Breastfeeding

What Price a Free Dinner

Lynda Williams, June 2008

On a wild wet windy evening in late June 2008 that made crossing the Auckland harbour bridge no mean feat, an event took place in the Spencer on Byron hotel in Takapuna that made even the most hardened cynics amongst us turn ashen-faced.

As the storm raged outside complete with thunder and lightning and a tornado or two waiting in the wings, inside it was all cosy and warm, with immaculately-clad waiters handing out free drinks and delectable nibbles as the guests drifted in and mingled with their colleagues.

The guests were nearly all GPs who at the end of May had received a letter from the drug company Bayer inviting them to a presentation by a senior paediatrician and a drug company representative, after which dinner would be served. The invitation was attractive enough to bring out over 100 GPs on such an inclement night.

The topic of what the letter described as “a dinner presentation” was Feeding Options for Women Not Fully Breast Feeding. After half an hour or so of “arrival drinks and canapé” we were ushered into a room and seated at tables set for dinner. Paediatrician Peter Nobbs was introduced and began his presentation on the history and politics of breastfeeding. He began setting the scene for the message he was there to give by focusing on an aspect of the environment that some new mothers in New Zealand 100 years ago were subjected to. The Plunket Society was put under the spotlight as Peter Nobbs described their staunch support for breastfeeding, their objections to an advertisement for an early version of what was then known as “humanised milk mixture” that appeared in the Otago Witness in the first decade of last century, and the two-faced behaviour of Plunket Nurses who, according to a letter that appeared in the Otago Daily Times in 1915, were telling mothers to breastfeed while they themselves were bringing up their babies on Glaxo.

We were told Plunket Society’s founder, Sir Truby King’s Melrose property in Wellington is listed as a category 1 Heritage Building, and that it was here that the earliest attempts to make “humanised milk mixture” or infant formula in New Zealand began. Vegetable oil, cod liver oil and dextrose were added to cows milk and this humanised milk mixture was marketed by the Plunket Society under the name of Karilac along with “Plunket cream” known as Kariol.

Following a bit more history Peter Nobbs showed a slide documenting the falling breastfeeding rates in the middle of last century – it was recorded as being 91.5% in 1939, 82.1% in 1945, and 74.4% in 1952.

By now it was clear that the message we were being given was that not fully breastfeeding was normal and natural, that health authorities were often hypocritical about the advice they were required to give to new mothers about breastfeeding and what they actually said and did, and that the pro-breastfeeding stance was just a lot of politically-correct behaviour. Along with this were some subtle and not so subtle messages about the problems and risks of breastfeeding.

Turning his attention to the politics of breastfeeding Peter Nobbs went on to talk about the WHO Code – the International Code of Marketing of Breast-Milk Substitutes – the advice given to new mothers in hospital, and the argument around whether complementary feeding with a bottle does have any affect on breastfeeding.

He referred to the erroneous perceptions of groups like La Leche League and quoted from one of the group’s 2007 newsletters in which the sentence “Formula companies’ only aim is to make money” appeared. He assured the audience that formula companies in New Zealand do comply with the WHO Code on the Marketing of Breastmilk Substitutes and therefore see themselves as providing a complementary service.

NZ Breastfeeding Authority

The next organisation to come under attack was the NZ Breastfeeding Authority. He described their website, their current proposals around the Baby Friendly Hospital Initiative, and the accreditation of the hospitals in the Auckland region in critical terms. The NZBA website refers to the benefits of breastfeeding but not the risks, and risks of infant formulas but not the benefits. He cited as an example the fact that the website mentioned bacterial contamination of infant formulas. He was very critical of how ridiculous this was when the incidence is less than one in a million.

Bottles and Pacifiers

The issues surrounding the use of pacifiers and bottles featured next with Peter Nobbs referring to some of the evidence about their supposed effects on breastfeeding. Studies on the use of pacifiers show no consistent results, he said. The effects of supplementary bottle-feeding had been studied in two studies from the USA and one from Swizterland. One showed an effect on breastfeeding and one did not. The duration of breastfeeding in both groups was the same.

No RTCs

The lack of randomised controlled trials was something Peter referred to several times during his presentation.

