.

Baur found that breastfeeding increases LCUFA level in skeletal muscles membrane and early development of relatively higher levels of LCPUFAs in the fasting plasma glucose. Early changes in skeletal muscles membrane phospholipid FA saturation may play a role in the subsequent development of diseases associated with insulin resistance.

Baur studied children up to 2 years who came to elective surgery, the formula fed group were who were breastfed for less than 4 weeks. Breastfed group- still being breastfed at the time of surgery. Average age for both groups was 0.59(ff) ad 0.54(bf) yr

5) Genetic issue cannot be ruled out. Lipoprotein concentration in toddlers serum is correlated with CHD in their grandparents( Routi et al, 1996, Acta Ped 85, 407-12)

and although below is not related to the heart disease we discuss now(, but to the role of media in interpretation of study results), beware of

6) a new article on breastfeeding and asthma.( Thorax, 2001, 56) The study reported that Children who were atopic and had asthmatic mothers( 6% of population) were more than eight times as likely to have asthma and six times as likely to have a recurrent wheeze after age six if exclusively breastfed. I did not see yet the study, but we are trying to get it as soon as possible to the LRC.

Gulnara Semenova,

Director, Lactation Resource Centre, NMAA

Date: Wed, 21 Mar 2001 12:41:35 +1100
From: Gulnara Semenova <
Subject: Re: severely malnourished infants under 6 months


Dear Adrienne,

Thank you for your message.

I think that the basic approach is to re-establish lactation, but simultaneously to feed a baby with either a formula or expressed breast milk. There are a number of books available on how to do it and the supplement line is also useful. It is necessary to identify first why baby is malnourished and why breastfeeding is not successful. The main problem might be related to the poor attachments and positioning of the baby at breast, ineffective suckling, restricted feedings, water or formulas supplementation, separation of mother and child soon after delivery, infections, LBW etc. You have to fix all of this, therefore it is necessary to train a caregivers on breastfeeding management and to extend the BFHI 10 Steps to successful breastfeeding [principles to the maternity services available at the place you are working or at the community health services. If mother of infant is dead, than it would be difficult to provide the baby with breastfeeding, unless the wet nursing is common in the community or for a grandmother to become a wet-nurse, then the HIV vertical transmission risk should not be overlooked.

The cup feeding technique is described in several documents produced by WHO Geneva and WHO Euro).

Look at the manuals for the 40-hour breastfeeding counseling course, by WHO Geneva, 1993. Or you can contact Dr. Felicity Savage King, as she is a primary author of many pages of this manual. He email is <savagekingfatwho.ch>.

Re what formula is the best one to use, it is difficult to me to advice as I never worked with severely malnourished infants. Basically all formulas are the same, but for severely malnourished might be a special one. I think you better to discuss this with Dr.Michael Golden, as he is the author of the WHO publication on severely malnourished infants, he also has a lot of experience working with refugees and particularly on lactation.

I have a concern, if you are going to recommend to use formula for severely malnourished infants at the hospital setting it is one thing, but you have to ensure the provision of the formula and it should comply with the International Code. If this for the home settings, then there are lots of problems, as the cost of formula is high and water and sanitary conditions usually are very bad. Of course formula seems to be a better solution, but you have to look at the reality, who can afford it and probably also to teach the mother how to make a simple formula at home, using a cows milk( this approach was undertaken by WHO at the breastfeeding and HIV course), but it is also have the same problems with safe water and fuel, etc. and was criticized. Re-lactation is the best solution of course. For the orphans it is a different story, but how many of them do you have in your region? Is it a big proportion? If not you might need some sort of a guidelines on infant feeding in a special circumstances, so it won't affect the general population.

Look at the draft of the Global strategy on infant and young child feeding for some strategic approaches.

