Margarett  K.Davis, MD , MPH


    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)


Volume 48.Number1.February 2001