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JAOA • Vol 106 • No 4 • April 2006 • 203Jackson and Nazar • Review Article
Breastfeeding provides unsurpassed natural nutrition to
the newborn and infant. Human breast milk also contains
numerous protective factors against infectious disease and
may influence immune system development, as noted in
previous studies of infant response to vaccination and
thymus gland development. If immune system develop-
ment is significantly improved with the introduction of
components of breast milk, then prematurely discontinued
breastfeeding may facilitate pathogenesis of many chronic
diseases later in life (eg, autoimmune disorders). The
authors summarize the reported effects of breastfeeding on
the development of the suckling infant’s immune system
and discuss possible consequences to immunologic health
when breastfeeding is discontinued prematurely.
J Am Osteopath Assoc. 2006;106:203–207
I
n addition to being the best source of nutrition for newborns
and infants, human breast milk also provides immuno-
logic protection against many infections.1,2 Although most of
the immunologic benefit cited by researchers relates to pro-
tection from diarrheal diseases that are especially prevalent
in developing countries,2,3 breastfeeding has also been shown
to protect infants against extraintestinal infections, such as
otitis media4–6 and respiratory diseases.7–10
Less convincing, but still substantial, is the evidence that
suggests breastfeeding can influence immune system devel-
opment, affecting the pathogenesis of autoimmune disorders,
including atopic allergies. This claim is difficult to prove, how-
ever, because immune system disregulation is multifactorial
in origin and may be asymptomatic for several years after
weaning. The early positive influences of human breast milk
may be a bulwark against chronic disease in later life.
This review summarizes many of the known immunologic
components of human breast milk and examines the evidence
for long-term health afforded to breastfed infants. In particular,
we will examine the influence of breastfeeding on immune
system development and the pathogenesis of chronic disease.
Immunologic Factors in Human Breast Milk
For the fetus and newborn, immunologic defenses are pre-
sent, but immature. To compensate, the mother’s immunoglob-
ulin (Ig) G antibody moves across the placental barrier to pro-
vide some protection. After birth, these maternal antibodies
wane in the first 6 to 12 months of human life. The neonate and
infant can receive additional maternal protection from breast
milk, however.
Human breast milk contains large quantities of secretory
Ig A (sIgA). These antibodies, which have formed as a conse-
quence of the mother’s previous exposure to infectious agents,
can bind to potential pathogens and prevent their attachment
to the infant’s cells. Secretory IgA is adapted to survive in the
respiratory and gastrointestinal mucosal membranes and resist
proteolytic digestion. Secretory IgA neutralizes infectious
agents while at the same time limiting the damaging effects of
tissue inflammation that can occur with other antibody types.
Human breast milk, and especially the early colostrum,
contains measurable levels of leukocytes. Colostrum contains
approximately 5⫻106cells per mL, an amount that decreases
tenfold in mature milk. Most of these leukocytes are
macrophages and neutrophils, which phagocytose microbial
pathogens. Lymphocytes, including T cells, natural killer cells,
and antibody-producing B cells, make up 10% of the leukocytes
in human breast milk. There is evidence to suggest that these
cells survive passage through the infant’s gastrointestinal
system where they are absorbed and influence the infant’s
immune response.11 Much of this evidence comes from
animal studies, however, which will be discussed later in the
present review.
In addition to these immunologic components, breast
milk contains several nonspecific factors that have anti-
microbial effects.12 These factors include the enzyme
lysozyme, which inhibits the growth of many bacterial
species by disrupting the proteoglycan layer of the bacterial
cell wall. Lactoferrin, one of the most abundant proteins in
human milk, also limits bacterial growth by removing
essential iron. Nucleotides in human milk have been
shown to enhance immune function in infants.13 Complex
sugars are found only in trace amounts in cow milk
but make up a substantial portion of human milk sugars,
where they may prevent adherence of various microbial
pathogens by acting as decoy receptors.11
Obviously, human breast milk contains a wealth of
Breastfeeding, the Immune Response, and Long-term Health
Kelly M. Jackson, PhD
Andrea M. Nazar, DO
From the West Virginia School of Osteopathic Medicine and the Robert C. Byrd
Clinic, both in Lewisburg.
