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      <h1 id="top">1.3 Relative risks</h1>
      <div>
    <p class="listTitle">Artificial feeding increases illnesses in infants by:</p>
    <ol>
      <li>denying the infant the many special, unique protective factors, both antibody and non-antibody, found in human milk</li>
      <li>exposing the infant to bacterial pathogens in other food sources</li>
      <li>not providing optimal nutrition, decreasing the infant's ablility to fight infections<br /></li>
    </ol>
    <br />
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            <td class="body"><h3>Clinical Note:</h3>
    <div>
      <p> To obtain true and fair scientifically-relevant results in research studies, the researcher must compare the variable being studied to the norm. For example: compare state of disease in adults who smoke (variable), to state of disease in adults who do not smoke (the norm). Results are then written up as a change from the norm - ie 'incidence of lung cancer is increased in those who smoke by X.' </p>
      <p> Breastfeeding is normal and breastfed babies enjoy a NORMAL state of health. Studies of infant health are notoriously reported incorrectly, making statements that equate to 'Breastfed babies are healthier' whereas correct breastfeeding language should read 'Artificially-fed babies are sicker'. </p>
      <p> Whenever you discuss feeding outcomes with your colleagues or with parents, ensure you are speaking factually using breastmilk and breastfeeding as the norm.</p>
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            <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>A little statistics...</h3>
    <div>
      <p>Relative risk (RR) is a ratio of the probability of a disease, in this case, occuring in the experimental group (ie artificially-fed) versus the control (breastfed) group. The equation to work it out is: RR = Probability in experimental group <em>divided by</em> Probability in control group.</p>
      <p>For example: If the probability of an infant contracting diarrhoea in the first month of life is 1% when breastfed, but 14% if artificially-fed then the RR=14. An artificially-fed infant has 14 times the risk of getting diarrhoea in the first month of life compared to the risk for a breastfed infant. <br /></p>
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      <div class="section" id="Acute_diseases_attributable_to_artificial_feeding"><h2>Acute diseases attributable to artificial feeding</h2>
    <div class="section" id="Diarrhoea_diarrhea_"><h3>Diarrhoea (diarrhea)</h3>
      <div>
        <p>
			Dewey et al (1995)<sup><a href="#note1">1</a></sup> reported twice the incidence of gastrointestinal morbidity in artificially-fed infants in a relatively affluent community in the United States while Kramer et al (2001)<sup><a href="#note2">2</a></sup> reported a 66% increase in a socially advantaged group where artificial feeding was predominant.
		</p>
        <p>
			In countries where poverty and poor hygiene are factors breastfeeding means the difference between healthy normal development, and malnutrition or possibly death.
		</p>
      </div>
    </div>
    <div class="section" id="Otitis_media_middle_ear_infection_"><h3>Otitis media (middle ear infection)</h3>
      <div>
        <p> A large literature review concluded that formula-fed infants' risk of otitis media is doubled in the first year.<sup><a href="#note3">3</a></sup> It has also been found that they experience a 75% increased incidence of otitis media of 10 or more days duration.<sup><a href="#note1">1</a></sup> Saarinen et al (1982)<sup><a href="#note4">4</a></sup> followed healthy term infants, noting that no exclusively breastfed infant suffered from otitis media in the first 6 months of life, while 10% of babies who were given any cow's milk did. </p>
      </div>
    </div>
    <div class="section" id="Pneumonia"><h3>Pneumonia</h3>
      <div>
        <p> The occurrence of pneumonia in infants living in poor socio-economic regions is significantly increased if they are artificially fed.<sup><a href="#note5">5</a>,</sup><sup><a href="#note6">6</a>,</sup><sup><a href="#note7">7</a></sup></p>
        <p>A meta-analysis of research has found that artificial feeding contributed a 3.6-fold increased risk of hospitalisation for lower respiratory tract infections.<sup><a href="#note8">8</a></sup><br /></p>
      </div>
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    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/chart.png" class="icon" alt="" /><h3>Summary of diarrhoea, otitis media and pneumonia</h3>
      <div>
        <p></p>
        <table>
          <caption><br />The relative risk of developing diseases throughout life for artificially-fed as compared to human milk-fed infants. (Heinz Sight, 2001)<sup><a href="#note9">9</a></sup></caption>
          <thead>
            <tr>
              <th></th>
              <th>0 - 1 month</th>
              <th>1 - 12 months</th>
              <th>1 - 6 years</th>
            </tr>
          </thead>
          <tbody>
            <tr class="row0">
              <th>Diarrhea </th>
              <td>14 </td>
              <td>4 - 10 </td>
              <td></td>
            </tr>
            <tr class="row1">
              <th>Otitis media</th>
              <td></td>
              <td>8.6</td>
              <td>3.3 - 4.3</td>
            </tr>
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              <th>Respiratory illness</th>
              <td></td>
              <td>3.3 - 4.3</td>
              <td></td>
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    <div class="section" id="Urinary_Tract_Infection"><h3>Urinary Tract Infection</h3>
      <div>
        <p>
			Marild et al (2004)<sup><a href="#note10">10</a></sup> demonstrated a significant increase in UTI amongst artificially-fed infants in Sweden; this protection for the breastfed infant persisted after weaning.