Peter ended his presentation with a list of the five most common conditions that mothers and babies present with at the doctor’s office. They included reflux, colic, poor weight gain, allergies, and diarrhoea. As he talked about each condition he showed a slide with the image of the appropriate Bayer Infant Formula (brand name is Novalac) product – Novalac Reflux, Novalac Colic, Novalac Hypoallergenic, Novalac Diarrhoea. There was even a Novalac Sweet Dreams! With the exception of Novalac Diarrhoea, all products are suitable for use from birth onwards and are described as a “nutritionally complete formula suitable for long-term everyday use.” Given that each of these special formulas costs around $30 a tin (almost double that of ordinary infant formula), the statement that the aim of the drug company is to make money does not seem at all unreasonable.

Bayer Consumer Care

The presentation by Ayumi Uyeda, the young female drug company rep was unremarkable in that it was clearly her job to promote the wonders of the Novalac range of specialised infant formulas. She consistently described them as “premium products’, and the higher cost was simply “a price differential.”

Ayumi Uyeda referred to the EDEN study of 3.500 babies, “an observational study of what happens in private practice” that was firstly an epidemiological study on presenting problems, and secondly the effects of Novalac on the problem. However, there was no mention of RTCs!

Her slides showed the ”scientifically developed” range of specialised infant formulas and how they differed from each other. The slick marketing of solutions to “problems” such as reflux, colic and constipation, the expansion of the diagnostic criteria used to identify such commonplace events as spilling or spitting up, periods of prolonged crying and distress, and constipation and diarrhoea, along with the supply of free drinks and good food, was both impressive and incredibly dishonest.

Needless to say, I left after the presentations – before dinner was served – because I suddenly found I had completely lost my appetite. I went instead to the bar and bought a spiced tomato juice and sat mulling over what I had just witnessed with the health professional friend who had got me into the event.

Result of Complaint to Ministry of Health Compliance Panel

From the Maternity Services Consumer Council Newsletter June 2010

It is nearly two years since the complaint referred to above was sent to the Ministry of Health’s WHO Compliance Panel for implementing and monitoring the International Code on the Marketing of Breast-milk substitutes in New Zealand.
The complaint concerned the free dinners organised for GPs, Plunket and midwives by the drug company Bayer on 23 and 25 June 2008 and the pre-dinner presentations given by Auckland paediatrician Peter Nobbs on “Feeding options for women not fully breastfeeding” which was followed by a presentation by a Bayer employee promoting a range of specialised infant formulas manufactured by Bayer.

Bayer Consumer Care NZ

“Bayer Consumer Care NZ” responded to the letter of complaint in a letter to the Compliance Panel dated 25 August 2008. When advised by email that we were not satisfied with Bayer’s response, the matter was referred to the next meeting of the Compliance Panel which was held on 12 December 2008. The Compliance Panel considered there was a breach of several articles in the NZ Infant Formula Manufacturers Association (NZIFMA) Code of Practice, and Bayer was subsequently notified of this decision. Bayer lodged an appeal in March 2009 and the matter was referred to the Adjudicator.

In a decision dated 7 May 2009 the Adjudicator determined that Bayer had a legitimate ground for an appeal and the complaint was referred back to the Compliance Panel for redetermination.

The Compliance Panel considered the matter again provided its redetermination in a decision dated 11 September 2009, and advised that Bayer was in fact in breach of several articles in the NZIFMA Code of Practice. In a letter dated 9 October 2009 Bayer again appealed the decision of the Compliance Panel. The result was that the Panel’s decision and Bayer’s appeal was once again referred back to the Adjudicator.
The Adjudicator considered Bayer’s appeal and stated in the final paragraph of an 11-page document dated 25 March 2010 that it was her view “that none of the grounds of appeal have been established and the accordingly the Compliance Panel decision should be upheld.”

Peter Nobbs

It was a very different story with Peter Nobbs. Peter hired a lawyer to deal with the complaint made about his presentation at the Bayer dinner. Although it was contrary to the Compliance Panel’s normal procedure, the lawyer requested the disclosure of the identity of the person/organisation who had made the complaint.
After getting a phone call from the Ministry of Health Lynda Williams agreed to have her name and that of the organisation she worked for released to the lawyer/Peter Nobbs.

In a letter dated 19 September 2008 the lawyer responded to the complaint on behalf of Peter Nobbs. The Compliance Panel was advised by email that we were not satisfied with the response provided. The lawyer then demanded a copy of the email but this time the request was declined.