Address correspondence to Kelly M. Jackson, PhD, Professor, Medical
Microbiology and Immunology, West Virginia School of Osteopathic Medicine,
400 N Lee St, Lewisburg, WV 24901-1128.
E-mail: kjackson@wv.wvsom.edu
REVIEW ARTICLE
204 • JAOA • Vol 106 • No 4 • April 2006
immunologic and other protective mechanisms that decrease
neonatal infections. But, is that the whole story, or are there
effects that reach beyond infancy? Do immunologic factors
in breast milk influence the development of the infant’s
immune system to the extent that they influence the patho-
genesis of chronic disease later in life?
Breastfeeding and Immune System Development
The thymus is a central organ in the immune system, respon-
sible for the proper development of T lymphocytes. Imma-
ture T cells, known as thymocytes, undergo a selection process
in the thymus to remove potentially self-reactive cells. Less than
5% of thymocytes survive this “education” to be released as
functionally mature, circulating T cells. While the clinical sig-
nificance of thymic size is not known, the central role of the
thymus gland in the development of the T-cell repertoire sug-
gests a potential for direct effects of breastfeeding on a crucial
organ of the maturing immune system.
Using an ultrasound technique to measure thymic index
size, Hasselbalch and colleagues14 found that, at 4 months of
age, infants who were breastfed exclusively had significantly
larger thymus glands than those who were partially breastfed
or formula fed only. There was no significant difference in
thymic size among the three study groups at birth.
A later study by Thompson and coauthors15 was unable
to confirm the findings of Hasselbalch et al14 by measuring
thymic weights at autopsy in infants who died of sudden
infant death syndrome.
Prentice and Collinson16 later tried to reconcile the work
of Hasselbalch and Thompson, speculating that in vivo thymic
size differs from that found at autopsy because of the inherent
plasticity of the organ.
Hasselbalch’s group (ie, Jeppesen et al17) has recently
published a report that not only substantiated their previous
findings regarding increased thymus size with breastfeeding,
but also found a correlation between breastfeeding and
CD8⫹T cells.
Breastfeeding and Childhood Vaccination
It has also been suggested that breastfeeding influences an
infant’s response to common childhood vaccinations.2,3 Several
studies have shown increased immune response to vaccines in
breastfed vs formula-fed babies.18,19 Greenberg and colleagues20
studied immune responses to Haemophilus influenzae type
b-tetanus toxoid conjugate vaccine in a subset of 10,000 immu-
nized infants and found a significant increase in antivaccine
antibody in infants that had been breastfed for at least 6 months.
Other studies21,22 have found no such positive effects, however.
Still others have even found a significant adverse effect on
seroconversion.23
Studies showing no effect or adverse effects of breast-
feeding in childhood vaccinations often used live viral vaccines
whose immunogenicity may be inhibited by the sIgA of human
breast milk. For example, the three studies included in the
meta-analysis by Pichichero,23 with approximately 500 infants
in total, all examined antirotaviral responses after an oral
dose of a live attenuated Rotavirus vaccine. Proper immu-
nization with live oral virus vaccines depends upon viral repli-
cation, which could be inhibited by the sIgA of breast milk.
Indeed, increasing the vaccine dose diminished the “adverse”
effect of breastfeeding.23
There is some evidence from animal studies and other
work to suggest that cells in breast milk survive passage
through the intant’s digestive tract, are taken up into the gut
mucosa, and are found in the draining lymph nodes.3,24–26 Evi-
dence that these cells remain functional comes from the obser-
vation that positive skin responses to injection of the mycobac-
terial-purified protein derivative can be transferred from one
individual to another by breast milk.27 Other studies28,29 have
shown reductions in the alloreactivity of breastfed infants
who were given maternal allografts. This evidence tends to
support the idea that breast milk leukocytes are able to survive
and interact with the intestinal mucosa of the infant, which
could lead to a form of tolerance to maternal antigens.
