Pediatrics*

Breast-feeding: should it be recommended? Protection from tract

infection

gastrointestinal

Colostrum is known to be rich in

of cow's milk, and probably of other foods, interferes with the protection af¬ forded by breast-feeding. The substitution of cow's milk for breast milk, then, leads not only to an increase in gastro¬ intestinal tract infection but also to an increase in respiratory tract infection. It is difficult to ascribe all the latter changes to deprivation of the gastroin¬ testinal tract of local antibody protec¬ tion; some changes are probably due to exposure of the baby to cow's milk antigens. Cow's milk antigens are an important and sometimes unsuspected cause of recurrent rhinorrhea, bronchiolitis, wheezy bronchitis and bronchopneumonia in infants. In Canada some 7% of all babies given cow's milk formulas have gastrointestinal, respira¬ tory and cutaneous problems (eczema) that are attributable in part to cow's milk antigens. The human baby is provided with humoral immunity to those organisms to which the mother has made IgG an¬ tibodies. These antibodies are trans¬ mitted to the baby regardless of the infections to which the latter may be exposed. In cows, however, the mammary gland itself can respond to in¬ fections in the calf, for organisms placed in the calf's mouth can gain access to the cow's udder and there provoke the production of antibodies that return in the cow's milk to the calf, affording the calf additional pro¬ tection. Breast milk and colostrum contain not only nutrients and antibodies but also leukocytes (2 to 4 x 107/, mainly monocytes). These cells may protect the baby against diseases such as tuberculosis and infection with Can¬ dida species, to which the mother has a cell-mediated immune response. We may therefore conclude that milks are

immunoglobulin A (IgA), but, because IgG crosses the placenta and serum IgG values are as high in the infant as in the mother, it has been assumed that IgG alone provides the baby with all the immunologic protection that is necessary. Human babies do obtain this protection transplacentally, but it is not correct to assume that, on this account, they do not need additional colostral protection. They do. They also need the additional protection afforded by breast-feeding. The effectiveness of this protection has been shown in three well docu¬ mented studies. The first study was conducted in Guatemala: babies re¬ ceiving breast milk alone remained free from the gastrointestinal tract infec¬ tions due to pathogenic Escherichia coli and Shigella species acquired by babies receiving formula in similar surroundings. The second and third studies were of two butbreaks of gastroenteritis due to enteropathogenic E. coli in newborn nurseries; the infections could be con¬ trolled only when all babies were given breast milk. One of these studies showed that boiled breast milk given by bottle to infants who were too small or too ill to breast-feed did not afford adequate protection; when all babies were given fresh, unboiled breast milk the outbreak of gastroenteritis ended. The value of breast-feeding was proved 40 to 50 years ago. Surprisingly, breast-feeding was associated not only with a decrease in the prevalence of gastrointestinal tract infections, but also with a decrease in the prevalence of respiratory tract infections. Mortality species-unique; they provide not only rates were also greatly reduced; deaths the nutrients needed for normal growth from gastrointestinal tract infections and development but also the immuno¬ were reduced by a factor of 40, and logic protection, both humoral and cel¬ those from respiratory tract infections, lular, needed to ensure a smooth tranby a factor of 100. These studies, as sition from a state of complete de¬ well as the more recent evidence from pendence on the mother to one of selfChile, indicated that the introduction dependency. Self-dependency is well on the way to being achieved by the age of 9 months, and breast-feeding, if it ¦"Selected abstracts of papers presented at the is to provide maximum protection, POGO refresher course held at the University should be continued for this of Saskatchewan, Saskatoon, Feb. 20 to 22, 1975. period. 138 CMA