		</p>
      </div>
    </div>
    <div class="section" id="Necrotising_Enterocolitis"><h3>Necrotising Enterocolitis</h3>
      <div>Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency in the NICU, with often devastating consequences.The key risk factors leading to NEC are prematurity, formula feeding, intestinal ischemia, and bacterial colonization.<sup><a href="#note11">11</a></sup> The mortality rate (15%-25%) for affected infants has not changed appreciably in 30 years.</div>
    </div>
    <div class="section" id="Septicemia_and_Meningitis"><h3>Septicemia and Meningitis</h3>
      <div>
        <p> Neonatal septicemia and meningitis is associated with severe morbidity and high mortality rates. Artificially fed infants in neonatal intensive care units, and artificially fed infants in developing countries, are most at risk. </p>
        <p> In a comparison of breastmilk-fed and artificially-fed babies in neonatal intensive care units the incidence of sepsis was:<sup><a href="#note12">12</a></sup> </p>
        <table>
          <thead>
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              <th>Postnatal Age</th>
              <th>Breastmilk Fed</th>
              <th>Artificial Milk Fed</th>
            </tr>
          </thead>
          <tbody>
            <tr class="row0">
              <th>first 10 days</th>
              <td>5%</td>
              <td>10%</td>
            </tr>
            <tr class="row1">
              <th>11 - 24 days</th>
              <td>9%</td>
              <td>20%</td>
            </tr>
            <tr class="row0">
              <th>25 - 38 days</th>
              <td>0%</td>
              <td>15%</td>
            </tr>
          </tbody>
        </table>
      </div>
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      <div class="section" id="Chronic_diseases_attributable_to_artificial_feeding"><h2>Chronic diseases attributable to artificial feeding</h2>
    <div class="section" id="Type_1_Diabetes_Mellitus_Insulin-dependent_diabetes_"><h3>Type 1 Diabetes Mellitus (Insulin-dependent diabetes)</h3>
      <div>
        <p class="listTitle">Type 1 diabetes is an auto-immune disease determined by a combination of genetic and environmental factors. <br /></p>
        <ul>
          <li> general population risk of developing Type 1 diabetes = 0.4%</li>
          <li>when a first-degree relative is affected = 6%</li>
        </ul>
        <p>Environmental factors provide the trigger that causes a child to develop diabetes.</p>
        <p class="listTitle">There are several hypotheses as to what these environmental factors are:</p>
        <ul>
          <li>early exposure to cow's milk protein</li>
          <li>introduction to solid food before 3 months</li>
          <li>not having all the protective benefits of breastmilk <br /></li>
        </ul>
        <p class="listTitle">Meta-analyses of the published research found a strong link between early introduction of artificial milks and the development of Type 1 diabetes:</p>
        <ul>
          <li>exposure to cow's milk in the first 3 months<sup><a href="#note13">13</a>,</sup><sup><a href="#note14">14</a></sup> <br /></li>
          <li>children who breastfed &lt;3 months, OR of 1.43 (1.15-1.77)<sup><a href="#note15">15</a></sup></li>
          <li> no-breastfeeding increased the risk (OR=1.93 [95% CI: 1.33-2.80]), while breastfeeding for more than 12 months was protective (OR=0.42 [95% CI: 0.22-0.81]).<sup><a href="#note16">16</a></sup> </li>
        </ul>
        <br />
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        <div>Mothers who have type 1 diabetes are more likely to NOT breastfeed.<sup><a href="#note17">17</a></sup> Cesarian section birth, prematurity and unstable baby's condition at birth are among the reasons given for this occurrence. The same author also found that breastfeeding duration is likely to be shorter amongst this group of mothers with breastfeeding &lt;4 weeks being associated with overweight at age 2 years.<sup><a href="#note18">18</a></sup> <br /><br />Can you see how the risk of type 1 diabetes can spiral through the generations? The birth and post-birth circumstances and management of the diabetic mother can lead to an intervention (ie. infant being not-breastfed/early exposure to cow's milk protein in artifical infant milk) which triggers the infant to later develop diabetes.<br /><br />Would mothers put their baby at risk if they knew this?<br />What can you do at your workplace to help break this cycle?<br /></div>