The Compliance Panel considered the complaint at its meeting on 12 December 2008. Letters were then exchanged between the lawyer and the Panel. The secretariat of the Compliance Panel requested a copy of Peter Nobbs’ Powerpoint presentation and speaking notes and asked Mr Nobbs to disclose the sum that he was paid by way of an honorarium for his presentations.

The Panel met again on 11 August 2009 and subsequent to that meeting a draft decision letter was sent to the Chair and members of the Panel.

In a decision dated 11 September 2009 the majority of the Panel considered that there had been a breach of the Code.

On 7 October 2009 Peter Nobbs wrote that he had a number of concerns about the Panel’s decision and he appealed. The matter was then referred to the Adjudicator.

The Adjudicator considered Peter Nobb’s appeal and stated in the final paragraphs of an 15-page document dated 8 April 2010 that:

“In the context of this decision it is apparent that the Compliance Panel was in possession of all of the relevant information and that it had the opportunity to consider the facts are arguments advanced by the complainant and the health worker. Accordingly it is not appropriate for the matter to be referred back to the Compliance Panel for redetermination.

Accordingly it is my view that the Compliance Panel is quashed.”

Basically Peter Nobbs and his lawyer claimed:

•  The Health Education presentations were organised by Bayer and covered an entirely legitimate and an important topic for health professionals dealing with breastfeeding and infant feeding issues.
• The amount of the honorarium ($1125) Peter Nobbs received was not relevant because Peter was not promoting Bayer products.
• The notes made by Lynda Williams at the presentation contained factual inaccuracies and misunderstandings.
• Lynda Williams was not invited to the evening for which invitations had been sent out to GPs and nurses.

The truth is that no-one attending these events (Bayer and Peter Nobbs continue to hold them) can be in any doubt that the free dinners provided by Bayer are part of a promotion pushing the range of Bayer’s infant formulas. There are stands and tables with tins of the various special formulas prominently displayed at these events, and the powerpoint presentations by both Peter Nobbs and the drug company rep contain slides with a photo of each of the infant formulas.

We have it on good authority that the “honorarium” was a great deal more than $1125.

Lynda Williams has 30 years experience of taking notes/minutes while attending meetings and is used to recording verbatim what is said by speakers. She was invited to attend by a midwife who asked the organisers if she could attend and bring a colleague.

Mother’s Milk: precious protection

By Sue Claridge

INTRODUCTION

There are numerous wonderful reasons for breastfeeding a baby from both the mother’s and baby’s point of view. Many of these relate to satisfying the emotional needs of both. There are the obvious nutritional benefits. Then there are the issues of convenience and economy. Breastmilk is free. It is always on hand, always the right temperature and consistency; no need for mixing or sterilising bottles and teats. But if these reasons fail to convince you of the importance of breastfeeding, then the overwhelming evidence that shows that breastfeeding is the single most important thing you can do to ensure your baby’s health surely must.

It has been known for a long time that babies who are breast-fed contract fewer infections than do those who are given formula. This is because breastmilk actively helps newborns avoid disease in a variety of ways. This is particularly important during the first few months of life, when an infant often cannot mount an effective immune response against foreign organisms¹. Research shows a baby’s immune system does not fully mature for several years^1,2. While it is developing, the baby will be protected by being breastfed. In addition the baby’s own immune system develops more rapidly than does baby who is fed formula^1,2.

Over recent years there has been research undertaken into the factors present in human milk that protect infants from infection and illness. Early on researchers became aware that certain substances (most notably IgA, lysozyme, and lactoferrin) that are abundant in human milk³ might protect babies from infection⁴.

During pregnancy, antibodies are passed to the baby through the placenta. Dr Jack Newman says that “these proteins circulate in the infant’s blood for weeks to months after birth, neutralising microbes or marking them for destruction by phagocytes – immune cells that consume and break down bacteria, viruses and cellular debris.”¹ However, when a baby is breastfed he or she is provided with extra protection from antibodies, other proteins and immune cells in human milk.

THE PROTECTIVE CONSTITUENTS OF BREASTMILK

Human milk contains proteins, non-protein nitrogen compounds, carbohydrates, lipids (fats), minerals and vitamins. Many of these components of breastmilk have non-nutritional roles some of which involve protecting the baby against infectious agents and disease⁷. Human milk contains both specific immune factors (immunoglobulins or antibodies and certain cellular systems) and non-specific immune factors (lactoferrin, lysozyme, lactoperoxidase, complement, vitamin B₁₂–binding protein, folic acid-binding protein, bifidus factor, lipid, interferon, cells)⁵. Specific immune factors have “adaptive memory that leads to the production of antibodies and certain cells (lymphocytes)” whereas non-specific immune factors have no intrinsic memory⁵.

