The document discusses several categories of potential health risks associated with infant formula feeding instead of breastfeeding: 1. Risks due to missing components in formula compared to breastmilk, including increased risks of infections, obesity, diabetes, leukemia, SIDS and more. 2. Risks due to potentially harmful contents in formula, such as contaminants from manufacturing or packaging. There are several product recalls each year. Powdered formula may not be sterile. 3. Risks associated with bottle use, such as development of nipple confusion or tooth decay from prolonged and frequent bottle use. The document provides evidence from multiple studies to support the various health risks discussed in each category. It argues that formula does not

1. Health risks of infant feeding with
formula
Stelios Papaventsis MBBS MRCPCH DCH IBCLC
Paediatrician Lactation Consultant Writer of parenting books
Temporary Director of IBFAN Greece
www.pediatros-thes.gr
www.ibfan.gr
Campaign for breastfeeding promotion November 2012
www.mitrikosthilasmos.com

2. “Give him some formula.. He is
hungry..It will do nothing wrong..”
• Embedded belief for
decades that artificial
feeding is the
“standard”, “normal”,
“safe” way to feed a
baby
• But does it hold true
with current scientific
evidence?

3. Types of health risks with feeding
infant formula
• Risks because of not breastfeeding (because
of the lack of content in formula)
• Risks because of the content and
constituents of infant formula
• Risks because of the use of infant bottles
• Risks of inadequate preparation of infant
formula

4. 1st category of health risks
for infants, children and
mothers because of..
Not breastfeeding (what is missing
from infant formula)

6. Health risks of not breastfeeding
• 100% more risk of acute otitis media
• 47% more risk for eczema (atopic dermatitis)
• 178% more risk for diarrhea and vomiting (gastroenteritis)
• 257% more risk of hospitalization for respiratory tract disease
within the first year of life
• 35% more risk for asthma (no family history)
• 32% more risk for childhood obesity
• 64% more risk for diabetes type 2
• 23% more risk for acute lymphocytic leukemia
• 18% more risk for acute myelogenous leukemia
• 56% more risk for sudden infant death syndrome
• 138% more risk for development of necrotizing enterocolitis
(premature infants)
• 4% more risk of breast cancer for the mother, compared to
mothers who breastfed for at least a year
• 27% more risk of ovarian cancer, compared to mothers who
breastfed for at least a year
US Surgeon General, 2011

7. The risks of not breastfeeding: United
Kingdom (1)
If half of the mothers that currently do not breastfeed were breastfeeding for 18
months during their lifetime, then in the UK there would be:
• 865 less diagnosis of breast cancer per year
• With cost savings to the NHS of over £21 million
•Improved quality of life equating to more than £10 million each year
If 45% of babies were exclusively breastfed for four months, and if 75% of
babies in neonatal units were breastfed at discharge, each year there
would be:
• 3,285 fewer babies hospitalised with gastroenteritis and 10,637 fewer GP
consultations, saving more than £3.6 million
• 5,916 fewer babies hospitalised with respiratory illness, and 22,248 fewer
GP consultations, saving around £6.7 million
• 21,045 fewer ear infection GP visits, saving £750,000
• 361 fewer cases of the potentially fatal disease NEC, saving more than £6
million
Preventing disease saving resources. UNICEF UK 2012

8. The risks of not breastfeeding: United
Kingdom (2)
• If the number of babies receiving any breastmilk at all
rose by 1% this could lead to a small increase in IQ that,
across the entire population, could result in more than
£278 million gains in economic productivity annually
• A very modest increase in exclusive breastfeeding rates
could lead to at least three fewer cases of Sudden Infant
Death Syndrome annually, avoiding the loss of life and
profound consequences for families and saving around
£4.7 million in monetary costs
• Increasing breastfeeding rates could lead to around a
5% reduction in childhood obesity, which would save
around £1.6million each year.
Preventing disease saving resources. UNICEF UK 2012