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      <div class="section" id="Type_2_Diabetes"><h4>Type 2 Diabetes</h4>
        <div>The mechanism is not entirely understood, however, studies report that formula-fed infants have higher basal and post-prandial concentrations of insulin and neurotensin.<sup><a href="#note19">19</a>,</sup><sup><a href="#note20">20</a></sup> Being formula-fed in infancy is associated with a 1.6 fold risk of developing type 2 diabetes.<sup><a href="#note21">21</a></sup> <sup><a href="#note22">22</a></sup></div>
      </div>
    </div>
    <div class="section" id="Coeliac_Celiac_Disease"><h3>Coeliac (Celiac) Disease</h3>
      <div>
        <p> Celiac disease is an autoimmune enteropathy. Genetic susceptibility and dietary exposure to gluten are necessary for it to occur. Controlled studies looking at infant feeding have shown an approximately four-fold increased risk, as well as an earlier onset, among artificially fed children. <sup><a href="#note23">23</a></sup> </p>
        <p> A meta-analysis of the literature <sup><a href="#note24">24</a></sup> reported more than double the incidence of celiac disease in infants who received breastmilk substitutes before 6 months and were not receiving any breastmilk during the introduction of gluten-containing foods. <br /> <br /> The current recommendation to prevent the development of celiac disease is for children to be breastfed exclusively for 6 months and for breastfeeding to continue while, and for several months after, gluten is introduced into the diet. <br /> </p>
      </div>
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    <div class="section" id="Obesity"><h3>Obesity</h3>
      <div>
        <p> Obesity is a serious condition that leads to chronic diseases such as heart disease, diabetes, hypertension, some cancers and an earlier death. Prevention of obesity starts at birth and is greatly influenced by the feeding method chosen. <br /></p>
        <p>Breastmilk contains an appetite regulator, leptin. Artifically-fed infants have half the normal serum leptin.<sup><a href="#note25">25</a></sup><br /></p>
        <p> Artificial feeding is significantly correlated with obesity in childhood and adulthood.<sup><a href="#note26">26</a>,</sup><sup><a href="#note27">27</a>,</sup><sup><a href="#note28">28</a>,</sup><sup><a href="#note3">3</a></sup> </p>
        <p class="listTitle">Closely associated with childhood obesity:</p>
        <ul>
          <li>early weaning to artificial infant formula</li>
          <li>introduction of artificial infant formula before 6 months of age while breastfeeding</li>
          <li>introduction of foods before 6 months of age</li>
        </ul>
      </div>
    </div>
    <div class="section" id="Childhood_Cancer"><h3>Childhood Cancer</h3>
      <div>
        <p>Fortunately childhood cancers are rare, but their rarity makes quality research difficult to achieve.</p>
        <p>There is a strong link between being artificially fed and the following cancers:<sup><a href="#note29">29</a>,</sup><sup><a href="#note30">30</a></sup></p>
        <ul>
          <li>acute lymphoblastic leukemia (leukaemia)</li>
          <li>lymphomas - Hodgkin's and non-Hodgkin's</li>
          <li>neuroblastomas</li>
        </ul>
      </div>
    </div>
    <div class="section" id="Inflammatory_Bowel_Diseases"><h3>Inflammatory Bowel Diseases</h3>
      <div>
        <ul>
          <li>Inflammatory bowel disease</li>
          <li>Ulcerative colitis</li>
          <li>Crohn's disease</li>
        </ul>
        <p> The causes of these conditions are multifactorial. However, researchers have been able to link infant feeding method to their development, finding that cases were much more common in those who had been artificially fed. </p>
      </div>
    </div>
    <div class="section" id="Allergic_Responses"><h3>Allergic Responses</h3>
      <div>
        <p> Cow's milk is the most common single allergen affecting infants. The proteins in cow's milk are the allergen, NOT lactose. Standard infant formulas are made from cow's milk. </p>