It is not the intention of this article to provide a comprehensive dissertation on the composition of human milk. What follows is a summary of some of the most important protective components of human milk and what protection they offer the breastfed infant.

Antibodies

Breastfed babies receive antibodies – highly specific protection against disease^2, 6. New-born babies have very immature immune systems and little ability to fight illness-causing germs. Antibodies are made by the mother’s immune system and are passed to the baby through the breast milk¹.

Antibodies (also called immunoglobulins) take five basic forms: IgA, IgD, IgE, IgG and IgM^1,7,8. The most abundant is IgA, specifically the form known as secretory IgA, which is found in great amounts throughout the gut and respiratory system of adults. Babies do not make secretory IgA on their own for several weeks or even months after birth¹ so the IgA that they receive through breastmilk is vital to the ability to fight ingested pathogens (disease causing micro-organisms such as bacteria and viruses). The antibodies passed on to the baby are antibodies made by the mother to fight pathogens in her environment; therefore the baby receives the protection it most needs against the pathogens it is most likely to encounter as a new-born^1,2.

The way in which antibodies work are complex and the some of the processes are not entirely understood by researchers. For example the antibodies that the baby receives do not harm the good bacteria that colonise the intestines. These good bacteria “crowd out the growth of harmful organisms, thus providing another measure of resistance”¹. In addition, Newman when talking about secretory IgA states that “unlike most other antibodies, they ward off disease without causing inflammation – a process in which various chemicals destroy microbes but potentially hurt healthy tissue”. He goes on to say that “secretory IgA can probably protect mucosal surfaces other than those in the gut” and notes that breast milk has been used by mothers’ to treat eye infections.

Cellular Defences

Immune cells, white blood cells, or leukocytes, that fight infection themselves and activate other defence mechanisms, are abundant in human milk particularly in colostrum^{1, 7}. In order of abundance these cells are neutrophils, macrophages and lymphocytes. Macrophages are cells that kill bacteria, fungi, and viruses. Macrophages also manufacture lysozyme, an enzyme that destroys bacteria by disrupting their cell walls^{1, 5}. Lymphocytes comprise B lymphocytes, which give rise to antibodies, and T lymphocytes, which kill infected cells directly or send out chemical messages that mobilise still other components of the immune system^1,7. Milk lymphocytes also manufacture several chemicals-including gamma-interferon, migration inhibition factor and monocyte chemotactic factor that can strengthen an infant’s own immune response^1.

In addition, macrophages in the digestive tract can rally lymphocytes into action against invaders. Lymphocytes constitute 10 percent of white cells in the milk and milk lymphocytes seem to behave differently from blood lymphocytes. Those in milk, for example, proliferate in the presence of Escherichia coli, a bacterium that can cause life-threatening illness in babies, but they are far less responsive than blood lymphocytes to agents posing less threat to infants.

Lactoferrin

Lactoferrin is  a natural antibiotic and protects the new-born baby from bacteria that can multiply in its stomach and intestines and cause vomiting and diarrhoea. The concentration of lactoferrin is particularly high in colostrum and the amount of lactoferrin in the milk decreases over time as the danger from germs recedes and the baby’s own defences develop. Lactoferrin prevents bacteria from getting any iron, the metal that is essential for germs (including Staphylococcus aureus¹) to multiply rapidly, thus stopping them from getting out of control. In addition lactoferrin stops bacteria digesting carbohydrates, further limiting their growth¹. Lactoferrin can also move iron around the body to where it is needed⁹.