9. Not breastfeeding and language
IQ
• Prospective cohort study of 2868 infants in Australia
from birth onwards
• Children that had not breastfed had on average:
– 3.5 points lower language IQ at 5 years of age
– 4 points lower language IQ at 10 years of age
Compared to children breastfed (even not exclusively)
for at least 6 months
Whitehouse AJ et al. Duration of breast feeding and language ability in
middle childhood. Paediatr Perinat Epidemiol. 2011;25(1):44-52

10. Not breastfeeding and IQ score
• 3253 subjects born in Denmark between 1959 and
1961
• Followed and estimated IQ at age 18 to 27 years
• Subjects that had breastfed for less than a month
had on average IQ score 99.4
• Subjects that had breastfed for at least 9 months
had on average IQ score of 106
• Dose dependency in between
Mortensen EL et al. The association between duration of
breastfeeding and adult intelligence. JAMA 2002;287(18):2365-2371.

11. Not breastfeeding and behavioral
problems
• Ten thousand term infants (Millenium Cohort Study:
large prospective cohort study at Oxford University,
started 2000)
• At 5 years of age, children that had never breastfed
had 33% increased chance for behavioral problems,
compared to children that had breastfed (even not
exclusively) for at least 4 months
Heikkilä K et al. Breast feeding and child behaviour in the Millennium Cohort
Study.Arch Dis Child. 2011 May 9. [Epub ahead of print]

12. Not breastfeeding and
childhood epilepsy
• Large prospective cohort study in Denmark (69750
infants born 1997 – 2003)
• Children never breastfed had increased risk of
developing childhood epilepsy by:
– 26%, compared to those breastfed for at least 5 months
– 39%, compared to those breastfed for at least 8 months
– 50%, compared to those breastfed for up to 12 months
– 59%, compared to those breastfed for more than 12
months
Dose dependency, no upper limit
Sun Y et al. Breastfeeding and Risk of Epilepsy in Childhood: A Birth Cohort
Study. J Pediatr. 2011 Jan 11. [Epub ahead of print]

13. Not breastfeeding and obesity
(1)
• 2066 children 9 to 16 years of age from Australia
• Children never breastfed had double risk of being
overweight or obese, compared to children that
breastfed for at least 6 months
Scott JA et al. The relationship between breastfeeding and weight status in a national
sample of Australian children and adolescents. Am J Respir Crit Care Med. 2012 Feb 3.
[Epub ahead of print]
• At population level, a 20% of childhood obesity can
statistically be attributed to feeding infants formula
United States Breastfeeding Committee. Statement on Breastfeeding as a Critical Strategy
for Obesity Prevention. Washington, DC: United States Breastfeeding Committee, 2010.

14. Not breastfeeding and obesity
(2)
• ½ kg more fat mass and ½ kg less muscle mass for
children age 4 years who never breastfed, compared
to children breastfed for at least 12 months
Robinson, 2009
• Among siblings: 6 kgs more on average at the age of
14 years for the sibling that didn’t breastfeed
Metzger, 2009
• Not breastfeeding related to central deposition of
subcutaneous fat, evident from 6 months of age,
persistent at 24 months of age
Durmus, 2011

15. Not breastfeeding and
childhood asthma
• Children never breastfed had increased risk of
wheezing, breathing difficulty, dry cough and
persistent mucus for the whole 4 first years of life,
compared to children breastfed for at least 6 months
Sonnenschein-van der Voort, 2011
• Increased risk of asthma at 4 to 6 years of age
Silvers, 2012
• Increased risk of asthma at 8 years of age
Kull, 2010

16. Not breastfeeding and obstructive
sleep apnea
• A prospective cohort of toddlers who snored
persistently at night had significantly more
behavioral problems, particularly hyper-activity,
depression and attention deficit
• Whilst none of the children given breastmilk for at
least 12 months developed persistently noisy
breathing, almost 1 in 4 children never breastfed
developed persistent noisy breathing
• Link to hypertrophic adenoids
Dean W. Beebe DW et al. Persistent Snoring in Preschool Children:
Predictors and Behavioral and Developmental Correlates.
Pediatrics; originally published online August 13, 2012

