25:1482–1488. 40. Anderson JW, Johnstone BM, Remley DT. Breastfeeding and cognitive development: a meta-analysis. American Journal of Clinical Nutrition, 1999, 70:525–535. 41. Daniels MC, Adair LS. Breast-feeding influences cognitive development in Filipino children. The Journal of Nutrition, 2005, 135:2589–2595. 42. Mortensen EL et al. The association between duration of breastfeeding and adult intelligence. Journal of the American Medical Association, 2002, 287:2365–2371. 43. Chua S et al. Influence of breast feeding and nipple stimulation on post-partum uterine activity. British Journal of Obstetrics & Gynaecology, 1994, 101:804–805. 44. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease. Lancet, 2002, 360:187–195. 45. Robenblatt K, Thomas D. Lactation and the risk of epithelial ovarian cancer. International Journal of Epidemiology, 1993, 22:192–197. 46. Feachem R, Koblinsky M. Interventions for the control of diarrhoeal disease among young children: promotion of breastfeeding. Bulletin of the World Health Organization, 1984, 62:271–291. 47. Victora C et al. Evidence for protection by breastfeeding against infant deaths from infectious diseases in Brazil. Lancet, 1987, 330:319–322. 48. Arifeen S et al. Exclusive breastfeeding reduces acute respiratory infection and diarrhoea deaths among infants in Dhaka slums. Pediatrics, 2001 Breast-milk composition Breast milk contains all the nutrients that an infant needs in the first 6 months of life, including fat, carbohydrates, proteins, vitamins, minerals and water (1,2,3,4). It is easily digested and efficiently used. Breast milk also contains bioactive factors that augment the infant’s immature immune system, providing protection against infection, and other factors that help digestion and absorption of nutrients. Fats Breast milk contains about 3.5 g of fat per 100 ml of milk, which provides about one half of the energy content of the milk. The fat is secreted in small droplets, and the amount increases as the feed progresses. As a result, the hindmilk secreted towards the end of a feed is rich in fat and looks creamy white, while the foremilk at the beginning of a feed contains less fat and looks somewhat bluish-grey in colour. Breast-milk fat contains long chain polyunsaturated fatty acids (docosahexaenoic acid or DHA, and arachidonic acid or ARA) that are not available in other milks. These fatty acids are important for the neurological development of a child. DHA and ARA are added to some varieties of infant formula, but this does not confer any advantage over breast milk, and may not be as effective as those in breast milk. Carbohydrates The main carbohydrate is the special milk sugar lactose, a disaccharide. Breast milk contains about 7 g lactose per 100 ml, which is more than in most other milks, and is another important source of energy. Another kind of carbohydrate present in breast milk is oligosaccharides, or sugar chains, which provide important protection against infection (4). Protein Breast milk protein differs in both quantity and quality from animal milks, and it contains a balance of amino acids which makes it much more suitable for a baby. The concentration of protein in breast milk (0.9 g per 100 ml) is lower than in animal milks. The much higher protein in animal milks can overload the infant’s immature kidneys with waste nitrogen products. Breast milk contains less of the protein casein, and this casein in breast milk has a different molecular structure. It forms much softer, more easily-digested curds than that in other milks. Among the whey, or soluble proteins, human milk contains more alpha-lactalbumin; cow milk contains betalactoglobulin, which is absent from human milk and to which infants can become intolerant (4). Vitamins and minerals Breast milk normally contains sufficient vitamins for an infant, unless the mother herself is deficient (5). The exception is vitamin D. The infant needs exposure to sunlight to generate endogenous vitamin D – or, if this is not possible, a supplement. The minerals iron and zinc are present in relatively low concentration, but their bioavailability and absorption is high. Provided that maternal iron status is adequate, term infants are born with a store of iron to supply their needs; only infants born with low birth weight may need supplements before 6 months. Delaying clamping of the cord until pulsations have stopped (approximately 3 minutes) has been shown to improve infants’ iron status during the first 6 months of life (6,7). Anti-infective factors Breast milk contains many factors that help to protect an infant against infection (8) including: K immunoglobulin, principally secretory immunoglobulin A (sIgA), which coats the intestinal mucosa and prevents bacteria from entering the cells; K white blood cells which can kill micro-organisms; K whey proteins (lysozyme and lactoferrin) which can kill bacteria, viruses and fungi; K oligosacccharides which prevent bacteria from attaching to mucosal surfaces. Session 2 10 Infant and Young Child Feeding – Model Chapter for textbooks The protection provided by these factors is uniquely valuable for an infant. First, they protect without causing the effects of inflammation, such as fever, which can be dangerous for a young infant. Second, sIgA contains antibodies formed in the mother’s body against the bacteria in her gut, and against infections that she has encountered, so they protect against bacteria that are particularly likely to be in the baby’s environment. Other bioactive factors Bile-salt stimulated lipase facilitates the complete digestion of fat once the milk has reached the small intestine (9). Fat in artificial milks is less completely digested (4). Epidermal growth factor (10) stimulates maturation of the lining of the infant’s intestine, so that it is better able to digest and absorb nutrients, and is less easily infected or sensitised to foreign proteins. It has been suggested that other growth factors present in human milk target the development and maturation of nerves and retina (11). 2.2 Colostrum and mature milk