Alpha-lactalbumin

Swedish and British immunologists have discovered that one identified protein in breast milk, alpha-lactalbumin, destroys cancer cells with which it comes into contact¹⁰. According to lead scientist Catharina Svanborg, her team pursued this exciting research in an attempt to determine why “the relative risk of childhood lymphoma is nine times higher in bottle-fed infants, and the risk for carcinoma is also elevated. “Alpha-lactalbumin is a “substance that kills lots of tumor cells, every cancer we test it against. Lung cancer, throat cancer, kidney cancer, colon cancer, bladder cancer, lymphoma, leukemia, and pneumococcus bacteria too.”¹¹

Other Immune and non-immune protective agents

The main carbohydrate in human milk is lactose. Any lactose not absorbed by the infant reaches the large intestine where it is fermented to lactic acid. The acid conditions which result help promote the growth of Bifidobacteria and Lactobacilli, beneficial colonising bacteria, thus restricting colonisation by disease causing organisms. Certain nitrogen containing oligosaccharides have a growth promoting effect on Lactobacillus bifidus, the predominant gut flora of the breast-fed infant. These compounds are known as the ‘bifidus factor’⁵ and are one of the oldest known disease-resistance factors in human milk. The bifidus factor is important in the prevention of diarhhoea in babies and is not found in cows milk⁵.

Some oligosaccharides can also intercept bacteria, forming harmless complexes that the baby excretes. In addition, human milk contains large molecules called mucins that include a great deal of protein and carbohydrate. They, too, are capable of adhering to bacteria and viruses and eliminating them from the body.¹

Milk prostaglandins (found in the lipid – or milk fat – fraction⁵) are  present in fresh human milk and are believed to protect the immature and delicate gastrointestinal mucosa of new-born babies. This is supported by the fact that in premature babies, normally at risk from severe gastrointestinal illnesses, it is rare to see necrotising enterocolitis when they are breastfed¹².

Lactadherin is a glycoprotein which specifically attaches to rotaviruses and inhibits their settling on the gut wall. Newburg et al. reported on a study¹³ which showed that the protection that breastmilk provides against symptomatic rotavirus infection is associated with this lactadherin.

B12 binding protein deprives micro-organisms of vitamin B12. Interferon, found primarily in colostrum, has strong anti-viral activity and fibronectin, also present in colostrum, can make certain phagocytes more aggressive so that they will ingest microbes even when the microbes have not been tagged by an antibody. Fibronectin minimizes inflammation and seems to aid in repairing tissue damaged by inflammation¹.

Recently, casein has been shown to prevent the attachment of Helicobacter pylori to human gastric mucosa¹⁴.

Some hormones in milk (such as cortisol) and smaller proteins (including epidermal growth factor, nerve growth factor, insulin-like growth factor and somatomedin C) act to close up the leaky mucosal lining of the young baby, making it relatively impermeable to unwanted pathogens and other potentially harmful agents¹.

Breastmilk Protects Babies from Illness

Numerous studies have shown that breastfeeding can protect babies from many illnesses, including ear infections, upper and lower respiratory tract infections, allergies, gastrointestinal disorders, colds and other  viruses, staphylococcus, streptococcus and E. coli infections, diabetes, juvenile rheumatoid arthritis, many childhood cancers, meningitis, pneumonia, urinary tract infections, salmonella, Sudden Infant Death Syndrome(SIDS)^2, 8. Dr Margit Hamosh writes in Breast-feeding: Unraveling the Mysteries of Mother’s Milk⁷ that “in addition to protection against some infectious diseases, breast-fed infants might also be protected at later ages from diseases that are sequelae of infectious insults. These include insulin-dependent diabetes mellitus¹⁵, lymphoma¹⁶, Crohn’s disease¹⁷ and coeliac disease^18.

Dr John May, from La Trobe University has stated that “epidemiological studies have been important in demonstrating that breastfeeding clearly protects infants against respiratory and gastointestinal infections, or decreases the severity of these infections.” He also says that “human milk contains a variety of potential anti-inflammatory agents, immuno-modulators and bioactive compounds that may influence the incidence of diarrhoea in infected infants.”⁸ Other researchers have confirmed that IgA antibodies play an important role in the protection of the newborn against enteropathogenic E. coli infections¹⁹.

Other studies have concluded that breastfeeding results in a lower incidence of necrotizing enterocolitis²⁰ and other gastrointestinal and respiratory infections in breast-fed infants than in formula-fed infants²¹ including infections caused by rotaviruses and respiratory syncytial viruses^22. Golding et al. write that “prolonged breastfeeding, as well as providing protection against digestive tract infections, provided an important protection against Haemophilus influenzae B infections and against the occurrence of otitis media.”²³

Several other studies have found that the incidence of otitis media is lower among breastfed babies^7, 24. Duffy et al. reported in Pediatrics that the longer the duration of breastfeeding the lower the incidence of otitis media but that even for periods as short as three months, breastfeeding reduces the risk. They found that there was a two-fold risk of suffering a first episode of otitis media in children fed exclusively with formula, as opposed to those fed exclusively with breast milk for the first six months of life.