JOURNAL/JULY 26, 1975/VOL. 113

During

the first 6 months cow's milk and other food antigens should, ideally, be avoided. After the first 6 critical months, new foods may gradually be added, and if these are tolerated, breast¬ feeding may be gradually discontinued. Furthermore, the mother should receive a good, nutritious diet with adequate calorie, mineral and vitamin conterit. If the mother is to be a satisfactory nurs¬ ing mother, she must first be made more fully aware of the incomparable value to the baby of breast-feeding, and that nipples and breasts should re¬ ceive adequate preparation before her baby is born; if she needs help and encouragement subsequently she should be given it and shielded from the blandishments of those who counsel formula feeding and the early introduction of cereals and other foods. Relevance of breast-feeding today Does our growing appreciation of the value of breast-feeding have any relevance today, particularly as formu¬ las are now relatively safe bacteriologically? True, when hygiene is good and gastrointestinal infections are rare, breast-feeding may no longer be essen¬ tial. But even when standards of hy¬ giene are high this does not always apply, as an outbreak of gastroenteritis in a newborn nursery in Newfound¬ land testified. And, in countries like Canada, were all babies to be breastfed, gastrointestinal, respiratory and cutaneous disorders would probably be¬ come much less common and doctors could then attend to other diseases less amenable to a ready resolution. The situation is different, however, when hygiene is unsatisfactory, gastrointesti¬ nal tract infections relatively common and infant mortality high. And unless a strong stand is taken, the developing countries, following the example of the feeding practices in developed coun¬ tries, will abandon the breast for the bottle, as is happening in Chile, and infant mortality will increase. Pediatri¬ cians and family doctors will then find themselves devoting much of their time and energy, as we do, to treating dis¬ eases that need never have arisen. John W. Gerrard, dm, frcp[c] Department of pediatrics University of Saskatchewan

Saskatoon, Sask.

AE, Billingham RE, Head J: The immunologic significance of the mammary gland. / Invest Dermatol 63: 65, 1974 2. Gerrard JW: Breast feeding: second thoughts. Pediatrics 54: 757, 1974 1. Beer

Obesity

in childhood

diagnosis nor a disease, but simply phenomenon that may result from a variety of causes some physiologic, some genetically de¬ termined and others acquired. Obesity in childhood cannot be regarded in the same diagnostic or therapeutic terms as obesity in adults, even though many obese children will retain their obesity throughout life. It is also misleading to think of most obese children as reflect¬ ing a state of "overnutrition", as is commonly done. The following points are important: 1. Obesity in some children occurs as a result of an increase in the number of fat cells (hyperplastic obesity), in others because of an increase in size of fat cells (hypertrophic obesity) and Obesity is

neither

fewer calories than are their though there are a few notable exceptions. 6. Although there is an association between obesity and hypertension, false recordings of hypertension in obese children and adults are common, due simply to the fact that the bladder of the blood pressure cuff is too narrow for an oversized arm. Readings should always be checked with the cuff on the forearm. 7. The concept of obesity as a dis¬ ease of affluence is misleading. In fact, a striking inverse relation between so¬ cioeconomic status and the prevalence of obesity has been well documented in Western society. This strengthens the concept that physical inactivity is a major determinant of the phenomenon. 8. Emotional disturbances are more often the result of than the cause of obese states. There are strong social pressures against the obese in our so¬ ciety, and medical treatment that focuses only on the obesity is not only likely to fail but also may aggravate the associated depression and diminished self-system of the obese youngster. 9. The physician's role in preventing obesity should probably be directed to¬ number

Background reading

a a

.

in some because of a combination of the two processes. This distinction has important implications for treatment: thus, in the hyperplastic type other tissues (e.g. muscle and bone) also are hyperplastic, obesity begins early in life, the children mature early and are taller than average, and the obesity is resistant to therapy. 2. Several specific and rare genetic disorders are associated with marked obesity. These include the LaurenceMoon-Biedl syndrome, the PraderWilli syndrome and pseudohypopara-

thyroidism. 3. Obesity due to endocrine disturb¬ ance is exceedingly rare, and the meta¬ bolic abnormalities associated with obesity (impaired glucose tolerance and insulin resistance) appear to be results of obesity rather than causes. 4. Genetic factors and reduced ca¬ loric expenditure (inactivity) are the major operative factors in most cases of childhood obesity. Although exces¬ sive calorie intake can occur, this is the main problem in a minority of in¬ stances. The insulating effect of a layer of adipose tissue and the lack of insulation in its absence probably tend to keep fat people fat and thin people thin, despite a wide variation in calorie intakes. 5. The recent suggestion that overfeeding in infancy is an important cause of obesity has not been substantiated in careful studies. Weight gain in the 1st year of life has been found to be of virtually no value as a predictor of obesity at age 7 years. In older chil¬ dren careful measurement of calorie intake shows that most obese indivi¬ duals are consuming either the same

or

nonobese peers,

encouraging daily physical ac¬ tivity in the schools, with less emphasis on team performance. A better under¬ standing of the mechanisms of obesity should help the physician to take a more sympathetic and realistic ap¬ proach to his obese patients of all ages.