For more specific answers I suggest you to contact directly

  1. Felicity Savage King( WHO, Geneva)
  2. Randa Saadeh, WHO Geneva,<saadehratwho.ch)
  3. James Akre, WHO Geneva(akrejatwho.ch>
  4. Michael Golden(UK, Aberdeen)<refugeesatabdn.ac.uk>
  5. Aileen Robertson( WHO EURO Regional Advisor on nutrition)>AROatwho.dk)
  6. Viviana Mangiaterra(WHO EURO, regional advisor on MCH)<VMAatwho.dk>
  7. Helen Armstrong(UNICEF NY, consultant on infant nutrition)<harmstrongatunicef.org>
  8. Fabio Uxa, neonatologist from Trieste, the author and team member for the WHO appropriate technology following birth, his email is< uxaatburlo.trieste.it>
  9. Dr. Audrey Naylor from Wellstart(kindatwellstart.org)

Hope it helps

Gulnara Semenova


At 03:52 PM 19/03/01 -0800, Adriana Hernandez wrote:

Dear Gulnara,

I saw your reply for "long breastfeeding" message and I would want your opinion, if it is possible on the next issue: We are assisting the development of national guidelines for the care of severely malnourished hospitalized children. One of the most complicated issues is the issue of severely malnourished infants under 6 months of age. None of the publications we have access to (including the recently published WHO manual "Management of severe malnutrition"), provides specific information on this issue.

We had received the suggestion of a regimen with infant formula with short peptides instead of complete proteins, preferably to be fed by naso-gastric tube, because these children are not able to digest complete proteins and therefore need a formula with peptides.

We are putting emphasis on breastfeeding, breastmilk and relactating, because severely malnourished <6 mo. old infants apparently are not able to breastfeed because of anorexia, weakness, etc..

We are looking for more information (if this exists) or recommendations, on:

1. What to feed the infant

Obviously there is a problem with breastfeeding if a baby <6 mo. old is severely malnourished: the mother is not there, has died, etc., and/or the baby is fed inadequate complementary feeding in combination with little or no breastmilk or formula. While breastfeeding is stimulated and/or relactation is started, but also if this is not feasible (mother not available/baby orphaned) the infant must be fed something. For older children, formula F-100 is recommended but it has complete proteins too. What happen with the digestion by severely malnourished infants < 6mo. of age? Are there other experiences?

2. How to feed the infant

According to the information we have access to, severely malnourished children are too weak, anorexic, etc. to suckle at the breast or to sip from a cup. Feeding through NG tube is often mentioned. The WHO manual insists that NG feeding should be as limited as possible, but it is probably required during the first days. We were informed about some good experiences with syringes in Honduras. We have not been able to find any information on cupfeeding in malnourished <6mo. children. What is your opinion / experience? And what about breastfeeding, including with a supplementer?

We would appreciate any information, suggestions for literature or people to contact for more information.

Kind regards,

Adriana Hernández Santana, ahernandezatunicef.org

Health & Nutrition Assistant


"Say yes for children"

From: Andre' Briend <briendaatcnam.fr>
Subject: severely malnourished infants under 6 months
Date: Mon, 26 Mar 2001 09:51:59 +0200 (MET DST)

Dear Adriana,

A few additional infos after the very useful comments you got from Gulanara re: severely malnourished children under 6 months. I am not sure Mike Golden who specifically worked on this topic is on the net right now, and these remarks below may help you.
This topic is now debated in NGO's, and you can read in issue 9 of ENN field news how this problem is tackled by some NGO's by promoting re-lactation while tube feeding diluted WHO F100 . This very interesting newsletter is available online:

I attach the article below.
The WHO manual does not mention a special diet for under 6 months because it assumes that F75 and F100 diets can be used in infants under 6 months of age. The major problem you can face, however, when giving F100 is not to give enough water. For this reason, it is preferable to give F100 diluted to make 70 kcal/100 ml, as mentioned in the ENN paper.
There is no reason to use very expensive hydrolysed formulas for under 6 months infants... unless malnutrition is related to allergy to cow's milk protein, but this occurs in a very special context not often met in developing countries with a high prevalence of breast feeding (this occurs with early feeding with infant formula). Please note these hydrolysed formulas are not recommended for young infants in the WHO manual.