In a study undertaken in 1992-93, Hylander et al. looked at the “effect of human milk on the incidence of infections in very low-birth-weight infants in the first stages of hospitalisation”²⁵ The authors found that “the incidence of infections (human milk 29.3% vs. formula 47.2%) and sepsis/meningitis (human milk 19.5% vs. formula 32.6%) were significantly different according to the type of feeding.” They concluded that very low-birth-weight infants who are fed with breast milk fared significantly better than those that were formula fed.

Breast-feeding over time – how the protection changes

The concentration of various protective factors in human milk varies over time from the first few days when the infant receives colostrum through to the milk that a toddler receives. Dr Margit Hamosh says that the “daily production of many immuno-protective factors changes as lactation proceeds. The secretion of many soluble defense agents by the mammary gland is inversely related to the capacity of the recipient infant to produce them at mucosal sites.”⁷

Dr Hamosh⁷ writes at length on the changing character of breastmilk over time: “Colostrum contains higher concentrations of protein (including higher levels of protective proteins such as secretory IgA, lactoferrin, and lysozyme), sodium, and chloride, and contains lower amounts of potassium, carbohydrate, fat, and certain vitamins.” She goes on to say that the changing concentration of immuno-globulins (IgA, IgG and IgM) illustrates the interaction between milk components and the functional development of the baby: while IgG and IgM rise rapidly after birth, the newborn maintains low levels of IgA during the first year of life. “Immune and non-immune protecting agents are present in milk throughout lactation and some, such as lysozyme, are present at higher concentrations during prolonged lactation than during the early stages.”

The lessening concentration of some protective factors in human milk are compensated for by the increased volume of milk ingested by the baby over time. While the concentration of protective factors may decline, the disease-fighting properties of human milk do not disappear with the colostrum. As long as a baby receives breast milk he or she will receive immunological protection against many different viruses and bacteria². However, Wendy Oddy from the Telethon Institute for Child Health Research in Australia, says that there may prolonged protection against infections after the cessation of breastfeeding due to the impact of breast milk on the baby’s developing immune system^26.

Antibacterial, Antiviral and Antiparasitic factors in Human Milk

Research undertaken by the Department of Microbiology at the La Trobe University has shown that various antibacterial, antiviral and antiparasitic factors in human milk are active (in vitro) against a wide range disease causing organisms8. Breastfed babies are protected by these factors which include immuno-globulins (Secretory IgA, IgG, IgM and IgD) Bifidobacterium bifidum growth factors, factor findig proteins, lactoferrin, lactoperoxidase, lysozyme, lipids and carbohydrates together with various other factors.

Bacterial illnesses which these factors protect against include: E. coli , C. tetani, C. diphtheriae, K. pneumoniae, various  Staphylococci and Streptococci, H. influenzae. H. pylori, B. pertussis, Salmonella, Candida albicans, V. cholerae among others.

Viral illnesses which these factors protect against include: Polio types, 1, 2 and 3, various Coxsackie viruses, rotavirus, rubella, varicella-zoster, rhinovirus, herpes simplex, mumps, influenza, respiratory syncytial virus, human immunodeficiency virus, hepatitis C, hepatitis B, measles, cytomegalovirus, Epstein-Barr, influenza among others.

Parasites which these factors protect against include: Giardia lamblia, Schistosoma mansoni, Cryptosporidium, Toxoplasma, Plasmodium falciparum (malaria), Trichomonas vaginalis among others.

Copyright © Sue Claridge, 2002.

REFERENCES

1     Newman, Jack, (MD, FRCPC) 1995: How Breast Milk Protects New-borns, Scientific American December 1995 Vol. 273 No. 6 Page 76.

2     La Leche League, 2001: on www.lalecheleague.com

3     Goldman, A.S. 1993: The immune system of human milk: Antimicrobial, antiinflammatory, and immunomodulating properties,. Pediatric Infectious Diseases Journal, 12:664-672.

4     Hamosh, M., Ellis, L.A., Pollock, D.R., et al., 1995: Breast-feeding and the working mother: Effect of time and temperature of short term storage on proteolysis, lipolysis and bacterial growth in milk. Pediatrics 97:492-498.