17. Not breastfeeding and cardio-
respiratory stamina at puberty
• 1025 children 10 years of age and 971 adolescents
of 16 years of age
• Evaluation of cardio-respiratory function (fitness
test)
• Dose-response relationship depicted: the more the
duration of breastfeeding in infancy, the higher the
cardio-respiratory stamina
Labayen I et al. Exclusive breastfeeding duration and cardiorespiratory fitness in
children and adolescents. Am J Clin Nutr. 2012 Feb;95(2):498-505. Epub 2012 Jan 11.

18. Not breastfeeding, general
morbidity and mortality
• At world population level, not breastfeeding is related to
10 to 15% of all deaths of children less than 5 years of
age
• 40 thousand infant deaths worldwide each day
• Breastfeeding and reduction of post-neonatal mortality
by 21% in a developed country
Αmerican Academy of Pediatrics. Breastfeeding and the Use of
Human Milk. Pediatrics 2005;115;496-506
• The risk of chronic disease is 30 to 200% greater for
those never breastfed, compared to those breastfed
• The proportion of the whole burden of chronic disease in
adulthood that is attributed statistically to not
breastfeeding is 6 to 24%
Smith JP et al. Chronic disease and infant nutrition: is it significant to public
health? Public Health Nutr. 2010 Jul 13:1-11. [Epub ahead of print]

19. Indications that not breastfeeding is
associated with..(1)
• More frequent and more severe infant colic ande
infant constipation
• Feeding difficulties, neophobia and food aversion at
toddler age
Shim JE et al. Associations of Infant Feeding Practices and Picky Eating
Behaviors of Preschool Children. J Am Diet Assoc. 2011 Sep;111(9):1363-1368
• Unhealthy diet/ less consumption of vegetables
Burnier D et al. Exclusive breastfeeding duration and later intake of
vegetables in preschool children. Eur J Clin Nutr. 2011;65(2):196-202.

20. Indications that not breastfeeding is
associated with..(2)
• Less strong bones at 17 years of age
Molgaard C et al. Are early growth and nutrition related to bone health in
adolescence? The Copenhagen Cohort Study of infant nutrition and growth. Am J
Clin Nutr. published 17 August 2011, 10.3945/ajcn.110.001214
• Diabetes type 1
Alves JG et al. Breastfeeding Protects Against Type 1 Diabetes Mellitus:
A Case-Sibling Study. Breastfeed Med. 2011 Aug 5. [Epub ahead of
print]
• Smaller size of thymus gland by half at 6 months of
age (the factory of the immune system)

21. Indications that not breastfeeding is
associated with..(3)
• 3 times bigger chance of child abuse or neglect
Strathearn L et al. Does Breastfeeding Protect Against Substantiated Child Abuse
and Neglect? A 15-Year Cohort Study. Pediatrics 2009; 123: 483 – 493
• Increased risk of atherosclerosis or hypertension at
puberty or adult age
Khan F et al. The beneficial effects of breastfeeding on microvascular function
in 11- to 14-year-old children. Vasc Med 2009;14(2):137-42.

22. Not breastfeeding: more
consequences for the mother (1)
• Increased risk of postnatal depression
• Increased risk of early conception and pregnancy
• A mother of 2 children that never breastfed is at 57
years of age on average 6.5 kilos heavier compared
to a mother of 2 children who breastfed overall for 4
years
McIntyre, 2012
• Less bone mass, increased risk of osteoporosis
after menopause, compared to women who
breastfed overall for at least 2 years
Wiklund, 2011

23. Not breastfeeding: More
consequences to the mother (2)
• Women age 45 – 58 years who never breastfed,
compared to women who breastfed for at least 3
months have on average:
– 28% more abdominal fat
– 6.5cm bigger waist size
– 4 times more chance for calcification
(atherosclerosis) of the aorta and of coronary
arteries
Schwarz 2010, McClure 2011