        <p> Compared to breastfed infants, artificially-fed infants have a significantly higher incidence of all forms of atopy.<sup><a href="#note31">31</a></sup>Feeding soy-based artificial baby milk, compared to standard cow's milk-based artifical baby milk does not reduce the risk.<sup><a href="#note32">32</a></sup> </p>
        <p> Asthma, eczema, urticaria, rhinitis, failure-to-thrive, colic, chronic respiratory disease, gastro-oesophageal reflux and gastro-intestinal disease are all examples of conditions caused by an allergy or intolerance to cow's milk protein. </p>
      </div>
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              <img src="design/books.png" class="icon" alt="" />
              <h3>Workbook Activity 1.5</h3>
              <p>Complete Activity 1.5 in your workbook.</p>
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      <div class="section" id="Developmental_Deficits"><h2>Developmental Deficits</h2>
    <div class="section" id="Intelligence"><h3>Intelligence</h3>
      <div>
        <p> The brain of the newborn infant continues to develop rapidly after full term birth, doubling in size by one year of age. The brain growth in the preterm infant is even more rapid and therefore has an even greater potential to be harmed by inappropriate nutrition. </p>
        <p> Since Lucas in 1992<sup><a href="#note33">33</a></sup> was able to demonstrate an intellectual deficit caused by artificial infant formula feeding, there have been numerous research papers confirming those findings. </p>
        <p> Assessment of children at 6.5 years of age reveals: </p>
        <ul>
          <li>
            <p class="listTitle">exclusive artificial feeding, or early introduction of artificial infant formula, contributes significantly to</p>
            <ul>
              <li>reduced total IQ</li>
              <li>reduced verbal IQ</li>
              <li>reduced performance IQ<sup><a href="#note34">34</a></sup></li>
            </ul>
          </li>
        </ul>
        <p> 90% of children artificially fed will have an average 7-point IQ deficit that is directly attributable to being artificially fed.<sup><a href="#note35">35</a></sup> </p>
      </div>
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  </div>
      <div class="section" id="Sudden_Infant_Death_Syndrome_SIDS_"><h2>Sudden Infant Death Syndrome (SIDS)</h2>
    <div>
      <p>Artificial feeding at one month of age was associated with double the risk for SIDS.<sup><a href="#note36">36</a></sup> The majority of babies older than one month who die of SIDS were infant formula fed. <sup><a href="#note37">37</a>,</sup><sup><a href="#note38">38</a>,</sup><sup><a href="#note39">39</a></sup></p>
      <p>A meta analysis of 23 SIDS studies revealed 19 studies which favourably supported breastfeeding in protection against SIDS. The combined analysis indicated that artificially-fed infants were twice as likely to die from SIDS.<sup><a href="#note37">37</a></sup></p>
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              <img src="design/callout_08.png" width="59" height="10" alt="" />
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            <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>Think about it:</h3>
    <div>
      <p>Most new parents do not know of the research that clearly demonstrates these poor health and developmental outcomes from artificial feeding. As a health professional do you feel it is fair to withhold this information from parents who generally just want to do the best thing for their children?
		</p>
      <p>Who do you think is being protected when this information is not shared with parents? Who stands to lose by withholding this information? Who stands to gain by withholding this information?</p>
    </div>
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            <td class="body"><a href="images/Center_Update_BFGuilt.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="images/Center_Update_BFGuilt.pdf" target="_blank">But we shouldn't make mothers feel guilty!</a></h3>
    <div>
      <p>
			Click on the icon above to read an article about making mothers feel guilty.