I hope this helps,



Infant feeding in a TFP
MSc Thesis1 by Mary Corbett, Concern, HQ Nutritionist

The benefits of breastfeeding are widely-know. In conditions characteristic of most emergencies breastfeeding becomes even more important for infant nutritional health and survival. However there are times when alternatives to breastmilk are necessary. It is important that they are used appropriately and do not replace breastmilk unnecessarily. Up until about 6 months breastfed infants' nutritional security is critically linked to the maternal supply of milk. This is why it is so important to protect that supply. However mothers and health workers' confidence in breastfeeding is often shaken when they see a malnourished infant attached to the breast. If there is a rush to rehabilitate the infant forgetting about the mother then there is a risk of discharging a healthy infant with no secure supply of 'food'. Mary Corbett as part of her MSc thesis carried out a study to assess the effectiveness of rehabilitating malnourished infants while maintaining or improving maternal milk supply.
This study was conducted in a therapeutic feeding centre run by Action Contre la Faim (ACF) in Liberia between mid May and mid July 1998. Twenty-five severely malnourished infants with weight for length less than 70% and less than 6 months of age were included in the study. A combination of breastmilk and supplemental milk was used to rehabilitate these infants using a special technique adapted for the study: -the "Supplemental Suckling" technique. This technique has been used previously in well babies.
On admission a detailed history was taken to ascertain the main reasons why the infants were not gaining weight. Routine medications were commenced as per protocols used for malnourished children over six months old. These included Vitamin A and a broad spectrum antibiotic.
The infant was started on three hourly breastfeeds. A supplemental feed was given after one hour following each breast feed. The tip of a naso-gastric tube was attached to the mother's breast at the nipple with the other end of the tube in the cup of supplemental milk (F100 diluted). The breast was offered to the infant. When the baby was attached to the breast it was important to ensure that the tip of the naso-gastric tube was in the infant's mouth. When the baby suckled at the breast the milk was sucked up the tube and then ingested by the infant. The amount given was calculated individually for each infant as per body weight (see below for calculations).
All supplemental milk consumed was recorded. Infants were weighed daily. Records were maintained of any vomiting or diarrhoea. It was assumed that the extra suckling at the breast would stimulate an increase in breastmilk output
To estimate required caloric intake from breastmilk it was necessary to calculate energy needs for body maintenance, Basal Metabolic Rate (BMR), and expected weight gain for each infant. It was assumed that 110 kcal/kg were required for BMR but for infants with high fevers it was estimated that extra energy was required, increasing the BMR to 120 kcal instead of 110kcal. It was assumed that five calories were required for each gram of weight gained. The calories supplied by the supplemental milk (enough for maintenance) were established. It was assumed that the balance of calories taken was from breastmilk and would be used for catch-up growth. Finally deductions were made for any vomiting or diarrhoea. Once the infants reached 85% weight for height the supplemental milk was reduced by half the amount for one day and then stopped completely. The infants remained in the centre for a minimum of 4 more days and were exclusively fed breastmilk.


Of the 25 patients admitted one was excluded from the study as the mother was dead while three others were subsequently excluded due to insufficient data as they had been admitted late in the study. During the study a total of 16 infants were discharged exclusively breastfeeding and gaining weight while five were transferred to the local hospital.
With the combined supplemental milk and breastmilk the mean of all the infants maximum daily weight gain was 17.9g/kg/day. Normal weight gain for this age group would be 2g/kg/day while 5g/kg/day would be the minimum weight gain for catch up growth for malnourished infants with 10g/kg/day being the target to aim for. The mean weight gain for the period when the infants were receiving both supplemental feeding and breastfeeding was 14.7g/kg, while the mean weight gain for the period on exclusive breastfeeding was 9.4g/kg/day. This suggests that the weight gain although reduced on exclusive breastfeeding was still adequate for maintenance and catch-up growth. The mean breastmilk output on exclusive breastfeeding reached 204ml/kg (sd 31) with the volume ranging from 390ml to 1131mls but this considerable difference was due to differences in weights of the infants. The mean number of days on supplemental feeding was 13 days.


Supplemental Suckling Technique

Calculating the amount of supplemental milk given

Calorie requirements for infants <6 months:

Feed amount required:

Example of Supplemental-milk calculation:

As the infant's weight increases the calorie requirements will increase but the supplemental feed will remain the same. The breast-milk produced will increase due to stimulation using the supplemental suckling technique. The infant will receive the calories needed to grow and catch up from the breastmilk.

Feeding Practices

Confidence building      

1 Corbett M. Severe Malnutrition in the Infant less than 6 months: Use of Supplemental Suckling Technique. Department of Medicine & Therapeutics. Fosterhill, Aberdeen.


André Briend, MD, PhD
5 rue du Vertbois,
75003 Paris, France
tel : 33-1-53 01 80 36 U 557 , fax : 33-1 53 01 80 05 ISTNA/CNAM