24. Not breastfeeding: more
consequences for the mother (3)
140 thousand women of 63 years average age
What percentage What percentage
of women who of women who
never breastfed breastfed for at
suffer from.. least a year suffer
from..
Hypertension 42.1% 38.6%
Diabetes 5.3% 4.3%
Hyperlipidemia 14.8% 12.3%
Coronary artery 9.9% 9.1%
disease
Schwarz EB et al. Duration of lactation and risk factors for maternal
cardiovascular disease. Obstet Gynecol. 2009;113(5):974-82

25. 2 category of health
nd
risks for infants, children
and mothers because
of..
The content/ constituents of infant
formula

26. 5 to 10 product recalls per year
worldwide (1)
– Metal pieces of nickel inside the milk powder
– Pieces of glass or plastic
– Lack of vitamins in the powder because of
interaction with the plastic package
– Presence of cadmium, bronze, lead, arsenic,
chrome and other heavy metals that increase
concentration with the boiling of water
– Coloring from the typed labels
– Huge doses of iodine, excess dose of vitamin
D
– Inadequate concentration of iron or vitamin C
– Nitrates well above the safe dose
www.ibfan.org

27. 5 to 10 product recalls worldwide
every year (2)
– Excess concentration of magnesium and 80
times more manganese compared to
breastmilk
– Association with botulism in infants
– Aluminium, melamine and perchlorate
– Large amounts of disphenol-A, of phthalates
and of silicone from the package
– Presence of aflatoxines or pesticides
– High concentrations of muco-estrogens
– Concentrations in substances different from
what is written on the package
www.ibfan.org

28. Infant powder formula is NOT a
sterile product
• Cronobacter (Enterobacter Sakazakii) present in
14% of samples
• Clostridium spores present in 20% of samples
• Salmonella reported
• GUIDELINE: Avoid giving powder milk to premature
infants and infants less than a month old
(European Food Safety Committee 2004, Health
Ministry of New Zealand 2011)

29. “Special formulas”: experimenting on infants
without any safety studies
• For a medication for children to be released, its safety profile
and effectiveness should be proved first
• One can find in infant formulas:
– Coconut oil, soy, carob, sunflower etc
– Proteins from cow’s milk, soy, fish, nuts
– Carbohydrates from potato, corn
– Elements of fish, egg or fungi
– Genetically modified substances such as genetically
modified soy and corn
– Absence of lactose, low fat
• Have there ever been any independent randomised control
trials looking at the immediate or long-term consequences of
such experimentations?
• Have there ever been any independent randomised control
studies looking at the effectiveness of these
experimentations?

30. 3 category of health
rd
risks for infants, children
and mothers because
of..
The use of infant bottles and
teatsΑπό την χρήση μπιμπερό

31. Documented risks of the prolonged
use of infant bottles
• Infant carries
• Dental crowding and overlapping
• Long narrow jaw receding
• High arched, long and narrow palate
• Protruding tongue, mouth breathing
• Hypertrophic adenoids
• Obstructive sleep apnea
• Speech disorder (dysarthria)

32. Bottle feeding and wheezing in
infancy
• 2833 infants (Infant Feeding Practices Study)
• With bottle feeding (either formula or breastmilk):
increased risk of developing coughing episodes of
wheezing episodes during the first 12 months of life,
compared to feeding directly at the breast
Soto-Ramirez N et al. Modes of Infant Feeding and the Occurrence of Coughing/Wheezing in
the First Year of Life. J Hum Lact. published 22 August 2012, 10.1177/0890334412453083

33. Use of infant bottles and pyloric
stenosis
• 70 thousand infant in Denmark followed
prospectively from birth until the end of infancy
• The chance of having an operation for pyloric
stenosis in infants who had bottle feeds before the
operation was 4.6 times higher, compared to infants
who didn’t feed with bottles
Krogh C et al. Bottle-feeding and the Risk of Pyloric Stenosis.
Pediatrics Published online September 3, 2012

