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PERSPECTIVES ON
COUNSELING
In 1994, the
American Academy of Pediatrics (AAP) Work Group on Cow's Milk
Protein and Diabetes Mellitus published a statement summarizing
research on the possible causal relationship between infant feeding
and IDDM. Their recommendations included the following : (1)
Pediatricians should strongly endorse breastfeeding as the primary
source of infant nutrition; and (2) "In families with a strong
history of IDDM, particulary if a sibling has diabetes,
breast-feeding and avoidance of commercially available cow's milk
and products containing intact cow's milk protein during the first
year of life are strongly encouraged." They endorsed the idea of
proceeding with a randomized controlled trial similar to TRIGR. The
strategy advocated by the AAP workgroup involves guidence for
at-risk families to avoid feeding their infants intact cow's milk
protein for at least 6 months post partum by breastfeeding
exclusively for up to 6 months and using casein hydrolysate formula
as a weaning food after exclusive breastfeeding or as a
supplementary food during partial breastfeeding.
It may seem premature to make recommendations before definitive
evidence of a causal relationship between artificial feeding and
IDDM. However, these recommendations for children with affected
first-degree relatives are not unresonable because they are similar
to recommendations for other normal infants. Many at-risk families
may want to know about this option and be willing to use this
preventive measure. Families should be made aware, however, that
their child's risk for IDDM, altough increased, is still quite low
and that exclusive breastfeeding for 6 months and use of hydrolysate
formula may not prevent IDDM. If familiese are inclined to take this
precautionary measure, they should probably avoid introduction of
other foods early in the first 6 month as well because it may turn
out that cow's milk has been such a strong research focus merely
because it is the most common non-breast milk food introduced early
in life. This recommendation is based on expert opinion in the
absence of conclusive evidence and constitutes a philosophic
approach that might be beneficial and would do no harm. One possible
drawback for some families is that casein hydrolysate formula might
be more expensive or less accessible than the more commonly used
cow's milk formula. If further research finds that the risk for IDDM
is not influenced by infant feeding , breastfeeding promotion will
still have been positive for many other established reasons.
As
for other chronic disease discussed in this article, the evidence
that breastfeeding is protective is most suggestive for celiac
disease. However, the evidence is far from definitive. There is no
AAP recommendation on infant feeding and celiac disease comparable
with that for IDDM, and it is not clear whether the introduction of
gluten under the protection of breastfeeding delays or prevents
celiac disease.
Concerned
pediatricians who would like to take a conservative philosophic
approach might consider monitoring Scandinavian recommendations and
practices related to celiac to disease and counseling families with
strong family histories accordingly. In Scandinavia, clinically
diagnosed celiac disease is far more common than in the United
States, and research and recommendations regarding the role of
infant feeding in risk for celiac disease attract considerable
attention.
The
relationship of infant feeding patterns to risk for childhood
cancers or IBD has been studied sufficiently to recommend
breastfeeding on this basis. These disease are rare in childhood.
Thus, raising the possibility of a connection with infant feeding is
unwarranted and may be alarming rather than comforting. Advisories
to selected families with strong family histories of IDDM, placed in
perspective with regard to the nondefinitive nature of the evidence,
are not radical departures from the current recommendations on
feeding for all infants without contraindications to breastfeeding.
The benefits of breastfeeding for optimal growth, development, and
protection against infection provide ample reason to carry out the
AAP recommendations that all infants breastfeed exclusively for at
least 4 months and with appropriate supplementation for one year or
more as mutually acceptable to mother and infant. Parents and
pediatricians working together to accopmlish these recommendations
will be performing a highly beneficial and accessible intervention
for general infant health.
(The Pediatric Clinic of North America)
BREASTFEEDING 2001, PART I:
THE EVIDENCE FOR BREASTFEEDING
Volume 48.Number1.February 2001
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