		</p>
    </div>
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              <img src="design/callout_06.png" width="10" height="80" alt="" />
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              <img src="design/callout_02.png" width="59" height="10" alt="" />
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            <td class="middleleft" style="background: repeat-y url(design/callout_04.png);">
              <img src="design/callout_04.png" width="10" height="80" alt="" />
            </td>
            <td class="body"><img src="design/thinker.gif" class="icon" alt="" /><h3>What would you say?</h3>
    <div>Well, have you thought about what you would say now if a mother said to you, "Is breastfeeding really worth all the effort it takes?"</div>
  </td>
            <td class="middleright" style="background: repeat-y url(design/callout_06.png);">
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      <div>
    <p class="listTitle">In Module 3 you'll learn that discussing specific effects of breastfeeding and artificial infant formula feeding is required of you. However, the next module will help you to see how you can discuss this topic (and many others) giving</p>
    <ul>
      <li>accurate, factual <strong>information</strong>,</li>
      <li>that the mother will be able to <strong>understand</strong> in the context of her situation,</li>
      <li>while building the mother's <strong>confidence</strong> to make decisions that suit her situation, and </li>
      <li>that she feels <strong>supported</strong> to carry out.</li>
    </ul>
  </div>
      <div class="section" id="What_should_I_remember_"><h2>What should I remember?</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><img src="design/remember.png" class="icon" alt="" /><h3></h3>
      <div>
        <ul>
          <li>the absence of breastmilk properties is the first contributing factor to disease processes</li>
          <li>the exposure to artificial substances such as artificial infant milk has a strong association with acute and chronic illness</li>
          <li>the acute conditions which are associated with infant formula feeding<br /></li>
          <li>the chronic conditions which are associated with infant formula feeding<br /></li>
          <li>there is a positive correlation between artificial infant formula feeding rates and the incidence of infant mortality and morbidity in <strong>every</strong> country in the World</li>
        </ul>
      </div>
    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div class="section" id="Self-test_Quiz"><h2>Self-test Quiz</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3></h3>
      <div></div><div class="activity" id="activity_t">
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	new MCQ('Artificial infant formula increases illness in infants by...', [{text:'not providing optimal nutrition, decreasing their ability to fight infections.',feedback:'That\'s one way. Any others?',score:0},{text:'denying them the special, unique protective factors in human milk.',feedback:'That\'s one way. Any others?',score:0},{text:'exposing them to bacterial pathogens in their food source.',feedback:'That\'s one way. Any others?',score:0},{text:'All of these answers.',feedback:'Yes, all these together increase the chance of morbidity in the artificially-fed infant.',score:1}]),
	new MCQ('Gastroenteritis is unlikely to affect artificially-fed babies who live in a clean environment where the mother is careful to prepare the bottle feed hygienically.', [{text:'True',score:0},{text:'False',feedback:'Even when preparation conditions are hygenic, artifical infant milk feeding increases risk of gastrointestinal illnesses',score:1}]),
	new MCQ('Compared to breastfed infants what was the incidence of septicemia and/or meningitis in artificially-fed infants in a neonatal intensive care unit at all age points during the first month of life?', [{text:'double, or more than double',score:1},{text:'about 50% more',feedback:'It\'s a greater incidence than this',score:0},{text:'about half',feedback:'No, they get this serious illness much more frequently.',score:0},{text:'about the same',feedback:'No, they get this serious illness much more frequently.',score:0}]),
	new MCQ('All of the following have been identified as increasing the risk of obesity in children, EXCEPT...', [{text:'early introduction of solids, ie before 6 months of age.',feedback:'That is a factor noted in obese children.',score:0},{text:'partial breastfeeding before 6 months of age',feedback:'That is a factor noted in obese children.',score:0},{text:'maternal high fat diet while lactating',feedback:'Correct! The mother\'s diet will not affect her child adversely in this manner.',score:1},{text:'early weaning to artificial infant formula',feedback:'That is a factor noted in obese children.',score:0}]),
	new MCQ('Which of the following cancers affecting children were found to be more prevalent in children who were artificially fed? Choose all correct answers.', [{text:'Hodgkins lymphoma',score:1},{text:'neuroblastoma',score:1},{text:'acute lymphoblastic leukemia',score:1},{text:'osteosarcoma',feedback:'Not this one. It appears to be the soft-tissue cancers that are more affected by an unsuitable first diet.',score:0}])
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    </td><td class="middleright" style="background: repeat-y url(design/callout_06.png);"><img src="design/callout_06.png" width="10" height="80" alt="" /></td></tr></tbody></table>
  </div>
      <div class="section" id="Assessment_Quiz"><h2>Assessment Quiz</h2>
    <div>
      <p>
		When you are happy that you've understood all the information in this topic you will be ready to complete the Module 1 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 1.