34. Infant bottles and obesity
Use of No use of
• 6750 children born in bottles at 24 infant
USA in 2001 months of bottles
age
• Bottle feeding shown
to be independent
predictor of childhood Obesity at 22.9% 16.1%
5.5 years of
obesity (ΟR 1.33) age
• Bottle emptying
behavior
Gooze RA et al. Prolonged Bottle Use and Obesity at 5.5 Years of Age in US
Children. J Pediatr. 2011 Apr 27. [Epub ahead of print]

35. The infant breastfed. Infant bottle
afterwards?
Continued Continue
• 202 infants breastfed with infant d with
bottles cup
exclusively for 6 Open 17% more
months mouth
• Divided thereafter to 2 Tongue in 26% less
groups correct
position
• Evaluation at 4 years of Exclusive 63% 31%
age mouth
breathing
Deformed Double
palate figure
Carrascoza KC et al. Consequences of bottle-feeding to the oral facial development of
initially breastfed children.J Pediatr (Rio J). 2006;82(5):395-7.

36. 4 category of health
th
risks for infants, children
and mothers because
of..
Inappropriate preparation of feeding
bottles

37. Is this the “safe” and “standard”
choice?
• 77% were not given any directions on how to prepare bottles
correctly
• 33% did never read the instructions for preparation at the
label
• 47% didn’t check the expiry date
• 55% were not washing their hands before preparing the bottle
• 32% were not cleaning the bottle adequately in between feeds
• 35% used microwave for heating
• 6% gave infant formula prepared more than 2 hours ago
• 47% put solid food inside the bottle together with the milk
• 20% let the infant sleep with the bottle in his mouth in
horizontal position
• 73% didn’t receive any instructions for correct storage
Labiner – Wolfe J et al. Infant formula-handling education
and safety. Pediatrics 2008;122 Suppl 2:S85-90.

38. Incorrect preparation of bottles
• Wrong size of spoon contained in the package,
resulting in incorrect proportion of water and
powder
• Wrong instructions for preparation in the package
(40 degrees Celcius instead of 70!)
• Arbitrary dilution or condensation to make the baby
less or more fat – by the mother or even after
instruction from health professional!
• Scalding and burns
• Inappropriate preparation: Often the only risk
realized by parents or doctors
• Some think that the Code refers only to these risks

39. Finally where is the ideal, the standard and
the dangerous in infant nutrition?
BREASTFEEDING IDEAL
INFANT FORMULA STANDARD
DANGEROUS
IDEAL
BREASTFEEDING
STANDARD
INFANT FORMULA
POTENTIALLY
DANGEROUS

40. With evidence based information, the
way you look at the issue changes!
Risks of continuing
Risks of not
breastfeeding when a
breastfeeding and of
mother has fever or takes
formula bottle feeding
a drug or doesn’t have a
proper diet etc

41. What we know so
far about infant
feeding
What we do not
yet know about
infant feeding

42. Are these findings likely to be
overestimated or underestimated?
• Well underestimated, because:
– Lack of will and money for independent research
– Lack of cohorts that follow ideal practices (6 months exclusive
breastfeeding followed by at least 2 years of continued
breastfeeding)
– Lack of studies on breastfeeding > 12 months
– No proper definitions in studies resulting in mediating of the
effects
– Recall bias in studies
– Inability to perform randomized trials
– Lack of good quality large prospective cohort studies looking at
several possible outcomes
– Lack of research on safety of formula composition
– Epigenetics, after successive generations with suboptimal infant
nutrition (?)

43. Conclusions: The role of infant
formula on infant nutrition
• For the few acceptable
medical reasons for not
breastfeeding
• 4th choice when insufficient
milk production or re-
lactation (optimization of
breastfeeding, breastmilk,
donor’s milk)
• Any unjustified intervention
can do more harm to the
breastfeeding dyad than
good