5     Rumball, S. and Darragh, A., 1995: Biology of Human Milk in Human Milk, Lactation and Infant Feeding Study Guide Department of Chemistry and Biochemistry, Massey University.

6     Packard, V.S., 1982: Human Milk and Infant Formula, Academic Press, pg 72-74

7     Hamosh, Margit, Ph.D.: Breast-feeding: Unraveling the Mysteries of Mother’s Milk, at http://www.medscape.com/Medscape/WomensHealth/journal/1996/v01.n09/w120.hamosh/w120.hamosh.html

8     May, J.T., PhD, 2001: Molecular Virology: Tables of Antimicrobial Factors and Microbial Contaminants in Human Milk, Based on tables presented in the Proceedings of Breast Milk and Special Care Nurseries: Problems and Opportunities Conference. August 1995. Melbourne.

9     Emsley, John, 1988: The magic ingredient in a mother’s milk, Kings College, London, published in The Independent

10    Hakansson, A., Zhivotovsky, B., Orrenius, S., Sabharwal, H., Svanborg, C., Apoptosis induced by a human milk protein, Proc Natl Acad Sci., 92 (17): 8064-8.

11    Radetsky, P., 1999: Got cancer killers, Discover, June 1999.

12  Bedrick, A., 1990: The physiologic significance of Milk-borne prostaglandins for the developing gastrointestinal tract, Mammary Gland Biology and Lactation Newsletter, Vol. 9, No. 4

13    Newburg, D.S., Peterson, J.A/, Ruiz Palacios, G.M., Matson, D,O,, Morrow, A.L., Shults J, et al. 1998: Role of human-milk lactadherin in protection against symptomatic rotavirus infection, The Lancet, 351(9110): 1160-4.

14    Stromquist, M., Folk, P., Bergstrom, S., et al. 1995: Human milk k-casein and inhibition of Helicobacter pylori adhesion to human gastric mucosa, Journal of Pediatric Gastroenterology and Nutrition, 21: 288-296, 1995.

15  Mayer, E.J., Hamman, R.F., Gay, E.C. et al. 1988: Reduced risk of IDDM among breast fed children. The Colorado IDDM Registry, Diabetes 37(12):1625-1632.

16    Davis, M.K., Savitz, D.A. and Grauford, B.1988: Infant feeding and childhood cancer, The Lancet 2(8607):365-368.

17    Koletzko, S., Sherman, P., Corey, M. et al 1989: Role of infant feeding practices in development of Crohn’s disease in childhood, British Medical Journal, 298(6688):1617-1618.

18    Challacombe, D.N., Mecrow, I.K., Elliot, K., Clarke, F.J. and Wheeler, E.E. 1997: Changing infant feeding practices and declining coeliac disease in West Somerset, Archives of Diseases in Childhood, 77(3): 206-9.

19    Carbonare, S.B., Silva, M.L., Palmeira, P. and Carneiro Sampaio, M.M., 1997: Human colostrum IgA antibodies reacting to enteropathogenic Escherichia coli antigens and their persistence in the feces of a breastfed infant, Journal of Diarrhoeal Disease Research, 15(2): 53-8.

20    Lucas, A. and Cole, T.J. 1990: Breast milk and neonatal necrotising enterocolitis, The Lancet 336 (8730): 1519-23.

21    Beaudry, M., Dufour, R. and Marcoux, S. 1995: Relation between infant feeding and infections during the first six months of life, Journal of Pediatrics, 126(2): 191-7.

22    Grover, M. et al. 1997: Effect of human milk prostaglandins and lactoferrin on respiratory syncytial virus and rotavirus” Acta Paediatrics, 86: 315-316.

23    Golding. J. Emmett, P.M. and Rogers, I.S., 1997:Does breast-feeding protect against non-gastric infections? Early Human Development, 49 Suppl: S105-20.

24    Duffy, L.C., Faden, H., Wasielewski, R., Wolf, J. and Krystofik, D., 1997: Exclusive breastfeeding protects against bacterial colonization and day care exposure to otitis media, Pediatrics, 100(4): E7.

25    Hylander, M.A., Strobino, D.M. and Dhanireddy, R. 1998: Human milk feedings and infection in very low birth weight infants, Pediatrics, 102(3): E38.

26    Oddy, W.H., 2001: Breastfeeding protects against illness and infection in infants and children: a review of the evidence, Breastfeed Rev., 9 (2): 11-8.