	</p>
    </div>
  </div>
      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#dewe95" title="See full details">#</a> Dewey KG et al. (1995) Differences in morbidity between breast-fed and formula-fed infants.</li>
          <li id="note2"><a href="references.html#kram01" title="See full details">#</a> Kramer MS et al. (2001) Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus.</li>
          <li id="note3"><a href="references.html#ips07" title="See full details">#</a> Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries.</li>
          <li id="note4"><a href="references.html#saar82" title="See full details">#</a> Saarinen UM (1982) Prolonged breast feeding as prophylaxis for recurrent otitis media.</li>
          <li id="note5"><a href="references.html#vict87" title="See full details">#</a> Victora CG et al. (1987) Evidence for protection by breast-feeding against infant deaths from infectious diseases in Brazil.</li>
          <li id="note6"><a href="references.html#wrig89" title="See full details">#</a> Wright AL et al. (1989) Breast feeding and lower respiratory tract illness in the first year of life</li>
          <li id="note7"><a href="references.html#oddy03" title="See full details">#</a> Oddy WH et al. (2003) Breast feeding and respiratory morbidity in infancy: a birth cohort study</li>
          <li id="note8"><a href="references.html#bach03" title="See full details">#</a> Bachrach VR et al. (2003) Breastfeeding and the risk of hospitalization for respiratory disease in infancy: a meta-analysis.</li>
          <li id="note9"><a href="references.html#hein01" title="See full details">#</a> Heinz (2001-02) Heinz Sight: Infant Nutrition Newsletter</li>
          <li id="note10"><a href="references.html#mari04" title="See full details">#</a> Marild S et al. (2004) Protective effect of breastfeeding against urinary tract infection</li>
          <li id="note11"><a href="references.html#yeos06" title="See full details">#</a> Yeo SL (2006) NICU update: state of the science of NEC.</li>
          <li id="note12"><a href="references.html#elmo97" title="See full details">#</a> el-Mohandes AE et al. (1997) Use of human milk in the intensive care nursery decreases the incidence of nosocomial sepsis</li>
          <li id="note13"><a href="references.html#kost93" title="See full details">#</a> Kostraba JN et al. (1993) Early exposure to cow's milk and solid foods in infancy, genetic predisposition, and risk of IDDM.</li>
          <li id="note14"><a href="references.html#gers94" title="See full details">#</a> Gerstein HC (1994) Cow's milk exposure and type 1 diabetes mellitus. A critical overview of the clinical literature.</li>
          <li id="note15"><a href="references.html#pere96" title="See full details">#</a> Perez-Bravo E et al. (1996) Genetic predisposition and environmental factors leading to the development of insulin-dependent diabetes mellitus in Chilean children</li>
          <li id="note16"><a href="references.html#malc06" title="See full details">#</a> Malcova H et al. (2006) Absence of breast-feeding is associated with the risk of type 1 diabetes: a case-control study in a population with rapidly increasing incidence</li>
          <li id="note17"><a href="references.html#humm07" title="See full details">#</a> Hummel S et al. (2007) Breastfeeding habits in families with Type 1 diabetes</li>
          <li id="note18"><a href="references.html#humm08" title="See full details">#</a> Hummel S et al. (2008) [Breastfeeding in women with gestational diabetes]</li>
          <li id="note19"><a href="references.html#luca80" title="See full details">#</a> Lucas A et al. (1980) Breast vs Bottle: endocrine responses are different with formula feeding</li>
          <li id="note20"><a href="references.html#salm88" title="See full details">#</a> Salmenperä L et al. (1988) Effects of feeding regimen on blood glucose levels and plasma concentrations of pancreatic hormones and gut regulatory peptides at 9 months of age: comparison between infants fed with milk formula and infants exclusively breast-fed from birth.</li>
          <li id="note21"><a href="references.html#ipsc07" title="See full details">#</a> Ip S et al. (2007) Breastfeeding and maternal and infant health outcomes in developed countries</li>
          <li id="note22"><a href="references.html#who07a" title="See full details">#</a> Horta BL et al. (2007) Evidence on the long term efects of breastfeeding:systematic review and meta-analyses</li>