Allergy, Autoimmunity, and Breastfeeding
Does breastfeeding decrease individuals’ future susceptibility
to autoimmune disorders? This question has been debated
and tested for many years with mixed results.30–36 In a special
report for the Journal of Pediatrics, Kramer30 developed 12 stan-
dards of biological and methodological parameters by which
studies on breastfeeding and atopic allergies could be evalu-
ated. Kramer30 applied these standards to studies that were
published from 1983 through 1986 and found on MEDLINE.
Weaknesses found in many of the studies included reliance on
long-term maternal recall data, insufficient data on duration
and exclusivity of breastfeeding, and lack of strict diagnostic
criteria for atopic allergies. No firm conclusions could be
drawn from the analysis.
A recent meta-analysis by Mimouni Bloch and coinvesti-
gators37 examined studies of breastfeeding and allergic rhinitis
published between 1966 and 2000. Prospective studies in which
infants were breastfed exclusively for the first 3 months were
included in this analysis of six studies. The authors concluded
that exclusive breastfeeding during the first 3 months of life
protects children against allergic rhinitis. This association was
substantial (summary odds ratio of 0.74), but not statistically
significant. The authors suggest that this small, though
statistically insignificant effect, might result from the strict
inclusion criteria for the meta-analysis, which used studies
that focused on allergic rhinitis rather than all forms of atopy,
and studies that met the strict methodologic criteria proposed
by Kramer.30
A multicenter group from Northern Europe also con-
ducted a review of the literature related to breastfeeding and
atopic allergies and concluded that breastfeeding seems to
protect individuals from atopic allergies.38 This study included
data from 56 published articles that were judged to be con-
Jackson and Nazar • Review Article
REVIEW ARTICLE
JAOA • Vol 106 • No 4 • April 2006 • 205
source for the neonate and infant, and it provides other widely
accepted benefits to the mother and child. Additionally, there
are specific maternal benefits, including the delayed resump-
tion of menses and subsequent reduced risk of anemia, as
well as substantial association with bonding and emotional
gratification. Indeed, there are even benefits to society overall
through reduced child mortality rates, the economic advantages
of breastfeeding over formula consumption, and the “envi-
ronmentally friendly” aspects of lactation. It is estimated
that improved breastfeeding practices could save 1 million to
2 million lives per year.51
Could early consumption of human breast milk also pro-
vide long-term benefits by protecting individuals from chronic
diseases later in life? We examined the literature for evidence
of long-term benefits of breastfeeding that may influence
autoimmunity. While the evidence is not conclusive, there is
enough evidence to suggest that breastfeeding may signifi-
cantly alter the immune system of the suckling infant. Clues
to this early influence are seen in the effects of breastfeeding
on thymic size, the antibody response to vaccination, and
increased tolerance to breast milk leukocyte antigens. Funda-
mental changes in the infant’s immune system as a result of
premature cessation of breastfeeding could lay the groundwork
for later dysfunction in the immunologic controls necessary to
prevent autoimmune disease or hypersensitivity reactions.
Autoimmune disorders are common and affect quality of
life for millions of Americans. The incidence rates for some of
these diseases have been increasing over the past several
decades. Much of this increase can be attributed to increased
levels of environmental allergens, pollutants, and lifestyle.
The preponderance of evidence suggests that exclusive breast-
feeding, for at least the first 6 months of life, can decrease the
incidence of atopic allergies. In theory, enhanced maturation
of the intestinal mucosal barrier could decrease translocation
of protein antigens and thereby decrease unwanted immune
stimulation. However, since there are multiple factors involved
in allergic disease (eg, genetic history of atopy, environmental
exposures), the effect of breastfeeding should be viewed as
one word in a very long sentence. Future studies on this rela-
tionship should adhere to the standards described by Kramer30
and should also require researchers to gather information on
maternal diet as a possible confounding factor.