wards

Richard B. Goldbloom, md Physician in chief The Izaak Walton Killam Hospital for Children Halifax, NS

Additives in infant foods A food additive is any substance added

to a food during production, processing, packaging or storing. Intentional addi¬ tives are included to provide specific functions and have either nutritional or non-nutritional properties. Nutritional compounds consist primarily of vita¬

mins and minerals and, to a minor ex¬ tent, certain amino acids. Non-nutritive additives may function as stabilizers or thickeners, flavouring agents, emulsi-

For the Optimum Management of Iron Deficiency

Slow-fe Formula: Each SLOW-FE tablet contains 160 mg. of dried ferrous sulfate U.S.P. (equivalent to 50 mg. of ferrous iron), in a specialty formulated slow release base. The iron content is released evenly over an aver¬ age period of 1 /2 hours, the optimum time for maximum effective absorption. The tablets are film-coated. Indications: The management of iron deficiency states. SLOW-FE is formulated to be better tolerated than ordinary ferrous sulfate tablets and it is therefore especially suitable for prolonged administration. The minimization of nausea and gastrointestinal irritation is advantageous in pregnancy, gastroin¬ testinal disorders, e.g. peptic ulcer, convalescence and in old age, all of which may be associated with simple iron deficiency anemias. and Administration: Because it is Dosage slowly released an adequate dose is possible by giving SLOW-FE only once daily. As the'ferrous sulfate content is evenly distributed through the special slow release base only a very small quantity is released in the stomach. There is therefore no need to advise that SLOW-FE tablets be taken with or after food as with other ferrous sulfate tablets. Prophylaxis; A single tablet daily is sufficient to maintain iron intake both during pregnancy and in patients with simple iron deficiency. Iron Deficiency; Depending on the severity, one or two tablets of SLOW-FE daily, usually in one dose. In mild anemias, e.g. hemoglobin above 75%, one tablet daily will usually suffice. For moderate or severe anemias two tablets daily should be given, until the hemoglobin levels return to normal. This physiological process may require up to approximately eight weeks. In most patients the dose can then be reduced to one tablet daily for maintenance, to build up iron reserves over a further 12 to 16 weeks. For Children: One tablet of SLOW-FE daily is a suitable dose for children able to swallow a small tablet. Side Effects: Gastrointestinal side effects such as nausea and gastrointestinal irritation usually occurring with other iron-containing tablets, are unlikely to arise with SLOW-FE. Treatment of Overdosage: Care has been taken to minimize the risk of accidental consumption of Slow-Fe by children by making the tablets a relatively unattractive off-white colour with an almost tasteless film coat rather than the customary sweet-tasting sugar coat. Moreover the push-through type of foil packaging makes the extraction of many tablets difficult and tedious for children. However, in the event of overdosage the usual treatment for iron poisoning should be instituted. Because the iron is only slowly released the risk of toxic levels of ionic iron being absorbed is less and there is a wider time margin in which to carry out stomach wash outs; also the use of an iron-chelating agent such as Desferal® (deferoxamine CIBA) is likely to be more effective. The treatment of iron poisoning is described in detail in the CIBA literature

Desferal®. fiers, acidulants, preservatives (antimi¬ on Contraindications: Iron therapy is contraindicated crobial and antioxidant), sweeteners or in the presence of hemochromatosis, hemosiderosis colouring agents. The general food and hemolytic anemia.

market of the future will be influenced primarily by the continued demand for convenience foods, the need for a longer shelf-life and increased empha¬ sis on nutritional value all of which make additives necessary. Therefore, use of additives will continue to in¬ .

crease.

In infant foods most of the additives nutritive. The types and amounts of additives and the foods to which are

Precautions: SLOW-FE like all oral iron prepara¬

tions, may aggravate existing peptic ulcer, regional

enteritis and ulcerative colitis. in Supplied: SLOW-FE tablets are30packaged push-through packs containing tablets per sheet and are available in units of 30,120 and 4,800 tablets. Reference: 1. Nutrition Canada National Survey. A report by Nutrition Canada to The Department of National Health and Welfare, Ottawa, Information Canada, 1973.

CIBA

DORVAL, QUEBEC

H9S1B1

C-5024

CMA JOURNAL/JULY 26, 1975/VOL. 113 139