          <li id="note23"><a href="references.html#davi01" title="See full details">#</a> Davis MK (2001) Breastfeeding and chronic disease in childhood and adolescence</li>
          <li id="note24"><a href="references.html#akob06" title="See full details">#</a> Akobeng AK et al. (2006) Effect of breast feeding on risk of coeliac disease: a systematic review and meta-analysis of observational studies</li>
          <li id="note25"><a href="references.html#savi04" title="See full details">#</a> Savino F et al. (2004) Breast-fed infants have higher leptin values than formula-fed infants in the first four months of life</li>
          <li id="note26"><a href="references.html#bake04" title="See full details">#</a> Baker JL et al. (2004) Maternal prepregnant body mass index, duration of breastfeeding, and timing of complementary food introduction are associated with infant weight gain.</li>
          <li id="note27"><a href="references.html#kali05" title="See full details">#</a> Kalies H et al. (2005) The effect of breastfeeding on weight gain in infants: results of a birth cohort study</li>
          <li id="note28"><a href="references.html#lick05" title="See full details">#</a> Li C et al. (2005) Additive interactions of maternal prepregnancy BMI and breast-feeding on childhood overweight</li>
          <li id="note29"><a href="references.html#shux99" title="See full details">#</a> Shu XO et al. (1999) Breast-feeding and risk of childhood acute leukemia</li>
          <li id="note30"><a href="references.html#mart05" title="See full details">#</a> Martin RM et al. (2005) Breast-feeding and childhood cancer: A systematic review with metaanalysis</li>
          <li id="note31"><a href="references.html#frie05" title="See full details">#</a> Friedman NJ et al. (2005) The role of breast-feeding in the development of allergies and asthma</li>
          <li id="note32"><a href="references.html#ramf02" title="See full details">#</a> Ram FS et al. (2002) Cow's milk protein avoidance and development of childhood wheeze in children with a family history of atopy.</li>
          <li id="note33"><a href="references.html#luca92" title="See full details">#</a> Lucas A et al. (1992) Breast milk and subsequent intelligence quotient in children born preterm</li>
          <li id="note34"><a href="references.html#gust04" title="See full details">#</a> Gustafsson PA et al. (2004) Breastfeeding, very long polyunsaturated fatty acids (PUFA) and IQ at 6 1/2 years of age.</li>
          <li id="note35"><a href="references.html#casp07" title="See full details">#</a> Caspi A et al. (2007) Moderation of breastfeeding effects on the IQ by genetic variation in fatty acid metabolism</li>
          <li id="note36"><a href="references.html#venn09" title="See full details">#</a> Vennemann MM et al. (2009) Does breastfeeding reduce the risk of sudden infant death syndrome?</li>
          <li id="note37"><a href="references.html#mcve00" title="See full details">#</a> McVea KL et al. (2000) The role of breastfeeding in sudden infant death syndrome</li>
          <li id="note38"><a href="references.html#almb02" title="See full details">#</a> Alm B et al. (2002) Breastfeeding and the sudden infant death syndrome in Scandinavia, 1992-95</li>
          <li id="note39"><a href="references.html#horn04" title="See full details">#</a> Horne RS et al. (2004) Comparison of evoked arousability in breast and formula fed infants.</li>
        </ol>
      </div>
      <div id="footer"><a href="topic_1-2.html" rel="prev" class="prev">&laquo; Previous</a><a href="topic_2-0.html" rel="next" class="next">Next &raquo;</a><br style="clear: both" /><a href="#top" id="topLink">Back to top</a><a href="javascript: window.print()" id="printLink">Print this page</a><span class="noPrint"> | </span>&copy; 2012 Health e-Learning<p class="printOnly">COPYRIGHT: You are permitted to print ONE (1) copy for your personal use only. No graphics, tables, quizzes, videos, etc, may be used in any form without express written consent. Author: Denise Fisher</p></div>
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    <div id="menu">
      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li class="current">1.3 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li>7.5.4 <a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
        <li class="appendix"> <a href="full.html">Print version</a></li>
      </ol>
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