Although recent claims point to breastfeeding as pre-
ventive of IDDM, the evidence is far from conclusive. The
most recent study cited above shows a protective effect.50
Arguments in favor of the protective effect of breastfeeding
include the apparent capacity of breast milk factors to enhance
maturation of the intestinal mucosal barrier and, thus, enhance
development of oral tolerance.11 Unfortunately, the numerous
confounding variables and potential for bias inherent in most
of the study designs used make definitive inferences very dif-
ficult. If further research can confirm this protective effect, the
implications for proactive interventions could be substantial.
In their early review of breastfeeding, Wold and Adler-
clusive. Several of these studies gathered follow-up data into
subjects’ adolescence.
It has been further suggested that breastfeeding facili-
tates increased immunologic tolerance, and may thus decrease
future risk of autoimmune disorder.24 Koletzko and coau-
thors39,40 found that formula feeding in place of breastfeeding
was independently associated with increased risk of Crohn’s
disease but not ulcerative colitis. These studies were conducted
using questionnaires sent to families with at least one child
(⬍18 years) who had been diagnosed with inflammatory
bowel disease.
In a more recent study, Corrao and colleagues41 found
that formula feeding was associated with an increased risk of
Crohn’s disease or ulcerative colitis in 819 patients with inflam-
matory bowel disease. This relationship was statistically sig-
nificant for Crohn’s disease in women. Lack of accurate parental
recall on infant feeding methods is a potential weakness in
these studies, however.
Insulin-dependent diabetes mellitus (IDDM) is largely a
result of genetic factors and disregulation of the immune
system. Breastfeeding has been shown to have protective
effects,42–44 no effects,45–47 and even detrimental effects48 on
the risk of IDDM or diabetes-related auto-antibodies.
In 1994, Gerstein44 attempted to bring some clarity to this
relationship with a critical review of the literature (N=19).
Overall, countries with the lowest prevalence of breastfeeding
at 3 months of age had the highest rates of IDDM. In case-
control studies, patients with IDDM were more likely to have
been breastfed for less than 3 months.
Norris and Scott49 published a meta-analysis of similar
studies (in fact 68% of Gerstein’s studies were also part of
Norris and Scott’s analysis) that found a moderate increased
risk of IDDM associated with age at first exposure to breast-
milk substitutes, which were defined as any milks or foods
other than breast milk in the infant diet. These authors dis-
cussed the many potential sources of bias in these studies
(eg, retrospective assessment of feeding practices, inaccurate
recall, and difference in response rates between cases and con-
trols) and concluded that small associations between infant diet
and risk of IDDM may be explained by problems in study
design that created bias.
In Sweden and Lithuania, a recent case-control study of
803 children (⭐15 years) was aimed at determining whether
forms of early nutrition were independent risk factors for dia-
betes.50 Information was gathered by questionnaires distributed
at the time of diagnosis with IDDM. The authors concluded that
formula feeding in place of breastfeeding was independently
associated with diabetes, after adjusting for other variables.
Conclusions
Disease prevention is critically important to individual and
public health. Breastfeeding is well known to provide immune
protection and prevent various diseases in the perinatal period.
Human breast milk is also accepted as the best nutritional
Jackson and Nazar • Review Article
REVIEW ARTICLE
206 • JAOA • Vol 106 • No 4 • April 2006
berth11 commented on the abundant protection provided to the
neonate and infant by human breast milk and added that per-
haps we should not expect lifelong immunologic protection as
well. Even if breastfeeding is later proven to have no effect on
the pathogenesis of chronic disease, there are enough short-
term benefits from breastfeeding to justify its continued pro-
motion as the exclusive nutritional supply for the newborn.
Osteopathic primary care physicians should promote
breastfeeding at every opportunity. The American Academy
of Pediatrics has listed specific steps that pediatricians and
family physicians should take to promote breastfeeding and
support those parents who have decided to breastfeed.52
Acknowledgments
The authors thank Zachary Comeaux, DO, William T. Blue, PhD,
Edward P. Dugan, PhD, and Craig S. Boisvert, DO, for reviewing
a draft of this manuscript. We also thank Mary Frances Bodemuller,
MLS, Valeria Barfield, and Amber Cobb at the West Virginia School
of Osteopathic Medicine Library in Lewisburg for their valuable
assistance.
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